Every finding on record at Hoosier Homecare Services LLC

An Emergency Preparedness survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102 for a Home Health Provider and Suppliers. Survey Dates: August 12, 13, 14, and 15, 2024 Census: 211 At this Emergency Preparedness survey, Hoosier Homecare Services was found to be in compliance with Conditions of Participation 42 CFR 484.102 Emergency Preparedness requirements for Medicare Participating Providers and Suppliers.

This visit was for a Federal Recertification and State Re-Licensure survey of a Home Health Provider. Survey Dates: August 12, 13, 14, and 15, 2024 12-Month Unduplicated Skilled Admissions: 720 This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Refer to State Form for additional State Findings. QR 8/23/24 A2

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure medications were reviewed as part of the comprehensive assessment for 2 of 7 patient records reviewed with a home observation visit (Patient #3 and #4). Findings include: 1. The comprehensive patient assessment policy indicated “The Comprehensive Assessment will include a review of all medications the patient is using.” 2. The medication profile policy indicated “To provide documentation of the comprehensive assessment of all medications the patient is currently taking, and identify discrepancies between patient profile and the physician and/or agency profile.” 3. Review of Patient #3’s clinical record indicated a start of care of 5/23/24 and included a comprehensive assessment performed by PT 2 on 7/17/24. The clinical record also included a medication list. The medication list included Amlodipine Besylate (a medication used to treat high blood pressure) 5 milligrams (mg) to be taken by mouth once daily and also included Norvasc (brand name for Amlodipine Besylate) to be taken by mouth once daily. The clinician failed to ensure the medication list did not contain duplicate medications. During an interview on 8/15/24 at 1:47 PM, PT 2 indicated he guessed that one of the medications must have stayed in the patient’s medication profile from a previous entry and had not been deleted. 4. Review of Patient #4’s clinical record indicated a start of care of 4/8/24 and included a comprehensive assessment performed by PT 2 on 8/01/24. The clinical record also included a medication list. The medication list included Lomotil (a medication used to treat diarrhea) 2.5-0.25 mg to be taken by mouth 4 times per day as needed, Tums gas relief chewy bites (a medication used to relieve heartburn, indigestion, and upset stomach) oral 750-80 mg to be taken by mouth as needed 3-4 times per day for indigestion, Miralax (a medication used to treat constipation) 17 grams to be taken 1 packet by mouth once per day, Amlodipine Besylate 5 mg to be taken by mouth once per day, and Triamcinolone Acetonide External 0.1% (a topical medication used to treat a variety of skin conditions) to be applied topically twice daily. During a home visit observation of PTA 1 providing care to Patient #4, Patient #4 and their caregiver indicated Patient #4 no longer had Lomotil, Tums, Miralax, Amlodipine Besylate, or Triamcinolone Acetonide in the home as it had been at least one year since the patient had used those medications. PT 2 failed to perform an accurate comprehensive assessment of Patient #4's medications. During an interview on 8/15/24 beginning at 1:47 PM, PT 2 indicated he looked at Patient #4’s pill bottles at start of care but wasn’t sure if he looked at them at the recertification assessment. PT 2 indicated he did not know why the Lomotil, Tums, Miralax, amlodipine, and triamcinolone were on the medication list when the patient and caregiver had indicated the patient had not taken these in at least a year. 410 IAC 17-14-1(a)(1)(B)

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the plan of care (POC) included all medical equipment for 1 of 4 active records reviewed receiving physical therapy (PT) service with no home visit observation (Patient #11). Findings include: 1. Review of the clinical record of Patient #11 included a PT Evaluation completed on 06/21/2024 by PT 1 that indicated an overhead trapeze was used (medical equipment used to assist with moving, raising and lowering the body while in bed) to assist with bed mobility. Review of the POC for Patient #11 for certification period 06/21/2024 – 08/19/2024 failed to evidence orders for an overhead trapeze. During an interview on 08/14/2024 at 12:37 PM, when asked what durable medical equipment was used by Patient #11, PT 1 indicated a wheelchair, shower chair, safety bars, hospital bed, and overhead trapeze. 410 IAC 17-13-1(a)(1)(c)(ii)

Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This ELEMENT is not met as evidenced by: Based on record review and interview, the skilled nurse failed to provide the patient with individualized education for 1 of 5 active records reviewed with no home visit observation (Patient #11). Findings include: 1. Review of the clinical record of Patient #11 with start of care date, 09/10/2020, included diagnoses, but were not limited to, cystostomy (surgical opening into the bladder through the abdominal wall to allow urine to drain) and hereditary spastic paraplegia (disorder that causes progressive weakness and stiffness in leg muscles). Review of documentation completed by licensed practical nurse (LPN) 1 on 04/25/2024, 05/22/2024, and 07/18/2024 included patient education provided by LPN 1 that included emptying bladder entirely each time urinating and to refrain from holding urine. The agency failed to ensure individualized education was given to the Patient. During an interview on 08/14/2024 at 12:46 PM, when asked how Patient #11 eliminated urine, LPN 1 indicated Patient #11 was unable to urinate due to paralysis, unable to hold urine, and urine was eliminated through a suprapubic catheter (a hollow tube used to drain urine from the bladder through a cut in the abdomen) 410 IAC 17-14-1(a)(2)(E)

Other pertinent instructions CFR(s): 484.60(e)(4) Any other pertinent instruction related to the patient's care and treatments that the HHA will provide, specific to the patient's care needs. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the home health agency failed to ensure all patients were provided a plan of care for 2 of 2 home visit observations (Patients #13, 14) and failed to ensure patients receiving home health aide services received a home health aide care plan for 1 of 1 home visit observations of a patient receiving home health aide services (Patient #13). Findings include: 1. Policy #C-660, titled “Care Plans,” indicated but was not limited to “… If the patient has specific complex care needs that require specific direction in the home, an individualized treatment plan will be left in the home ….” 2. During a home visit conducted on 01/24/2023 at 12:00 PM with Patient #13 and Home Health Aide #1 the patient’s home folder was reviewed. The home folder failed to evidence a plan of care nor an aide care plan. Patient #13 was queried during the home visit whether they had received a plan of care or aide care plan from the agency and the patient indicated they had not received either plan. 3. During a home visit conducted on 01/24/2023 at 1:30 PM with Patient #14 and Licensed Practical Nurse #2 the patient’s home folder was reviewed. The home folder failed to evidence a plan of care. Patient #14’s family member (who was also the patient’s primary caregiver) was queried during the home visit whether they had received a plan of care from the agency and the family member indicated they had not received the plan of care. 4. An interview was conducted on 01/24/2023 beginning at 4:11 PM with the Administrator and Clinical Manager. When queried if the patient home folder should include the patient’s current plan of care, the Administrator provided agency policy #C-660. The Administrator confirmed the agency's policy indicated that agency was only required to keep a plan of care in the patient’s home if the patient had “complex care needs that require specific direction.” The Administrator also confirmed the agency did not provide written home health aide care plans to patients who received home health aide services.

This visit was for a Federal and State complaint survey of a HHA Provider. Survey Dates: November 17, 18, 21, 22, 23, 28, and 29, 2022 Complaint: IN0094194 - substantiated. Federal and State deficiencies were cited. Unrelated deficiencies were cited. During this Federal Complaint Survey, Hoosier Homecare Services LLC was found to be out of compliance with Conditions of Participation 484.60 Care planning, coordination of services, and quality of care. Based on the Condition-level deficiencies during the November 29, 2022 survey, your HHA was subject to a partial or extended survey pursuant to section 1891(c)(2)(D) of the Social Security Act on November 29, 2022. Therefore, and pursuant to section 1891(a)(3)(D)(iii) of the Act, your agency is precluded from operating or being the site of a home health aide training, skills competency and/or competency evaluation programs for a period of two years beginning November 29, 2022 and continuing through November 28, 2024. Census: 910 This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Refer to State Form for additional State Findings. QR: Area 2 12/12/22

Transfer and discharge CFR(s): 484.50(d) Standard: Transfer and discharge. The patient and representative (if any), have a right to be informed of the HHA's policies for transfer and discharge. The HHA may only transfer or discharge the patient from the HHA if: This STANDARD is not met as evidenced by: Based on record review and interview, the home health agency failed to verify the patient was currently hospitalized prior to discharging the patient for hospitalization for 1 of 2 records reviewed of a patient discharged for hospitalization (Patient #6). Findings included: An agency policy #C-500 “Patient Discharge Process” indicated but was not limited to “… To avoid charges of ‘abandonment’ at the time of discharge agency documentation will include the following: … d. Documentation of all communication with the patient, including the rationale for discharge, will be kept in the patient file … Discharge Criteria: 1. Criteria for discharge may include, but are not limited to the following: … i. The patient is hospitalized and the hospitalization period … exceeds the current home care episode of care ….” Review of the clinical record of Patient #6 included a plan of care for the recertification period 08/08/2022-10/06/2022. The record included a physician order, dated 10/03/2022 and signed by the Administrator, which indicated the patient’s home health services were placed on hold due to the patient being hospitalized for COVID-19. The record included a second physician order, dated 10/06/2022 and signed by the Administrator, which indicated the patient was discharged from the home health agency “effective this date as home health certification expires while patient remains inpatient. Patient/caregiver were involved in the development and/or aware of the updates to the plan of care.” The record included hospitalization records for Patient #6 which indicated the patient was admitted to a local hospital on 10/02/2022 and was discharged on 10/05/2022. An interview was conducted on 11/23/2022 at 12:54 PM with Patient #6’s caregiver. During the interview, the caregiver confirmed the agency had not called the caregiver or patient on 10/06/2022 to verify the patient was still admitted to the hospital nor had the agency notified the patient or caregiver that the patient was discharged from the agency. An interview was conducted on 11/28/2022 at Office Staff Member #1 and the Administrator. During the interview, Office Staff Member #1 reported they spoke with Patient #6’s family member on 10/04/2022 and the family member had indicated Patient #6 would be in the hospital for the remainder of the week. The office staff member stated they notified the caregiver to call the office when the patient was discharged from the hospital. The Administrator confirmed the agency did not confirm the patient was still admitted to the hospital when the patient was discharged on 10/06/2022.

Standard: Initial assessment visit. CFR(s): 484.55(a) Standard: Initial assessment visit. This STANDARD is not met as evidenced by: Based on record review and interview, the home health agency failed to follow their own policy and failed to complete an initial assessment within 48 hours for 2 of 8 active patient records reviewed (Patient #3,10.) Findings include: 1. Undated policy C-140 titled “Patient Admission Process” indicated but not limited to “… Each patient referred to the agency shall be evaluated by a Registered Nurse/ Therapist to determine the immediate care and support needs of the patient… The initial assessment will be completed within forty-eight (48) hours of referral or within forty-eight (48) hours of the patient’s return home…” 2. Record review for Patient #3 indicated the home health agency received a referral by fax on 09/08/2022 for physical therapy, occupational therapy, nursing services, and home health aide services with a discharge date from a facility of 09/09/2022. The record included an initial assessment completed on 09/13/2022 which indicated “… delay in care per pt request…” The record failed to evidence a conversation with the patient or family indicating a request to delay the initial assessment. 3. Record review for Patient #10 indicated a referral on 02/10/2022 for skilled nursing for catheter care. The record included a faxed request for order dated 02/15/2022 for patient to be admitted for skilled nursing. The initial assessment was completed on 02/16/2022 with verbal order for frequency and treatment faxed to the physician that day. The record failed to evidence a conversation with the patient or a representative indicating a request to delay the initial assessment. 4. During an interview on 11/21/2022 at 11:45AM, Patient #3’s daughter indicated she did not request a delay in the start of care for Patient #3. 5. During an interview on 11/29/2022 beginning at 11:30AM, the administrators deferred the question of who specifically requested a delay in the initial assessment for Patient #3 to their office assistant who indicated it was Patient #3’s daughter who requested it but was unable to provide documentation of same. The administrators also deferred the question of who specifically requested a delay in the initial assessment for Patient #10 to their office assistant who indicated the delay was due to the referring agency sending the patient’s information to the incorrect fax number but could not provide any documentation of same. The administrator indicated it was possibly an issue with prior authorization due to the patient’s insurance. The human resources director checked and indicated Patient #10 did not require prior authorization at the time of their admission.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview the home health agency failed to follow their own policy and failed to include all medications on the medication list, failed to include frequency of medications, and failed to include indications for PRN (as needed) medications for 4 of 8 active patient records reviewed (Patient #1,5,8,10.) Findings include: 1. Policy C-700 titled “Medication Profile” included but not limited to “… The Medication Profile shall document… the route and frequency of administration… The Medication Profile shall be reviewed by a Registered Nurse every sixty (60) days and updated whenever there is a change or discontinuation in medication… During therapy only cases, a Registered Nurse will review and sign/ initial medication profile and any changes to medication profile…” 4. Review of the clinical record for Patient #10, SOC 06/15/2022, included a medication profile, completed as part of the assessment process and initialed by the current DON (director of nursing.) The medication list included but not limited to “…Zims Max-Freeze External 3.7% [an over-the-counter topical pain relief medication]1 Take as directed… Senna S Oral 8 6-50 MG [used to treat constipation] 1 Tab(s) Take as directed… metformin HCl [used to treat Type 2 diabetes] Oral 1000 MG 1 Tab(s) Take as directed…” The medication profile failed to include the frequency for each of these medications. 5. During an interview on 11/28/2022 at 12:41PM, the DON indicated those were her initials on Patient #10’s medication list and the medication list should have specific instructions for administration. When asked if the phrase “take as directed” was appropriate for a patient’s medication list, the DON indicated “it could definitely be more specific.” 2. Review of the clinical record for Patient #1 included a medication profile completed as part of the recertification comprehensive assessment process by Physical Therapist (PT) #3 on 11/12/2022. The medication list included orders for as-needed medications: fleet enema (medication given rectally to treat constipation), Miralax (given to treat constipation), Bisacodyl (given to treat constipation), and Refresh Tears Opthalmic (eye drops given to treat dry or itchy eyes). The medication list failed to evidence indications for administration for the as-needed medications. 3. Review of the clinical record for Patient #5 included a medication profile completed as part of the recertification comprehensive assessment process by Physical Therapist #2. The medication list included an order for Triamcinolone Acetonide (a steroid cream used to treat a variety of skin conditions) with the directions “apply to affected area.” The medication list failed to evidence clear directions on the specific location the patient was to apply the medication. 4. Review of the clinical record for Patient #8 included a medication profiled completed as part of the recertification comprehensive assessment completed on 11/04/2022 by Registered Nurse (RN) #2. The medication list included orders for as needed medication Tylenol (over-the-counter medication given to treat pain and/or fever), but failed to evidence an indication(s) for administration for the Tylenol. 5. During an interview conducted on 11/22/2022 beginning at 4:13 PM, when queried if the medication list should included an indication for administration for as needed medications, the Administrator and Alternate Administrator were unable to provide an answer.

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on observation, record review, and interview, the home health agency failed to ensure the patient received all services as written in the plan of care (See G572); failed to evidence a single plan of care and failed to include all medications and treatments in the plan of care (See G574); failed to coordinate care to meet the patient's needs (See G608); and failed to provide the name and contact information for the current clinical manager (See G622). Findings include: The cumulative effect of these systemic problems resulted in the agency’s inability to ensure patients received appropriate care and services which could result in the agency not providing quality health care, thus being out of compliance with Condition of Participation 42 CFR 484.60 Condition of participation: Care planning, coordination of services, and quality of care. 410 IAC 17-13-1(a)

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on observation, record review, and interview, the home health agency failed to ensure the patient received all treatments as written in the plan of care for 1 of 2 home visit observations of a Registered Nurse (RN) (Patient #8). Findings included: An agency policy #C-580 titled “Plan of Care” indicated but was not limited to “Policy: Home care services are furnished under the supervision and direction of the patient’s physician ….” An agency job description for the role “Registered Nurse” indicated but was not limited to “… Essential Functions/Areas of Accountability … c … Follows an individualized Plan of Care … d. Provides skilled interventions ….” Review of the clinical record for Patient #8 included a plan of care for the recertification period 11/04/2022 – 01/02/2023 and included orders for skilled nursing 2 visits per week for 8 weeks and 1 visit per week for 1 week. The plan of care indicated nursing interventions included but were not limited to “… SN [Skilled Nurse] to perform finger stick for fasting blood sugar/random blood sugar during visit if it has not been done ….” During a home visit with Patient #8 and Registered Nurse (RN) #2 on 11/21/22 at 11:34 AM the nurse failed to check the patient’s blood sugar. RN #2 was interviewed at 12:22 PM and confirmed they had completed the visit and did not check the patient’s blood sugar. The nurse asked Patient #8 if they checked their blood sugar, and the patient indicated they did not routinely check their blood sugar. 410 IAC 17-13-1(a)

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the home health agency failed to follow their own policy and failed to provide a single Plan of Care containing all medications and treatments for 5 of 8 active patient records reviewed (Patient #1,2,3,4,5.) Findings include: 1. Policy C-580 titled “Plan of Care” indicated “… The Plan of Care shall be completed in full to include… Type, frequency, and duration of all visits/ services… If a service is not scheduled to begin until a subsequent week then the order should read, “blank services to evaluate and treat effective the week of… Specific procedures and modalities for therapy services… Medications, treatments, and procedures… All of the above items must always be addressed on the Plan of Care… The plan of care is developed as required by agency/state guidelines…” 3. Review of the clinical record for Patient #2, SOC (start of care) 11/11/2022, failed to evidence a POC (Plan of Care) which included specific procedures and modalities for therapy services. 4. Review of the clinical record for Patient #3, SOC 09/13/2022, included a POC (Plan of Care) for the certification period from 11/12/2022 to 01/10/2023. The POC failed to include the indications for the PRN medication acetaminophen oral 500 mg and failed to include specific procedures and modalities for therapy services. 5. Review of the clinical record for Patient #4, SOC 10/26/2022, included a POC for certification period 10/26/2022 to 12/24/2022. The POC failed to include indications for four (4) PRN medications, Valtrex (a drug used to treat herpes virus infections), Ipratropium-Albuterol Inhalation (a drug used to treat to prevent bronchospasm), Diclofenac Sodium External (a drug used to treat pain and inflammation), and Clobetasol Propionate External (a drug used to treat a variety of skin conditions such as eczema or psoriasis). The POC also failed to include the frequency or location to apply Nystatin External (a drug used to treat fungal skin infections) and failed to include O2 (oxygen) 2L per nasal cannula during sleep. During a home visit with Patient #4 on 11/18/2022 beginning at 01:13PM, observed Patient #4 confirmed to nurse the patient is using O2 2L at night. 7. During an interview on 11/22/2022 at 04:13PM, the alternate administrator indicated route, dosage, name, and frequency should be included for each medication. 8. During an interview on 11/23/2022 at 3:45PM, the alternate administrator confirmed orders for oxygen were not on Patient #4’s POC. 9.During an interview on 11/29/2022 at 11:30AM, when asked which document was considered the POC, the administrator indicated if PT (physical therapist) did the initial assessment the 485 (POC) would be PT orders and aide orders also but if a nurse does the initial assessment then PT and OT (occupational therapist) do their assessments separately and become part of the POC as an addendum. When asked where on the Physical Therapy Assessment or Occupational Therapy Assessment it indicated it was an addendum to the POC, the administration was unable to show. 2. Review of the clinical record for Patient #1 included a plan of care for the recertification period 09/13/2022 - 11/11/2022 which indicated the patient was to receive physical therapy and home health aide services. The plan of care failed to evidence specific procedures and modalities for therapy services. 6. Review of the clinical record for Patient #5 included a plan of care for the recertification period 10/21/2022 - 12/19/2022 which indicated the patient was to receive skilled nursing and physical therapy services. The plan of care failed to evidence specific procedures and modalities for therapy services.

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure coordination of care to meet the patient's needs for 2 of 8 active patient records reviewed (Patient #2 and 8). Findings include: 1. Policy C-360 titled “Coordination of Patient Services” indicated “… Purpose… to ensure appropriate, quality care is being provided to patients… to establish effective interchange reporting, and coordination of patient care does occur… to ensure continuity of care… After the initial assessment, the admitting Registered Nurse/ Therapist shall discuss the findings of the initial visit with the Clinical Manager to ensure… coordination with other agencies and institutions, if the need arises…” 2. During a home visit with Patient #2 on 11/17/2022, a copy of the patient’s medication record was received from the patient’s ALF (assisted living facility.) The medication record indicated but not limited to no blood pressures or lab draws to the left upper extremity due to a history of left breast mastectomy and TED hose (stockings used to prevent blood clots in the legs) to be applied in the morning and removed in the evening. Record review for Patient #2, SOC (start of care) 11/11/2022, failed to evidence the above information from the ALF was addressed by the agency. 4. During an interview on 11/23/2022 at 03:45PM, the Administrator confirmed the nurse assessing a patient at an ALF should review the ALF’s medication record. Neither the Administrator nor the Alternate Administrator could show mention of TED hose or the restriction on blood pressures to the left arm in Patient #2’s record. 3. Review of the clinical record for Patient #8 included a plan of care for the recertification period 09/05/2022 – 11/03/2022 and included orders for skilled nursing, 3 visits per week for 8 weeks and 2 visits per week for 1 week. The plan of care indicated the skilled nurse was to perform wound care to Patient #8’s right plantar (bottom of the foot) diabetic wound and right lateral foot diabetic wound. The wound care was ordered to be performed at each visit and included “… cleanse with [normal saline], apply Prisma [type of wound dressing], cover with Hydrofera Blue [type of wound dressing], apply ABD [pad, type of wound dressing], apply Kerlix [gauze wrap]. Change three times a week ….” The record included a clinic visit note from Patient #8’s physician, dated 10/26/2022, which indicated Apligraf (a skin substitute wound dressing) was applied to Patient #8’s wounds. The note indicated the patient’s wound dressing change frequency was decreased to once a week by the home health agency and once by the wound clinic. The wound dressing orders also indicated the home health agency was to “keep Mepitel layer [wound dressing] in place as Apligraf is under the Mepitel.” The record included a physician order dated 11/02/2022 which indicated the physician approved to continue Patient #8’s home health orders and the patient was to receive skilled nursing, 2 visits per week for 8 weeks and 1 visit per week for 1 week. The order indicated the skilled nurse was to perform wound care to both wounds once a week. The wound dressing care included keeping the Apligraf and Mepitel in place, cleansing the wound and surrounding area with normal saline, apply Hydrofera Blue, cover with ABD pad, and wrap with Kerlix. The record included a physician order, dated 11/07/2022, which indicated Patient #8’s home health services were to be put on hold due to the patient being hospitalized. A second physician order, dated 11/10/2022 and signed by RN #2, indicated the patient’s home health services were to resume that same day for 1 visit per week for 1 week then 2 visits per week for 7 weeks. Patient #8’s wound care to both wounds included “cleanse with normal and pat dry, apply Prisma to wound bed, cover with Hydrofera Blue dressing and wrap with Kerlix and secure with tape,” to be completed at each skilled nurse visit. During a home visit with Patient #8 and Registered Nurse (RN) #2 on 11/21/22 at 11:34 AM, the patient’s right foot wounds were observed. No Apligraf nor Mepitel dressings were observed. RN #2 was interviewed during the home visit and confirmed they obtained the 11/10/2022 physician order to resume care and the wound change orders from Patient #8’s physician. The nurse reported Patient #8 had their Apligraf and Mepitel dressing removed while hospitalized, was to return to the wound clinic on 11/16/2022 to have the Apligraf and Mepitel placed on again, after which the wound clinic would send the home health agency new wound clinic orders. RN #2 also reported Patient #8 had missed the 11/16/2022 visit and the agency had continued the current wound care orders. A follow up interview was conducted with RN #2 on 11/22/2022 at 4:42 PM. During the interview, the nurse reported when they obtained the 11/10/2022 order for Patient #8’s wound care, the office nurse had stated the home health agency was to change the dressing on 11/10/2022 and 11/14/2022, then the home health agency would receive new wound care orders on 11/16/2022. A second follow up interview was conducted with RN #2 on 11/28/2022 at 3:50 PM. During the interview, the nurse confirmed they had spoken with the Clinical Manager after obtaining Patient #8’s physician orders on 11/10/2022 and had reported the wound clinic was to send new wound care orders to the home health agency after the patient’s appointment on 11/10/2022. The record included a skilled nurse visit note dated 11/17/2022 by LPN #2. The visit note indicated no Apligraf or Mepitel was observed in either of Patient #8’s wounds and the nurse performed wound care according to the order dated 11/10/2022. An interview was conducted on 11/28/2022 at 04:14 PM with LPN #2. During the interview, the nurse confirmed Patient #8 did report they missed the wound clinic visit on 11/16/2022 however the nurse did not report this to the Clinical Supervisor as the patient’s family member had already rescheduled the visit. The nurse stated they were not aware the patient’s wound care orders were to change after the wound care visit on 11/16/2022. The record indicated Patient #8’s wound care was performed twice by the home health agency during the week of 11/13/2022 – 11/19/2022, which was one dressing change less per week than when the patient previously had the same dressing orders. The home health agency failed to ensure effective communication between all staff members and failed to ensure the frequency of wound care dressing change twice per week was to continue one additional week after the patient missed their wound care visit on 11/16/2022.

Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the home health agency failed to ensure all patients were provided with the name of the Clinical Manager for 3 of 5 patients who had patient folders in the home during home visit observations (Patient #3,5,8.) Findings include: 1. An untitled document from the admission packet provided to the surveyors failed to evidence the name of the Clinical Manager. 2. During a home visit with Patient #3 on 11/18/2022 at 11:04AM, review of the patient folder failed to evidence the name of the Clinical Manager. 5. During an interview on 11/17/2022 at 10:25AM, the Clinical Manager confirmed the admission packet provided was the most current version being distributed to patients. 3. During a home visit with Patient #5 on 11/18/2022 at 10:15 AM, review of the patient home folder failed to evidence the name of the current Clinical Manager. 4. During a home visit with Patient #8 on 11/21/2022 at 11:34 AM, review of the patient home folder failed to evidence the name of the current Clinical Manager.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation, record review, and interview, the home health agency failed to ensure all staff followed infection prevention and standard precaution policies and procedures for 4 of 7 home visit observations (Patient #3, 4, 5, 7). 3. During a home visit with Patient #3 on 11/18/2022 at 11:04AM, PTA (Physical Therapy Assistant) #1 failed to perform hand hygiene after touching the front of his face mask and before touching the patient two times and failed to perform hand hygiene after touching his face mask and before touching his tablet one time. After wiping used equipment, PTA #1 failed to allow the items to dry before placing them into his bag. 4. During a home visit with Patient #4 on 11/18/2022 at 01:13PM, LPN (Licensed Practical Nurse) #1 wiped her used equipment and failed to allow the items to dry before placing them into her bag. 5. During an interview on 11/22/2022 at 04:13PM, the Alternate Administrator indicated the agency process for disinfecting equipment was to clean and allow to dry on a barrier before putting back into the bag. The Alternate Administrator also confirmed staff, if they touched their face mask, should perform hand hygiene before touching the patient or equipment. 410 IAC 17-12-1(m) Findings included: 1. Agency policy #G-160 titled “Pressure Ulcer Dressing Change,” dated 4/2008, indicated but was not limited to “… Procedure … 4. Put on gloves and remove old dressing and discard … 6. Apply new pair of gloves. 7. Measure wound perimeter with disposable device … 10. Cleanse the wound bed ….” 2. An agency competency evaluation for “Supply Bag Technique” indicated but was not limited to “… Hands washed before entering bag. Equipment cleaned prior to returning to bag … Hands washed prior to re-entry after possible contamination ….” 5. During a home visit with Patient #5 and Physical Therapist (PT) #3 on 11/18/2022 at 10:15 AM, the PT was observed failing to perform hand hygiene prior to entering their supply bag. 6. During a home visit with Patient #8 and Registered Nurse (RN) #2 on 11/21/22 at 11:34 AM, the nurse was observed assessing and performing wound care to the patient’s two wounds on their right foot. After removing the old dressings, cleaning each wound with saline soaked gauze, and performing a glove change with hand hygiene, RN #2 measured the length and width of both wounds using the same disposable measuring tape. The nurse then applied new dressings to each wound, rotating back and forth between each wound when applying the different layers of dressing (Mepitel, Hydroferra blue, ABD pad, then wrapped with Kerlix and tape). The nurse failed to use a new, clean measuring tape for each wound and failed to perform hand hygiene and change gloves when going between the two wounds while applying new dressings.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the home health aide (HHA) failed to perform all tasks ordered on the aide care plan for 1 of 1 home visit observations with a home health aide (Patient #1). Findings included: An agency job description for the position Home Health Aide, revised 10/2017, indicated home health aide “essential functions” included but were not limited to “… Follows the assignment sheet/service plan ….” Review of the clinical record of Patient #1 included an aide care plan created and signed by Physical Therapist (PT) #3 on 11/12/2022. The aide care plan included the tasks “… Change Linen … Light Housekeeping … Make Bed” to be done “PRN” (as needed). A home visit observation was conducted on 11/17/2022 at 12:22 PM with Patient #1 and Home Health Aide #1. During the visit, HHA #1 failed to perform or ask the patient if the following tasks were to be done “Change Linen … Light Housekeeping … Make Bed ….” During an interview conducted on 11/22/2022 beginning at 4:13 PM, the Administrator and Alternate Administrator confirmed the home health aide should ask the patient if PRN task(s) are/were to be done during the visit.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on record review and interview, the home health agency failed to follow their own policy and failed to ensure appropriate authentication of patient records for 2 of 8 active patient records reviewed (Patient #3,10.) Findings include: 1. A policy titled “Authentication Policy” indicated “… Authentication must include signatures, written initials, or computer secure entry by a unique identifier of a primary author who has reviewed and approved the entry…” 2. Policy C-873 titled “Documentation of Changes to the Medical Record” indicated “…Any changes or revisions of information documented in the patient record documented in the patient record must follow accepted legal requirements… If it is necessary to make an addition to a previous entry, this must be done using an addendum to the record… The clinician who completes the assessment form is responsible for making changes (corrections, revisions, or additions, to the document… The clinical supervisor or designee may enter changes based on the review of the assessment. These changes must be documented in the record identifying the reason for the changes and the communication of those changes to the authoring clinician. These changes must also be initialed and dated…” 3. Review of Patient #3’s clinical record, SOC (start of care) 09/13/2022, included an order signed by the DON (director of nursing) and dated 09/13/2022 which indicated but not limited to “… Delay in SOC per patient/ family request…” and an order signed by RN (Registered Nurse) #2 and dated 10/20/2022 which indicated “… decrease HHA [home health aide] 1xWK3 [1 time per week for 3 weeks] per patient request…] During a home visit with Patient #3 on 11/18/2022 at 11:04AM, Patient #3’s wife, when asked if they requested a decrease in home health aide visits, she answered no but that she understands the aide must see multiple patients per day and that it was okay because their daughter comes to shower and shave Patient #3 on the weekend. During an interview on 11/21/2022 at 11:45AM, Patient #3’s daughter indicated that she did not request a delay in SOC nor did she request a reduction in HHA service frequency. The patient’s daughter also denied she or her parents requested any decreases in services and indicated more frequent HHA services would be helpful for her parents. When asked about several missed HHA visits, she indicated missed aide visits were probably from the family canceling scheduled visits due to Patient #3’s doctor visits. 4. Review of Patient #10’s record, SOC 06/15/2022, included a comprehensive assessment authored by RN #3 and initially signed on 07/28/2022 at 07:40PM per the work log for the assessment. The work log also indicated the DON (Director of Nursing) reopened and signed the assessment on 10/05/2022 at 03:43PM. The assessment appears in the EMR (electronic medical record) as if the DON performed the assessment as there is no mention of the original author on the OASIS assessment. The clinical record included a POC with a SOC of 06/15/2022 for certification period 06/15/2022 to 08/13/2022 signed by RN #3 and dated 06/15/2022, faxed to the physician 08/05/2022, and signed and dated by the physician 08/05/2022. The record also included an order to admit for skilled nursing 1 time every other week signed by RN #3 and dated 06/15/2022 and signed and dated by the physician on 08/03/2022 and included an order for discharge due to insurance change, effective 06/14/2022, signed by RN #3 and dated 06/14/2022, faxed to the physician on 08/01/2022, and signed and dated by the physician 08/01/2022. The closed clinical record for Patient #10 included a Plan of Care with a SOC of 02/16/2022 for certification period 06/16/2022 to 08/14/2022 and signed by RN #3 and dated 06/16/2022, faxed to the physician on 07/05/2022, and signed by the physician on 07/05/2022. The record also included an order for Patient #10 to be re-certified for skilled nursing 1 time every other week signed by RN #3 and dated 06/15/2022 and signed and dated by the physician on 06/17/2022. The Case Conference note for Patient #3 dated 06/15/2022 indicated a SOC of 02/16/2022 with a recommendation for recertification; the note failed to indicate a need for discharge and readmission. An insurance eligibility and verification form indicated the patient’s insurance was checked on 07/28/2022 and the insurance had terminated 05/31/2022. 5. During an interview on 11/28/2022 at 12:41PM, when asked who completed the comprehensive assessment for Patient #10, the DON looked at the record and indicated she did. When asked why the admission paperwork for that day was signed by RN #3, the DON looked at the work log and noted RN #3 had completed the assessment but it had to be corrected and signed by the DON for a billing issue after RN #3 had left the agency. 6. During an interview on 11/29/2022 at 11:30AM, when asked how the agency should handle an assessment that needs to be re-signed after the nurse who completed the assessment has left the agency, the administrator indicated he would have to check the regs (regulations) but someone with equal credentials could sign if the the employee was no longer available and that the work log showed who has opened and signed it. When asked how someone without access to the work log would know the DON did not complete the assessment she signed, the administrator could not provide an answer. During the same interview, when asked who specifically requested a delay in the initial assessment for Patient #3, the office assistant indicated it was Patient #3’s daughter who requested it but was unable to provide documentation of same. When asked who specifically requested a decrease in frequency of home health aide (HHA) visits, the office assistant indicated the patient requested the change in front of his spouse and HHA #1 and indicated Patient #3 had missed several Friday visits in a row. When questioned who specifically requested a delay in the initial assessment for Patient #10, the office assistant indicated the delay was due to the referring agency sending the patient’s information to the incorrect fax number but could not provide any documentation of same. The administrator indicated it was possibly an issue with prior authorization due to the patient’s insurance. The human resources director checked and indicated Patient #10 did not require prior authorization at the time of their admission. 17-15-1(a)(7)

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102. Survey Dates: 08/09, 08/10, 08/11, 08/12, 08/13, 08/16, and 08/17 of 2021. At this Emergency Preparedness survey, Hoosier Homecare Services LLC., was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 484.102.

This visit was for a Federal recertification, complaint investigation, and COVID-19 focused infection control survey of a Home Health Agency. Complaint #: 29903; substantiated with findings. Complaint #: 29904; substantiated with findings. Survey Dates: 08/09, 08/10, 08/11, 08/12, 08/13, 08/16, and 08/17 of 2021. A fully extended survey was announced on 08/12/2021 at 2:58 p.m. An Immediate Jeopardy related to §484.60 Care Planning, Coordination of Services, and Quality of Care was identified and announced on 08/13/2021 at 11:50 a.m. Based on the Condition-level deficiencies identified during the 08/17/2021 survey, your home health agency was subject to a partial or extended survey pursuant to section 1891(c)(2)(D) of the Social Security Act, on 08/12/2021 at 2:58 p.m. Therefore, and pursuant to section 1891(a)(3)(D)(iii) of the Act, your agency is precluded from operating or being the site of a home health aide training and/or competency evaluation programs for two years beginning 08/17/2021 and continuing through 08/16/2023.

Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview the agency failed to provide all services as outlined in the plan of care and failed to perform complete accurate assessments as ordered in the plan of care for 3 of 17 patients reviewed. (Patient 11, 13, and 16). Findings include: 1. A document titled Patient Rights and Responsibilities was provided by the administrator on 8/9/2021. The document indicated but is not limited to; “Patient Rights: … 5. You have the right to an appropriate assessment … the right to refuse care … the right to receive all services outlined in the Plan of Care …” 2. A policy titled "Care Plan" was provided by the administrator on 8/12/2021 at 10:37 a.m. The document indicated but is not limited to, "Each patient will have a care plan on file that addresses their identified needs ... the care plan shall include ... a list of specific interventions with plans for implementation ... " 3. A policy titled “Pressure Ulcer Dressing Change” was provided by the alternate administrator on 8/10/2021 at 10:00 a.m. The document indicated but was not limited to “Documentation Guidelines 1. Document in the clinical record … c. Location, size of the ulcer. … color and appearance of the wound bed.” 4. A policy titled “Photo Documentation” was provided by the alternate administrator on 08/09/2021 at 1:30 p.m. The policy indicated, but was not limited to, “ ... To document the initial condition of the client’s skin upon admission ... To document clear, accurate status of skin ... To facilitate communication between the treatment team and prescribing physician ... Applies To: Registered Nurses, Licensed Practical/Vocational Nurses, Therapists ... ” 5. The complete clinical record for patient 13, the start of care 5/13/2021, was reviewed on 8/11/2021. The record evidenced the following: A document titled "Home Health Certification and Plan of Care" indicated but was not limited to, a diagnosis of neuromuscular dysfunction of the bladder, unspecified and paraplegia. The document included the following orders and treatments, " SN (skilled nursing) 1x9 (1 time a week times 9 weeks) ... Patient has or is at risk for having pressure ulcers-risk for infection ... SN to assess skin for breakdown every visit ..." A document titled, "RN-Skilled Nursing Visit" for 5/20/2021 signed by an employee I, Registered Nurse. The document indicated but was not limited to, "Skin ... WNL (within normal limits) ... A document titled, "RN-Skilled Nursing Visit" for 5/24/2021 was signed by employee C, Registered Nurse. The document indicated but was not limited to, "Skin ... Dry ... Warm ... Good/Elastic ... Assessment ... provided [sic] has no open areas or wounds at this time ..." A document titled, "LPN/LVN-Skilled Nursing Visit" for 6/02/2021 was signed by employee D, Licensed Practical Nurse. The document indicated but was not limited to, "Skin ... Dry ... Warm ... Good/Elastic ... Assessment ... " 6. Hospitalization records for patient 13 were received on 8/13/2021. The records indicated but were not limited to an emergency room visit dated 6/1/2021. The clinical impression documented by the medical provider indicated an open wound, 4 cm (centimeters) by 5 cm ulceration with central eschar (dead tissue) on the proximal posterior right thigh. The wound was cultured, and the results indicated evidenced heavy growth of Proteus mirabilis, heavy growth of Pseudomonas aeruginous, and heavy growth of Providencia stuartii. The patient received IV (intravenous) antibiotics and was prescribed oral antibiotics for home. 7. Documentation from the personal services agency providing care for patient 13 received on 8/17/2021 evidenced a document titled "Incident Report" dated 5/27/2021 for patient 13 that indicated, but was not limited to, "I was cleaning him [patient 13] up and noticed a rash on the front right leg and a fluid pocket on the back of his right leg underneath his butt." The family was notified at 7:44 p.m. signed by non-employee A. A picture of the wound was attached. A second document titled "Activity" evidenced an entry from non-employee B stated the personal care agency was notified of emergency room admission on 6/2/2021 for patient 13 and that patient would receive oral antibiotics. The non-employee also documented non-employee A had reported that the wound had worsened. 8. The complete clinical record for Patient 16, start of care 02/13/2021, was reviewed on 08/10/2021 and evidenced the following: A document dated 02/11/2021, signed by Non-employee C on 02/12/2021, titled F2F (Face 2 Face). The document indicated, but was not limited to, “ ... Home Health Services PT (physical therapy), OT (occupational therapy), NSG (nursing), HHA (home health aide) ... ” A document dated 02/13/2021, signed by Employee G, titled Physician Order, indicated but was not limited to, “This patient has been admitted to skilled home health services for the following disciplines: PT/OT/SN ... Skilled Nursing warranted due to active surgical wound ... Physical therapy to evaluate and treat at 1x1w (1 time a week for one week), 2x4w (2 times a week for 4 weeks), 1 times per week for 4 weeks … Fall prevention … Assess environment for personal safety hazards … Gait and balance exercises ... ”. The clinical record failed to evidence orders for a home health aide, orders for specific interventions, frequency, or duration for skilled nursing, orders for wound care, and orders for occupational therapy. A 2/18/2021 document titled PTA visit indicated during the PTA (physical therapy assistant) visit, the PTA documented the patient declined all intervention except laying supine due to weeping from a liver laceration wound. The PTA stated the patient was supposed to be changing his liver bandage every day but ran out of pads and has been using a towel. The document failed to indicate that they physician was made aware of the status of the patient’s living condition, status of the patient's wound, or the need for wound care and supplies. A 02/19/2021 document titled OT (occupational therapist) Evaluation indicated that the patient had no assistance, the patient lived on the 3rd floor and there was clutter and garbage scattered throughout. There was an insect/rodent infestation present. The patient was sleeping with a mattress on the floor with no sheets. Skilled OT was necessary to address deficits. The document failed to indicate that the physician was made aware of the living conditions of the patient. The clinical record failed to indicate that the physician was made aware that Patient 16 would not be receiving therapy as ordered. 9. The complete clinical record for Patient 11, start of care date 07/01/2021, was reviewed on 08/11/2021 and evidenced the following: A document titled “Home Health Certification and Plan of Care”, for the certification period from 07/01/2021-08/29/2021, indicated but was not limited to, “ ... SN (skilled nurse): 1wk1 (1 time a week for 1 week), 2wk8 (2 times a week for 8 weeks) ... Assessment of patient with Pressure ulcer of the left buttock, stage 2, pressure ulcer of right heel, stage 2, Pressure ulcer of right buttock, stage 2 ... SN to Perform wound care to R (right) and L (left) buttocks ... R heel ... SN to assess skin ... every visit ... “ A document titled “LPN/LVN (licensed practical nurse/licenses vocational nurse) Skilled Nursing Visit” dated 07/07/2021, signed by Employee D, indicated but was not limited to, “ ... dressing to R and L buttocks removed, areas cleansed with NS (normal saline) and patted dry bordered foam applied ... dressing to R heel removed Cleansed with NS, applied NS moistened prisma to wound bed, covered with dry gauze, wrapped in kerlix, secured with tape ... ” The document failed to evidence wound measurements, wound appearance, or condition of the wound bed and surrounding skin. A document titled “LPN/LVN Skilled Nursing Visit” dated 08/03/2021, signed by Employee L, indicated but was not limited to, “ ... Cleansed wound to R and L buttocks with NS, patted dry, applied hydrocolloid dressing to wound bed ... ” The document failed to evidence that wound care was done to the right heel. The document failed to evidence wound measurements, wound appearance, or condition of the wound bed and surrounding skin. 10. During an interview with the administrator and the alternate administrator on 08/12/2021 at 11:23 a.m., when notified that the RN notes provided wound measurements, but the LPN visit notes did not, the alternate administrator stated “When COVID began, we changed the policy. LPN’s don’t have to measure wounds.” When asked if the alternate administrator considered LPN’s skilled nurses, as the plan of care contains orders for a skilled nurse to change wound dressings and assess skin, the alternate administrator stated, “LPN’s aren’t obligated to measure wounds.” An updated wound measurement policy was requested, but not provided by the agency.

Advise the patient of discharge for cause CFR(s): 484.50(d)(5)(i) (i) Advise the patient, representative (if any), the physician(s) or allowed practitioner(s), issuing orders for the home health plan of care, and the patient's primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) that a discharge for cause is being considered; This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to notify in advance a discharge for cause was being considered for 2 of 5 closed records. (Patient 13 & Patient 16) 4. The complete clinical record for Patient 16, start of care date 02/13/2021, was reviewed on 08/10/2021 and evidenced the following: A 02/16/2021 document, signed by Employee H, titled Missed Visit Form (PTA Visit) was faxed to Non-employee D on 02/18/2021. The document indicated, but was not limited to, “PTA (physical therapy assistant) has called Pt (patient) 3 days in a row without answer. In person attempt made ... Apartment building door was locked (at 4:30 p.m.) with a sign posted that it is locked daily at 4:00 p.m. ... Further phone and in person attempts to be made this week ... “ A 02/17/2021 document, signed by Employee I, titled Patient Communication. The document indicated, but was not limited to, “SN (skilled nurse) received phone call from pt (patient) emergency contact ... expressed concern that ... unable to reach pt for the last 24-48 hours ... Voiced concern as homecare staff had been unable to reach him via phone or knocking ... SN notified supervisors at this time ... pt slurring ... words … hadn’t eaten and was walking … to get food ... SN informed emergency contact ... would be contacting authorities to do a welfare check ... SN notified 911 at this time ... ” The document failed to evidence that the physician was made aware of changes in the patient’s status or the need for emergency services. A 2/18/2021 document titled PTA Visit, signed by Employee H, indicated during the PTA (physical therapy assistant) visit, the PTA documented the patient declined all intervention except laying supine due to weeping from a liver laceration wound. The PTA documented that the patient did participate in 4 different exercises. The PTA documented that the patient needed food and water; the PTA reached the emergency contact who stated they were unable to provide food for the patient. The PTA stated the patient was supposed to be changing his liver bandage every day but ran out of pads and has been using a towel. The PTA noted that the agency was informed of patient’s current situation. The document failed to indicate that the physician was made aware of the status of the patient’s living conditions, the patient’s wound status, or the need for wound care and wound care supplies. A 02/19/2021 document titled OT (occupational therapist) Evaluation, signed by Employee J, indicated that the patient had no assistance, the patient lived on the 3rd floor and there was clutter and garbage scattered throughout. There was an insect/rodent infestation present. The patient was sleeping with a mattress on the floor with no sheets. The patient had poor judgement and safety awareness. Skilled OT was necessary to address deficits. A 02/19/2021 document titled SN (skilled nurse) Evaluation, signed by Employee I, indicated that nurse was visiting the patient for evaluation assessment, vital signs, and wound assessment. The document indicated, but was not limited to, “ ... Psychosocial WNL (within normal limits) ... alert and forgetful ... Stated PT was not here this day ... SN had spoke with therapist and pt (patient) while (therapist) was in home ... Denied SN evaluating wound ... had a paper towel over it ... Demonstrated Medication Compliance: Yes ... ” A 02/22/2021 document titled Discharge Summary indicated, but was not limited to, "Physician notified of discharge prior to discharge date, per agency policy & timeline ... Pt requires extensive assistance to complete ADL's and transfers ... Pt advised to go to the ER due to concerns regarding drainage form wound site and elevated temp ... had falls since being home; 2 of which occurred this day ... yellow, thick drainage from puncture site ... no food noted in home; pt stated he had food last Thursday ... Pt determined to not be safe at home and is non-compliant with SN care ... ". A 02/22/2021 document, signed by Employee E, titled Patient communication indicated, but was not limited to, “SN called MD (medical doctor) office to notify of patient noncompliant with care and meds. Advise patient to go to ER.” The clinical record for Patient 16 failed to evidence that the patient and physician were notified in advance, with a 15-day notice, that the patient was being discharged from the agency, or that a transfer to another agency was arranged. 5. During an interview on 08/09/2021 at 12:15 p.m. with administrator and alternate administrator, when asked how patient noncompliance was addressed, the alternate administrator stated, “It’s a case-by-case situation. We would involve the physician or family if it wasn’t improving. After 3 consecutive missed visits, we would send out a 30-day discharge notice.” 6. During an interview on 8/16/2021 at 3:43 p.m. with the administrator and alternator administrator, when informed there is no documentation of the medical doctor being notified the patient hadn't eaten in days, appeared neglected, and was acutely ill, the administrator stated the physician would receive a copy of the discharge summary when the summary was ready. The alternate administrator stated “ ... I feel like we did everything we could have ... ” Findings include: 1. A policy titled “Patient Rights and Responsibilities” was provided by the administrator on 08/09/2021. The policy indicated, but was not limited to, “7. You have the right to expect the agency to have the proper resources to render safe care ... If the agency is unable to do so, you will be referred elsewhere unless a more suitable provider is not available, in which case ... will be informed of the agency’s limitations and lack of suitable alternate arrangements before care is initiated ... 13. You have a right to receive all services outlined in the Plan of Care ... 20. You have the right to be informed of anticipated termination of services ... in writing and verbally before services are to stop and with reasonable time ... Patient Rights Regarding Transfer and Discharge of Services ... 1. The transfer or discharge is necessary for the patient’s welfare ... the HHA can no longer meet the patient’s needs ... The HHA must arrange a safe and appropriate transfer to other care entities ... The HHA must do the following before it discharges a patient ... a. Advise the patient ... physician(s) issuing orders or the home health plan of care ... that a discharge is being considered; b. Make efforts to resolve the problem(s) presented ... c. Provide the patient ... with contact information for other agencies or providers ... d. Document the problem(s) and efforts made to resolve the problem ...” 2. 1. A document titled "Patient Discharge Process" was provided by the alternate administrator on 8/10/2021 at 10:00 a.m. The document indicated but was not limited to; "Agency staff will provide the patient with a 15-day notification of the impending discharge ... Upon discharge to self-care, the patient will receive verbal/written information regarding community services, medication use, any procedures/treatments to be performed, and follow-up visits for physician care ... To avoid charges of 'abandonment' at the time of discharge agency documentation will include the following: a. Evidence that the decision was not made unilaterally. The patient, family, and the physician participated in the decision to discharge the patient from the agency. b. Evidence that the patient no longer qualifies for home care services. c. If there are unmet needs and the agency is no longer able to meet those needs documentation that appropriate notice was given (verbal and written) and referrals made as indicated." 3. The complete clinical record for patient 13 was reviewed on 8/10/2021 and evidenced the following: A document titled "Home Health Change of Care Notice (HHCCN) indicated that starting on 6/11/2021 the agency would discharge the patient if they did not have a face-to-face visit with a physician within 30 days of admission due to insurance nonpayment. The document stated, "Your doctor's orders for your home care have changed." The HHCCN was signed on admission 5/13/2021 prior to care being delivered and prior to any physician changes having occurred. A document titled "Patient Communication" dated 5/27/2021 signed by employee E, Office Manager, indicated but was not limited to "Spoke with patients mother as well as patient. Patient has not showed up for past 2 md (medical doctor) appts (appointments) that was scheduled. Patient has an appt set up for 6/10/21 and was told to make sure he makes the appointment." A document titled "Patient Communication" dated 6/10/2021 signed by employee E, Office Manager, indicated, but was not limited to "Md office called to inform that patient missed F2F appt this date. Could not get him rescheduled by 6/11/2021. Called and informed patients mother and patient that services would be stopped effective 6/11/21 due to not showing up for F2F." A document titled "Discharge Summary" dated 6/11/2021 signed by employee F, Registered Nurse. "The document indicated, but was not limited to, "Reason for discharge ... Noncompliant ... Information Provided for Continuing Needs/Specific Discharge Instructions? ..."The RN failed to document who the information was provided to on the discharge assessment. The agency failed to provide a 15-day discharge notice, failed to identify barriers and implement interventions for non-compliance, and failed to notify the physician prior to the discharge date a discharge for cause was being considered for patient 13. During an interview on 8/12/2021, the administrator stated the regulations allow for discharge without notice if they are unsafe and needed extended care and the patient was a danger to himself.

Make efforts to resolve the problem(s) CFR(s): 484.50(d)(5)(ii) (ii) Make efforts to resolve the problem(s) presented by the patient's behavior, the behavior of other persons in the patient's home, or situation; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to make efforts to resolve the problem(s) presented by the patient's behavior or situation for 1 of 17 records reviewed. (Patient 16). Findings include: 1. A document titled RN Job Description indicated, but was not limited to, “ ... Reports significant changes in client status to physician ... in a timely manner consistent with client needs ... Maintains client records showing ... intervention, and evaluation ... ” 2. A policy titled "Care Plans" was provided by the administrator on 8/12/2021 at 10:37 a.m. The document indicated but was not limited to, "Each patient will have a care plan on file that addresses their identified needs and the agency's plan to respond to those needs ... the care plan shall be reviewed, evaluated, and revised ... based upon the patient's health status and/or environment ... Following the initial assessment ... interventions shall correspond to the problems identified ... c. A list of specific interventions with plans for implementation ... " 3. A policy titled “Patient Rights and Responsibilities” was provided by the administrator on 08/09/2021. The policy indicated, but was not limited to, “7. You have the right to expect the agency to have the proper resources to render safe care ... If the agency is unable to do so, you will be referred elsewhere unless a more suitable provider is not available, in which case ... will be informed of the agency’s limitations and lack of suitable alternate arrangements before care is initiated ... 13. You have a right to receive all services outlined in the Plan of Care ... 20. You have the right to be informed of anticipated termination of services ... in writing and verbally before services are to stop and with reasonable time ... Patient Rights Regarding: Transfer and Discharge of Services ... 1. The transfer or discharge is necessary for the patient’s welfare ... the HHA can no longer meet the patient’s needs ... The HHA must arrange a safe and appropriate transfer to other care entities ... The HHA must do the following before it discharges a patient ... a. Advise the patient ... physician(s) issuing orders or the home health plan of care ... that a discharge is being considered; b. Make efforts to resolve the problem(s) presented ... c. Provide the patient ... with contact information for other agencies or providers ... d. Document the problem(s) and efforts made to resolve the problem ... ” 4. The complete clinical record for Patient 16, start of care date 02/13/2021, was reviewed on 08/10/2021 and evidenced the following: A document dated 02/13/2021, signed by Employee G, titled Physician Order, indicated but was not limited to, “This patient has been admitted to skilled home health services for the following disciplines: PT/OT/SN ... Skilled Nursing warranted due to active surgical wound ... Physical therapy to evaluate and treat at 1x1w (1 time a week for one week), 2x4w (2 times a week for 4 weeks), 1 times per week for 4 weeks ... Fall prevention ... Assess environment for personal safety hazards ... Gait and balance exercises ... ” The document failed to included orders for a home health aide. The clinical record failed to evidence orders for specific interventions, frequency, or duration for skilled nursing, orders for wound care, and orders for occupational therapy. A 02/17/2021 document, signed by Employee I, titled Patient Communication. The document indicated, but was not limited to, “SN (skilled nurse) received phone call from pt (patient) emergency contact ... expressed concern that ... unable to reach pt for the last 24-48 hours ... Voiced concern as homecare staff had been unable to reach him via phone or knocking ... SN notified supervisors at this time ... pt slurring ... words … hadn’t eaten and was walking … to get food ... SN informed emergency contact ... would be contacting authorities to do a welfare check ... SN notified 911 at this time ... ” The document failed to evidence that the physician was made aware of changes in the patient’s status in a timely manner, or the need for emergency services. The clinical record failed to evidence an outcome after emergency services were summoned. A 2/18/2021 document titled PTA Visit indicated that during the PTA (physical therapy assistant) visit, the PTA documented the patient declined all intervention except laying supine due to weeping from a liver laceration wound. The PTA documented the patient needed food and water; the PTA reached the emergency contact who stated they were unable to provide food for the patient. The PTA stated the patient was supposed to be changing his liver bandage every day but ran out of pads and has been using a towel. The document indicated that the PTA notified their supervisor but failed to evidence further interventions or outcomes. A 02/19/2021 document titled OT (occupational therapist) Evaluation indicated that the patient had no assistance, the patient lived on the 3rd floor and there was clutter and garbage scattered throughout. There was an insect/rodent infestation present. The patient was sleeping with a mattress on the floor with no sheets. The OT documented that the patient was educated on ordering food via their smartphone, but patient declined. The document failed to indicate that the physician was made aware of the living conditions of the patient. A 02/19/2021 document titled SN (skilled nurse) Evaluation, signed by Employee I, indicated that nurse was visiting the patient for evaluation assessment, vital signs, and wound assessment. The document indicated, but was not limited to, “ ... Psychosocial WNL (within normal limits) ... alert and forgetful ... Stated PT was not here this day ... SN had spoke with therapist and pt (patient) while (therapist) was in home ... Denied SN evaluating wound ... had a paper towel over it ... Demonstrated Medication Compliance: Yes ... Reviewed medications, but the pt has no system to set meds up ... ”. A 02/22/2021 document titled Discharge Summary indicated, but was not limited to, "Physician notified of discharge prior to discharge date, per agency policy & timeline ... Pt requires extensive assistance to complete ADL's and transfers ... Pt advised to go to the ER due to concerns regarding drainage form wound site and elevated temp ... had falls since being home; 2 of which occurred this day ... yellow, thick drainage from puncture site ... no food noted in home; pt stated he had food last Thursday ... Pt determined to not be safe at home and is non-compliant with SN care ... ". A 02/22/2021 document, signed by Employee E, titled Patient communication indicated, but was not limited to, “SN called MD (medical doctor) office to notify of patient noncompliant with care and meds. Advise patient to go to ER.” The clinical record failed to evidence that any effort was made by the agency to address the insect/rodent infestation, to set the patient up with a meal delivery system, or to address the lack of wound care. The clinical record failed to evidence that the physician was made aware of the patient’s poor living conditions, inability to set up a medication system, or the worsening condition of the patient and the patient's wound. 5. During an interview with the administrator on 08/12/2021 at 11:23 a.m., when asked why the patient was discharged in the state they were, the administrator stated, “The patient was unsafe to be home alone.” When asked if the agency had a social worker or ever referred patients to a social worker, the administrator stated, “We would refer the patient to meals on wheels. We take on the role of social worker in that case.” 6. During an interview with the administrator and the alternate administrator on 08/16/2021 at 3:00 p.m., when the status of the patient on 02/22/2021 was reiterated, and the administrator and alternate administrator were asked if they thought adult protective services (APS) should have been called, the administrator stated, “ ... the police were called on 02/14 ... I mean, what can you do?” When asked again why APS wasn’t called, the alternate administrator stated, “The occupational therapist tried to teach the patient to order groceries online, but the patient declined. I feel like we did everything we could.”

Provide contact info other services CFR(s): 484.50(d)(5)(iii) (iii) Provide the patient and representative (if any), with contact information for other agencies or providers who may be able to provide care; and This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to provide contact information for other agencies or providers who may be able to provide care for 1 of 5 closed records reviewed. (Patient 16) Findings include: 1. A document titled "Patient Discharge Process" was provided by the alternate administrator on 8/10/2021 at 10:00 a.m. The document indicated but was not limited to; " ... Upon discharge to self-care, the patient will receive verbal/written information regarding community services, medication use, any procedures/treatment to be performed, and follow-up visits for physician care ..." 2. A policy titled "Patient Rights and Responsibilities" was provided by the administrator on 08/09/2021. The policy indicated, but was not limited to, "7. You have the right to expect the agency to have the proper resources to render safe care ... If the agency is unable to do so, you will be referred elsewhere unless a more suitable provider is not available, in which case ... will be informed of the agency's limitations and lack of suitable alternate arrangements before care is initiated ... 20. You have the right to be informed of anticipated termination of services ... in writing and verbally before services are to stop and with reasonable time ... Patient Rights Regarding: Transfer and Discharge of Services ... 1. The transfer or discharge is necessary for the patient's welfare ... The HHA must arrange a safe and appropriate transfer to other care entities ... The HHA must do the following before it discharges a patient ... c. Provide the patient ... with contact information for other agencies or providers ... " 3. The complete clinical record for Patient 16, start of care date 02/13/2021, was reviewed on 08/10/2021 and evidenced the following: A 02/22/2021 document titled Discharge Summary indicated, but was not limited to, "Physician notified of discharge prior to discharge date, per agency policy & timeline ... Pt requires extensive assistance to complete ADL's and transfers ... Disoriented, Forgetful ... Poor Home Environment, Impaired Decision Making ... Pt advised to go to the ER due to concerns regarding drainage form wound site and elevated temp ... had falls since being home; 2 of which occurred this day ... yellow, thick drainage from puncture site ... no food noted in home; pt stated he had food last Thursday ... Pt determined to not be safe at home and is non-compliant with SN care ... Patient remained in the community (without formal assistive services) ... ". The document failed to evidence that the agency arranged for a safe and appropriate transfer to another agency, and that the patient received information regarding community services or contact information for alternate home health agencies. 4. During an interview on 8/12/2021, the administrator stated the regulations allow for discharge without notice if they are unsafe and needed extended care and the patient was a danger to themselves.

Document efforts to resolve problems CFR(s): 484.50(d)(5)(iv) (iv) Document the problem(s) and efforts made to resolve the problem(s), and enter this documentation into its clinical records; This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to document efforts for resolving non-compliance for 2 of 2 patients discharged for non-compliance. (Patient 13 and Patient 16) 5. The complete clinical record for Patient 16, start of care date 02/13/2021, was reviewed on 08/10/2021 and evidenced the following: A 02/17/2021 document, signed by Employee I, titled Patient Communication. The document indicated, but was not limited to, “ ... pt slurring ... words … hadn’t eaten ... would be contacting authorities to do a welfare check ... SN notified 911 at this time ... ” The document failed to evidence that the physician was made aware of changes in the patient’s status or the need for emergency services. A 2/18/2021 document titled PTA Visit indicated that during the PTA (physical therapy assistant) visit, the PTA documented the patient declined all intervention except laying supine due to weeping from a liver laceration wound, and lack of wound care supplies. The document failed to evidence that the physician was made aware of the patient’s status, the lack of adequate wound care, or that the plan of care may need to be altered to address the patient's needs. A 02/22/2021 document titled Discharge Summary indicated, but was not limited to, "Physician notified of discharge prior to discharge date, per agency policy & timeline ... Pt requires extensive assistance to complete ADL's and transfers ... Pt advised to go to the ER due to concerns regarding drainage form wound site and elevated temp ... had falls since being home; 2 of which occurred this day ... yellow, thick drainage from puncture site ... no food noted in home; pt stated he had food last Thursday ... Pt determined to not be safe at home and is non-compliant with SN care ... ". The document failed to evidence that the physician was made aware of the poor living conditions or current condition of the patient. A 02/22/2021 document, signed by Employee E, titled Patient communication indicated, but was not limited to, “SN called MD (medical doctor) office to notify of patient noncompliant with care ... advise patient to go to ER.” The document failed to evidence that the physician was made aware of the patients poor living conditions or the safety of the patient and why the patient was advised to go to the emergency room. 6. The clinical record failed to evidence efforts made to address any non-compliance from the patient, or attempts to alter the plan of care to meet the needs of the patient. Findings include: 1. A policy titled "Care Plans" was received on 8/10/2021 at 10:00 a.m. by the alternate administrator. The document indicated, but was not limited to "a Care Plan shall be developed ... interventions shall correspond to the problems identified ... the Care Plan shall include ... a list of specific interventions with plans for implementation ..." 2. A policy titled "Clinical Documentation" was provided by the administrator on 8/12/2021 at 10:37 a.m. by the alternate administrator. The document indicated but was not limited to, "Purpose To ensure that there is an accurate record of the services provided, patient response, and ongoing need for care. To document conformance with the Plan of Care, modifications to the plan, interdisciplinary involvement." 3. The complete clinical record for patient 13, the start of care 5/13/2021, was reviewed on 8/11/2021. The record evidenced the following: A document titled "Home Health Certification and Plan of Care" indicated but was not limited to, a diagnosis of neuromuscular dysfunction of the bladder, unspecified and paraplegia. The document included the following orders and treatments, " SN (skilled nursing) 1x9 (1 time a week times 9 weeks) ... Patient has or is at risk for having pressure ulcers-risk for infection ... SN to assess skin for breakdown every visit ..." A document titled "Patient Communication" dated 5/20/2021 signed by employee E, Office Manager, indicated, but was not limited to "Spoke with patients mother Teresa and informed her that patient needed set up with his PCP (primary care physician) by 6/11/2021." A document titled "Patient Communication" dated 5/27/2021 signed by employee E, Office Manager, indicated but was not limited to "Spoke with patients mother as well as patient. Patient has not showed up for past 2 md (medical doctor) appts (appointments) that was scheduled. Patient has an appt set up for 6/10/21 and was told to make sure he makes the appointment." A document titled "Patient Communication" dated 6/10/2021 signed by employee E, Office Manager, that indicated, but was not limited to "Md office called to inform that patient missed F2F appt this date. Could not get him rescheduled by 6/11/2021. Called and informed patients mother and patient that services would be stopped effective 6/11/21 due to not showing up for F2F." A document titled "Discharge Summary" dated for 6/11/2021 signed by employee F, Registered Nurse. "The document indicated, but was not limited to, "Reason for discharge ... Noncompliant ... Information Provided for Continuing Needs/Specific Discharge Instructions? ..." 4. During an interview on 8/16/2021 at 2:00 p.m. when asked if the agency had to try to identify barriers to the patient missing their MD appointments such as transportation being a paraplegic or if any alternatives had been offered such as telehealth the administrator stated that if the barriers aren't documented in the communication note then there were no barriers patient was just non-compliant.

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: An Immediate Jeopardy related to §484.60 Care Planning, Coordination of Services, and Quality of Care was identified and announced on 8/13/2021 at 11:50 a.m. The immediate jeopardy was unremoved at survey exit date of 8/17/2021. The immediate jeopardy began on 2/13/2021 when the agency accepted a patient (patient 16) with a referral signed by a physician for skilled nursing, physical therapy, occupational therapy, and home health aide services. The patient had a diagnosis of major laceration of the liver, fracture of the lumbar vertebra, multiple fractures of the ribs, and fusion of the spine/lumbosacral region. The agency's physical therapist performed an initial assessment on the patient. The comprehensive assessment indicated the patient had abnormal weight loss, weakness, and severe protein-calorie malnutrition. The patient was at high nutritional risk and had an inadequate diet. The patient lived alone in poor, unstable living conditions. The patient had a mattress on the floor due to a bug infestation. The agency failed to follow its own policy when identifying an insect infestation. The clinical record failed to evidence professional treatment was sought. On 02/22/2021 the patient was discharged from the agency without a 15-day notice. During the discharge visit, the patient was noted to be found down in the hallway by an unknown male who stated the patient had fallen twice. The patient was noted to have a temp of 102.2, thick yellow drainage coming from puncture wound, had not eaten since the prior Thursday (this was the following Monday). The home was still infested with bugs. The patient was advised to go the the ER (emergency room), but declined. The agency left the patient in poor condition with no receiving agency or caregiver and with a high potential for death. A second patient (Patient 13) was admitted on 5/13/2021. Patient 13 was a paraplegic with a history of right glute/hip wounds. The comprehensive assessment indicated the patient had no active wounds or open areas. On 5/13/2021 the physical therapy evaluation indicated the patient had a history of right glute/hip wounds. Skilled nursing visit notes for 5/20/2021 and 5/24/2021 indicated the patient had no open wounds. On 6/1/21 the patient went to the emergency room. The documentation from the emergency room note signed by the medical provider indicated the patient had a 4cm by 5cm ulceration with central eschar on the proximal posterior right thigh. The wound culture evidenced heavy growth of Proteus mirabilis, heavy growth of Pseudomonas aeruginoa, and heavy growth of Providencia stuartii. The patient received IV (intravenous) antibiotics and was prescribed oral antibiotics for home. A skilled nurse visit note dated 6/2/2021 indicated the patient had no medication changes, a skin assessment was performed, and the patient had no wounds. On 6/11/2021 the patient was discharged for non-compliance and not having a face-to-face. The clinical record evidenced a face-to-face on 4/27/2021. On 6/22/2021 the patient returned to the emergency room and was admitted for multiple right lower extremity wounds and the wound to the right hip had increased in size to golf ball size. The patient was admitted for sepsis related to an unknown organism. The right heel had purulent drainage and a foul smell. Complainant stated patient was found with maggots in the wound and taken to the emergency room on this date and there is a high likelihood the patient will be losing his right foot. The agency failures resulted in 2 of 2 patients discharged without notice suffering adverse outcomes. (Patient 13 and 16) Based on observation, record review, and interview, the agency failed to follow their own policies and procedures to prevent adverse outcomes for 2 of 2 patients who were not assessed appropriately and were discharged without notice and without referring to another agency (See G0570); failed to ensure that patients received the home health services that were written in the Plan of Care for 2 of 17 records reviewed (See G0572); failed to address changes in the patient's discharge plan and document the communication in the clinical record for 2 of 5 discharged clinical records reviewed (See G0598); failed to integrate all orders in the plan of care and failed to assure coordination of care for all services required for 2 of 5 discharged patients reviewed (See G0604); and failed to coordinate care for 2 of 2 patients discharged for noncompliance (See G0608). The cumulative effect of this systemic problem resulted in the agency being out of compliance with 484.60 Condition of participation: Care planning, coordination of services, and quality of care. 8. The complete clinical record for patient 13, start of care 5/13/2021, was reviewed on 8/11/2021. The record evidenced the following: A document titled "Home Health Certification and Plan of Care" indicated but was not limited to, a diagnosis of neuromuscular dysfunction of the bladder, unspecified and paraplegia. The document included the following orders and treatments, " SN 1x9 (1 time a week times 9 weeks) ... Patient has or is at risk for having pressure ulcers-risk for infection ... SN to assess skin for breakdown every visit ..." A document titled, "RN [registered nurse] -Skilled Nursing Visit" for 5/20/2021 signed by employee I, Registered Nurse. The document indicated but was not limited to, "Skin ... WNL (within normal limits) ... A document titled "Patient Communication" dated 5/20/2021 signed by employee E, Office Manager, indicated, but was not limited to "Spoke with patients mother and informed her that patient needed set up with his PCP (primary care physician) by 6/11/2021." A document titled, "RN-Skilled Nursing Visit" for 5/24/2021 signed by employee C, Registered Nurse. The document indicated but was not limited to, "Skin ... Dry ... Warm ... Good/Elastic ... Assessment ... provided [sic] has no open areas or wounds at this time ..." A document titled "Patient Communication" dated 5/27/2021 signed by employee E, Office Manager, indicated but was not limited to "Spoke with patients mother as well as patient. Patient has not shown up for the past 2 MD (medical doctor) appts (appointments) that was scheduled. Patient has an appt set up for 6/10/21 and was told to make sure he makes the appointment." A document titled "Patient Communication" dated 6/10/2021 signed by employee E, Office Manager, that indicated, but was not limited to "Md [medical doctor] office called to inform that patient missed F2F [face to face] appt this date. Could not get him rescheduled by 6/11/2021. Called and informed patients, mother, and patient, that services would be stopped effective 6/11/21 due to not showing up for F2F." A document titled, "LPN/LVN-Skilled Nursing Visit" for 6/02/2021 signed by employee D, Licensed Practical Nurse. The document indicated but was not limited to, "Skin ... Dry ... Warm ... Good/Elastic ... Assessment ... " A document titled "Discharge Summary" dated for 6/11/2021 signed by employee F, Registered Nurse. "The document indicated, but was not limited to, "Reason for discharge ... Noncompliant ... Information Provided for Continuing Needs/Specific Discharge Instructions? ..."The RN failed to document who the information was provided to on the discharge assessment. A document titled "F2F (face to face) Encounter" dated 4/27/2021. The document indicated but is not limited to, "Date of In-Person Visit: 04/27/2021" signed by Non-Employee G, Nurse Practitioner. 9. Hospitalization records for patient 13 were received on 8/13/2021 for patient 13. The records indicated but were not limited to an emergency room visit dated 6/1/2021. The clinical impression documented by the medical provider indicated an open wound, 4cm by 5cm ulceration with central eschar on the proximal posterior right thigh. The wound was cultured, and the results indicated evidenced heavy growth of Proteus mirabilis, heavy growth of Pseudomonas aeruginous, and heavy growth of Providencia stuartii. The patient received IV antibiotics and was prescribed oral antibiotics for home. 10. During an interview on 8/16/2021 the administrator stated the LPN (licensed practice nurse) who performed the visit on 6/2/2021, the day after the hospital admission, would have documented an ER visit had she known and that maybe she rolled the patient to one side, therefore, missing the wound. The administrator stated the patient also had a responsibility to report the visit and the agency can't take full responsibility when they didn't know. The patient was discharged with no wound care services or other receiving agencies. 11. Documentation from the personal services agency providing care for patient 13 received on 8/17/2021 evidenced a document titled "Incident Report" dated 5/27/2021 for patient 13 that indicated, but was not limited to, "I was cleaning him [patient 13] up and noticed a rash on the front right leg and a fluid pocket on the back of his right leg underneath his butt." The family was notified at 7:44 p.m. signed by non-employee A. A picture of the wound was attached. A second document titled "Activity" evidenced an entry from non-employee B stated the personal care agency was notified of emergency room admission on 6/2/2021 for patient 13 and that patient would receive oral antibiotics. The non-employee also documented non-employee A had reported that the wound had worsened. 12. Hospitalization records for patient 13 received on 8/13/2021 indicated the patient returned to the emergency room on 6/22/2021. The patient was admitted for "multiple right lower extremity wounds and the wound to the right hip had increased in size to golf ball size ... The right heel had purulent drainage and a foul smell." The patient was diagnosed with sepsis-related to an unknown organism. The right heel had purulent drainage and a foul smell. 13. During an interview on 8/11/2021 with the patient's caregiver, the caregiver stated patient 13 was found to have maggots in his wound on the right hip area and was potentially losing his right foot from wounds and infection found on the heel. An Immediate Jeopardy related to §484.60 Care Planning, Coordination of Services, and Quality of Care was identified and announced on 8/13/2021 at 11:50 a.m. The immediate jeopardy was unremoved at survey exit date of 8/17/2021. The immediate jeopardy began on 2/13/2021 when the agency accepted a patient (patient 16) with a referral signed by a physician for skilled nursing, physical therapy, occupational therapy, and home health aide services. The patient had a diagnosis of major laceration of the liver, fracture of the lumbar vertebra, multiple fractures of the ribs, and fusion of the spine/lumbosacral region. The agency's physical therapist performed an initial assessment on the patient. The comprehensive assessment indicated the patient had abnormal weight loss, weakness, and severe protein-calorie malnutrition. The patient was at high nutritional risk and had an inadequate diet. The patient lived alone in poor, unstable living conditions. The patient had a mattress on the floor due to a bug infestation. The agency failed to follow its own policy when identifying an insect infestation. The clinical record failed to evidence professional treatment was sought. On 02/22/2021 the patient was discharged from the agency without a 15-day notice. During the discharge visit, the patient was noted to be found down in the hallway by an unknown male who stated the patient had fallen twice. The patient was noted to have a temp of 102.2, thick yellow drainage coming from puncture wound, had not eaten since the prior Thursday (this was the following Monday). The home was still infested with bugs. The patient was advised to go the the ER (emergency room), but declined. The agency left the patient in poor condition with no receiving agency or caregiver and with a high potential for death. A second patient (Patient 13) was admitted on 5/13/2021. Patient 13 was a paraplegic with a history of right glute/hip wounds. The comprehensive assessment indicated the patient had no active wounds or open areas. On 5/13/2021 the physical therapy evaluation indicated the patient had a history of right glute/hip wounds. Skilled nursing visit notes for 5/20/2021 and 5/24/2021 indicated the patient had no open wounds. On 6/1/21 the patient went to the emergency room. The documentation from the emergency room note signed by the medical provider indicated the patient had a 4cm by 5cm ulceration with central eschar on the proximal posterior right thigh. The wound culture evidenced heavy growth of Proteus mirabilis, heavy growth of Pseudomonas aeruginoa, and heavy growth of Providencia stuartii. The patient received IV (intravenous) antibiotics and was prescribed oral antibiotics for home. A skilled nurse visit note dated 6/2/2021 indicated the patient had no medication changes, a skin assessment was performed, and the patient had no wounds. On 6/11/2021 the patient was discharged for non-compliance and not having a face-to-face. The clinical record evidenced a face-to-face on 4/27/2021. On 6/22/2021 the patient returned to the emergency room and was admitted for multiple right lower extremity wounds and the wound to the right hip had increased in size to golf ball size. The patient was admitted for sepsis related to an unknown organism. The right heel had purulent drainage and a foul smell. Complainant stated patient was found with maggots in the wound and taken to the emergency room on this date and there is a high likelihood the patient will be losing his right foot. The agency failures resulted in 2 of 2 patient's discharged without notice suffering adverse outcomes. (Patient 13 and 16) Based on record review and interview, the agency failed to follow their own policies and procedures to prevent adverse outcomes for 2 of 2 patients who were not assessed appropriately and were discharged without notice and without referring to another agency. (Patient 13 and 16) The cumulative effect of this systemic problem resulted in the agency being out of compliance with 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Findings include: 1. A policy titled "Care Plans" was provided by the administrator on 8/12/2021 at 10:37 a.m. The document indicated but was not limited to, "Each patient will have a care plan on file that addresses their identified needs and the agency's plan to respond to those needs ... the care plan shall be reviewed, evaluated, and revised ... based upon the patient's health status and/or environment ..." 2. A policy titled "Clinical Documentation" was provided the alternate administrator on 8/10/2021 at 10:00 am. The document indicated but was not limited to, "Telephone or other communication with patients, physicians, families, or other members of the health care team will be documented in clinical progress notes or other interagency communication form." 3. A policy titled "Standard Infection Control Procedures for Home Care" was provided by the administrator on 8/12/2021 at 10:37 a.m. The document indicated but was not limited to, "In the event of insect or rodent infestation noted by agency staff, the agency will be immediately notified, and the agency staff will begin making arrangements with the patient/family to seek professional treatment for the infestation ..." 4. A policy titled "Patient Discharge Process" was provided by Employee B on 08/10/2021 at 10:00 a.m. The document indicated, but was not limited to, "4 ... Agency staff will provide the patient with a 15 day notification of the impending discharge ... 8. Upon discharge to self-care, the patient will receive verbal/written information regarding community services, medication use, any procedures/treatments to be performed and follow-up visits for physician care. 9. To avoid charges of "abandonment" at the time of discharge agency documentation will include the following: a. Evidence that the decision was not made unilaterally. The patient, family, and physician participated in the decision to discharge patient from the agency. b. Evidence that the patient no longer qualifies for home care services. c. If there are unmet needs and the agency is no longer able to meet those needs, documentation will demonstrate that appropriate notice was given (verbal and written) and referrals made as indicated ... ". 5. The complete clinical record for Patient 16 was reviewed on 08/10/2021. The clinical record indicated, but was not limited to, the following: A document titled Physician's Telephone Order dated 02/12/2021 included orders to "Obtain home health to eval [evaluate] and treat. PT[physical therapy], OT [occupational therapy], NSG [nursing], HHA [home health aide]". A document titled Home Health Certification and Plan of Care for the certification period of 02/13/2021-02/22/2021. The document indicated, but was not limited to, "Mental Status: Oriented, agitated ... SN (skilled nurse): eval and tx (treat), PT: 1X1 (1 time a week for 1 week), 2X4 (2 times a week for 4 weeks), 1X4 (1 time a week for 4 weeks), OT: eval and treat ... Goals and Outcomes: The patient will be free from falls ... free from injury ... skin integrity will remain intact ... " The document failed to evidence any HHA orders. The clinical record failed to evidence documentation of notifying the physician the patient would not be receiving therapy services. A 02/13/2021 document titled OASIS-D1 Start of Care indicated, but was not limited to, "Inpatient Facility Diagnosis: a. fracture of lumbar vertebra b. major laceration of liver ... c. multiple fractures ... fusion of spine, lumbosacral region ... Other diagnosis ... protein-calorie malnutrition ... problems related to living alone ... Risk for Hospitalization ... 1-History of falls (2 or more falls- or any fall with an injury- in the past 12 months 2-Unintentional weight loss of a total of 10 pounds or more ... " A 2/18/2021 document titled PTA visit indicated during the PTA (physical therapy assistant) visit, the PTA documented the patient declined all intervention except laying supine due to weeping from a liver laceration wound. The PTA documented the patient needed food and water; the PTA reached the emergency contact who stated they were unable to provide food for the patient. The PTA stated the patient was supposed to be changing his liver bandage every day but ran out of pads and has been using a towel. A 2/19/2021 document titled SN Evaluation indicated that when the SN performed their initial evaluation, the SN stated the patient was forgetful. The patient stated that PT was not present on 2/19/2021 although the SN knew PT had visited that day. SN stated the patient had leftover Chinese food and stated the patient had no system to set up medications; the patient stated he wasn't interested in a system to set up medications. A 02/19/2021 document titled OT (occupational therapist) Evaluation indicated that the patient had no assistance, the patient lived on the 3rd floor and there was clutter and garbage scattered throughout. There was an insect/rodent infestation present. The patient was sleeping with a mattress on the floor with no sheets. Skilled OT was necessary to address deficits. A 02/22/2021 document titled Discharge Summary indicated, but was not limited to, "Physician notified of discharge prior to discharge date, per agency policy & timeline ... Pt [patient] requires extensive assistance to complete ADL's [activities of daily living] and transfers ... Emergency contact is a friend that lives in apt [apartment] complex; but not the same building. Pt uses walker, but continues to experience falls ... apartment in poor condition with bed bugs noted in chair at DC [discharge] visit ... Pt advised to go to the ER [emergency room] due to concerns regarding drainage from wound site and elevated temp [temperature] ... had falls since being home; 2 of which occurred this day ... yellow, thick drainage from puncture site ... Continued to work with therapy to work towards goals ... No food noted in home; pt stated he had food last Thursday ... Pt determined to not be safe at home and is noncompliant with SN care ... ". The patient was not discharged with appropriate notice. A 02/22/2021 document signed by Employee I titled OASIS-D1 Discharge indicated, but was not limited to, " ... Temp 102.2 ... Intensity of pain 4 ... Nutrition: Meals Prepared Appropriately, Diet Adequate ... Neurological: Disoriented, Forgetful ... Psychosocial: Poor Home Environment, Impaired Decision Making ... failure to perform usual ADL's ... inability to appropriately stop activities, jeopardizes safety through actions ... Emergent Care: at the time of or at any time since ... SOC ... assessment as the patient utilized a hospital emergency department? 0-No ... Response to Skilled Intervention: Verbalized Understanding 50% ... ". The SN found the patient in the hallway being escorted by an unknown male who informed the SN the patient had fallen twice, and he (the unknown male) had found the patient on the floor. The SN documented they advised the patient to go to the emergency room and that patient was not safe at home. A 02/22/2021 document titled Communication note signed by the SN states "SN called MD (medical doctor) office to notify patient non-compliant with care and meds. Advised patient to go to the ER." The agency failed to evidence documentation that the MD was notified of the patient's living conditions, falls, temperature, wound, rodent infestation, and recent falls. A 02/22/2021 physician order request for signature, that was not faxed until 2/23/2021, indicated the patient was seen for "SN for the the following interventions, assessment, V.S. (vital signs), oxygen saturation, and education. The outcome of this intervention led to pt (patient) dc (discharge) due to noncompliance." The patient was discharged with no other agency assuming care, an active rodent infestation, high fever, multiple falls, and potentially infected wound, all having a high potential for an adverse outcome of death. The agency failed to document interventions for noncompliance and the outcome of the interventions and failed to document barriers leading to non-compliance. 6. During an interview on 8/12/2021, the administrator stated the regulations allow for discharge without notice if they are unsafe and needed extended care and the patient was a danger to himself. 7. During an interview on 8/16/2021 at 3:43 p.m. with the administrator and alternator administrator, when asked if the patient's financial situation had been assessed, or if they had made a referral as the patient needed help and had no caregiver, the alternate administrator stated they had previously called adult protective services on other patients and the patient's families would get angry and call them (the agency) so the agency would leave it up to the physician. When informed there's no documentation of the medical doctor being notified the patient hadn't eaten in days, appeared neglected, and was acutely ill, the administrator stated the physician would receive a copy of the discharge summary when the summary was ready.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure that patient's received the home health services that were written in the Plan of Care for 2 of 17 records reviewed. (Patient 13 and 16) 8. The complete clinical record for patient 13, the start of care 5/13/2021, was reviewed on 8/11/2021. The record evidenced the following: A document titled "Home Health Certification and Plan of Care" indicated but was not limited to, a diagnosis of neuromuscular dysfunction of the bladder, unspecified and paraplegia. The document included the following orders and treatments, " SN (skilled nursing) 1x9 (1 time a week times 9 weeks) ... Patient has or is at risk for having pressure ulcers-risk for infection ... SN to assess skin for breakdown every visit ..." A document titled, "RN-Skilled Nursing Visit" for 5/20/2021 signed by employee I, Registered Nurse. The document indicated but was not limited to, "Skin ... WNL (within normal limits) ... A document titled "Patient Communication" dated 5/20/2021 signed by employee E, Office Manager, indicated, but was not limited to "Spoke with patients mother Teresa and informed her that patient needed set up with his PCP (primary care physician) by 6/11/2021." A document titled, "RN-Skilled Nursing Visit" for 5/24/2021 signed by employee C, Registered Nurse. The document indicated but was not limited to, "Skin ... Dry ... Warm ... Good/Elastic ... Assessment ... provided [sic] has no open areas or wounds at this time ..." A document titled "Patient Communication" dated 5/27/2021 signed by employee E, Office Manager, indicated but was not limited to "Spoke with patients mother as well as patient. Patient has not shown up for the past 2 MD (medical doctor) appts (appointments) that was scheduled. Patient has an appt set up for 6/10/21 and was told to make sure he makes the appointment." A document titled "Patient Communication" dated 6/10/2021 signed by employee E, Office Manager, indicated but was not limited to "Md office called to inform that patient missed F2F appt this date. Could not get him rescheduled by 6/11/2021. Called and informed patients, mother, and patient, that services would be stopped effective 6/11/21 due to not showing up for F2F." A document titled, "LPN/LVN-Skilled Nursing Visit" for 6/02/2021 signed by employee D, Licensed Practical Nurse. The document indicated but was not limited to, "Skin ... Dry ... Warm ... Good/Elastic ... Assessment ... " A document titled "Discharge Summary" dated for 6/11/2021 signed by employee F, Registered Nurse. "The document indicated, but was not limited to, "Reason for discharge ... Noncompliant ... Information Provided for Continuing Needs/Specific Discharge Instructions? ..."The RN failed to document who the information was provided to on the discharge assessment. A document titled "F2F (face to face) Encounter" dated 4/27/2021. The document indicated but is not limited to, "Date of In-Person Visit: 04/27/2021" signed by Non-Employee G, Nurse Practitioner. 9. Hospitalization records for patient 13 were received on 8/13/2021 for patient 13. The records indicated but were not limited to an emergency room visit dated 6/1/2021. The clinical impression documented by the medical provider indicated an open wound, 4cm by 5cm ulceration with central eschar on the proximal posterior right thigh. The wound was cultured, and the results indicated evidenced heavy growth of Proteus mirabilis, heavy growth of Pseudomonas aeruginous, and heavy growth of Providencia stuartii. The patient received IV antibiotics and was prescribed oral antibiotics for home. 10. During an interview on 8/16/2021 the administrator stated the LPN (licensed practice nurse) who performed the visit on 6/2/202,1 the day after the hospital admission, would have documented an ER visit had she known and that maybe she rolled the patient to one side, therefore, missing the wound. The administrator stated the patient also had a responsibility to report the visit and the agency can't take full responsibility when they didn't know. The patient was discharged with no wound care services or other receiving agencies. 11. Documentation from the personal services agency providing care for patient 13 received on 8/17/2021 evidenced a document titled "Incident Report" dated 5/27/2021 for patient 13 that indicated, but was not limited to, "I was cleaning him [patient 13] up and noticed a rash on the front right leg and a fluid pocket on the back of his right leg underneath his butt." The family was notified at 7:44 p.m. signed by non-employee A. A picture of the wound was attached. A second document titled "Activity" evidenced an entry from non-employee B stated the personal care agency was notified of emergency room admission on 6/2/2021 for patient 13 and that patient would receive oral antibiotics. The non-employee also documented non-employee A had reported that the wound had worsened. 12. Hospitalization records for patient 13 received on 8/13/2021 indicated the patient returned to the emergency room on 6/22/2021. The patient was admitted for "multiple right lower extremity wounds and the wound to the right hip had increased in size to golf ball size ... The right heel had purulent drainage and a foul smell." The patient was diagnosed with sepsis-related to an unknown organism. The right heel had purulent drainage and a foul smell. 13. During an interview on 8/11/2021 with the patient's caregiver, the caregiver stated patient 13 was found to have maggots in his wound on the right hip area and was potentially losing his right foot from wounds and infection found on the heel. Findings include: 1. A policy titled "Care Plans" was provided by the administrator on 8/12/2021 at 10:37 a.m. The document indicated but was not limited to, "Each patient will have a care plan on file that addresses their identified needs and the agency's plan to respond to those needs ... the care plan shall be reviewed, evaluated, and revised ... based upon the patient's health status and/or environment ... Following the initial assessment ... interventions shall correspond to the problems identified ... c. A list of specific interventions with plans for implementation ... " 2. A policy titled “Patient Rights and Responsibilities” was provided by the administrator on 08/09/2021. The policy indicated, but was not limited to, “7. You have the right to expect the agency to have the proper resources to render safe care ...13. You have a right to receive all services outlined in the Plan of Care ... ” 3. The complete clinical record for Patient 16 was reviewed on 08/10/2021. The clinical record indicated, but was not limited to, the following: A document titled Home Health Certification and Plan of Care for the certification period of 02/13/2021-02/22/2021. The document indicated, but was not limited to, "Mental Status: Oriented, agitated ... SN (skilled nurse): eval and tx (treat), PT: 1X1 (1 time a week for 1 week), 2X4 (2 times a week for 4 weeks), 1X4 (1 time a week for 4 weeks), OT: eval and treat ... Goals and Outcomes: The patient will be free from falls ... free from injury ... skin integrity will remain intact ... " The document failed to include orders for a home health aide, specific orders for wound care, frequency, and duration of visits for skilled nursing, and orders for OT. A 2/19/2021 document titled SN Evaluation indicated that when the SN performed their initial evaluation, the SN stated the patient was forgetful. The patient stated that PT was not present on 2/19/2021 although the SN knew PT had visited that day. SN stated the patient had leftover Chinese food and stated the patient had no system to set up medications; the patient stated he wasn't interested in a system to set up medications. The document failed to evidence any efforts to address the needs of the patient to ensure that the patient was receiving the medications ordered and had access to adequate food. A 02/19/2021 document titled OT (occupational therapist) Evaluation indicated that the patient had no assistance, the patient lived on the 3rd floor and there was clutter and garbage scattered throughout. There was an insect/rodent infestation present. The patient was sleeping with a mattress on the floor with no sheets. Skilled OT was necessary to address deficits. The document failed to indicate that the physician was made aware of the living conditions of the patient. The clinical record failed to evidence that the patient would not be receiving therapy services as ordered in the Plan of Care. A 02/22/2021 document titled Discharge Summary indicated, but was not limited to, "Physician notified of discharge prior to discharge date, per agency policy & timeline ... Pt [patient] requires extensive assistance to complete ADL's [activities of daily living] and transfers ... Emergency contact is a friend that lives in apt [apartment] complex; but not the same building. Pt uses walker, but continues to experience falls ... apartment in poor condition with bed bugs noted in chair at DC [discharge] visit ... Pt advised to go to the ER [emergency room] due to concerns regarding drainage from wound site and elevated temp [temperature] ... had falls since being home; 2 of which occurred this day ... yellow, thick drainage from puncture site ... Continued to work with therapy to work towards goals ... No food noted in home; pt stated he had food last Thursday ... Pt determined to not be safe at home and is noncompliant with SN care ... ". A 02/22/2021 document titled Communication note signed by the SN states "SN called MD (medical doctor) office to notify patient non-compliant with care and meds. Advised patient to go to the ER." The agency failed to evidence documentation that the MD was notified of the patient's living conditions, falls, temperature, wound status, rodent infestation, and recent falls. 4. The agency failed to document interventions for noncompliance and the outcome of the interventions and failed to document barriers leading to non-compliance. The patient was discharged with no other agency assuming care, an active rodent infestation, high fever, multiple falls, and potentially infected wound, all having a high potential for an adverse outcome of death.

Discharge plans communication CFR(s): 484.60(c)(3)(ii) (ii) Any revisions related to plans for the patient's discharge must be communicated to the patient, representative, caregiver, all physicians or allowed practitioner's issuing orders for the HHA plan of care, and the patient's primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any). This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to address changes in the patient's discharge plan and document the communication in the clinical record for 2 of 5 discharged clinical records reviewed. (Patient 13 and Patient 16) 8. The complete clinical record for Patient 16, start of care 02/13/2021, was reviewed on 08/10/2021 and evidenced the following: A document dated 02/11/2021, signed by Non-employee C on 02/12/2021, titled F2F (Face 2 Face). The document indicated, but was not limited to, “ … has two medications that require a prescription, Klonopin (used to treat seizures, panic disorder and anxiety) and Oxycodone (used to treat moderate to severe pain) … Home Health Services PT (physical therapy), OT (occupational therapy), NSG (nursing), HHA (home health aide) ... medically necessary due to potential re-hospitalization, debility (weakness), lumbar fractures/ S/P (status/post) Lumbar spine fusion L1-4, Gait abnormality. Severe protein calorie malnutrition ... Plan Note .... Laceration of liver ... Neuropathy (dysfunction of one or more peripheral nerves, causing numbness or weakness), anxiety disorder, acute posthemorrhagic anemia ... Abnormal weight loss ... ” A document dated 02/12/2021, signed by Employee A, titled Physician Verbal Orders for Hoosier Homecare Services; Order Type-Request for Order. The document included a request for an order for PT (physical therapy) to evaluate and treat as indicated. The document was signed by Non-employee D on 02/15/2021. A document dated 02/13/2021, signed by Employee G, titled Physician Order, indicated but was not limited to, “This patient has been admitted to skilled home health services for the following disciplines: PT/OT/SN ... Skilled Nursing warranted due to active surgical wound ... Physical therapy to evaluate and treat at 1x1w (1 time a week for one week), 2x4w (2 times a week for 4 weeks), 1 times per week for 4 weeks … Fall prevention … Assess environment for personal safety hazards … Gait and balance exercises ... “ The document failed to included orders for a home health aide. The document was faxed to Non-employee D on 02/17/2021. The document was signed by Non-employee D and returned to the agency on 02/24/2021, two days after the patient was discharged from the agency. A 02/16/2021 document, signed by Employee H, titled Missed Visit Form (PTA Visit) was faxed to Non-employee D on 02/18/2021. The document indicated, but was not limited to, “PTA (physical therapy assistant) has called Pt (patient) 3 days in a row without answer. In person attempt made ... Apartment building door was locked with a sign posted that it is locked daily at 4:00 p.m. ... Further phone and in person attempts to be made this week. A 02/17/2021 document, signed by Employee I, titled Patient Communication. The document indicated, but was not limited to, “SN (skilled nurse) received phone call from pt (patient) emergency contact ... expressed concern that ... unable to reach pt for the last 24-48 hours ... Voiced concern as homecare staff had been unable to reach him via phone or knocking ... SN notified supervisors at this time ... pt slurring ... words … hadn’t eaten and was walking … to get food ... SN informed emergency contact ... would be contacting authorities to do a welfare check ... SN notified 911 at this time ... ” A 2/18/2021 document titled PTA visit indicated during the PTA (physical therapy assistant) visit, the PTA documented the patient declined all intervention except laying supine due to weeping from a liver laceration wound. The PTA documented the patient needed food and water; the PTA reached the emergency contact who stated they were unable to provide food for the patient. The PTA stated the patient was supposed to be changing his liver bandage every day but ran out of pads and has been using a towel. The document failed to indicate that they physician was made aware of the status of the patient’s wound, or the need for wound care and wound care supplies. A document titled Home Health Certification and Plan of Care for the certification period of 02/13/2021-02/22/2021. The document indicated, but was not limited to, "Mental Status: Oriented, agitated ... SN: eval and tx, PT: 1X1 (1 time a week for 1 week), 2X4 (2 times a week for 4weeks), 1X4 (1 time a week for 4 weeks), OT: eval and treat ... Goals and Outcomes: The patient will be free from falls ... free from injury ... skin integrity will remain intact ... " The document failed to evidence any home health aide orders. The clinical record failed to evidence orders for specific interventions, frequency, or duration for skilled nursing, orders for wound care, and orders for occupational therapy. The clinical record failed to evidence documentation of notifying the physician the patient would not be receiving therapy services. A 02/19/2021 document titled OT (occupational therapist) Evaluation indicated that the patient had no assistance, the patient lived on the 3rd floor and there was clutter and garbage scattered throughout. There was an insect/rodent infestation present. The patient was sleeping with a mattress on the floor with no sheets. Skilled OT was necessary to address deficits. A 2/19/2021 document titled SN Evaluation indicated that when the SN performed their initial evaluation, the SN stated the patient was forgetful. The patient stated that PT was not present on 2/19/2021 although the SN knew PT had visited that day. SN stated the patient had leftover Chinese food and stated the patient had no system to set up medications; the patient stated he wasn't interested in a system to set up medications. A 02/22/2021 document titled Discharge Summary indicated, but was not limited to, "Physician notified of discharge prior to discharge date, per agency policy & timeline ... Pt requires extensive assistance to complete ADL's and transfers ... Emergency contact is a friend that lives in apt complex; but not the same building. Pt uses walker, but continues to experience falls ... apartment in poor condition with bed bugs noted in chair at DC visit ... Pt advised to go to the ER due to concerns regarding drainage form wound site and elevated temp ... had falls since being home; 2 of which occurred this day ... yellow, thick drainage from puncture site ... Continued to work with therapy to work towards goals ... No food noted in home; pt stated he had food last Thursday ... Pt determined to not be safe at home and is non-compliant with SN care ... ". The patient was not discharged with appropriate notice. A 02/22/2021 document, signed by Employee E, titled Patient communication indicated, but was not limited to, “SN called MD (medical doctor) office to notify of patient noncompliant with care and meds. Advise patient to go to ER.” The document failed to indicate that the patient was being discharged from the agency. A 02/22/2021 document, signed by Employee E, titled Physician Order indicated, but was not limited to, “This patient may be discharged ... The reason for the discharge is pt is noncompliant ... was seen for the discipline of SN for the following interventions Assessment, vs (vital signs), oxygen saturation, education. The outcome of this intervention has led to pt DC (discharge) ... ” The document was faxed to Non-employee D on 02/23/2021. The document was signed and returned to the agency on 02/24/2021, two days after the patient was discharged from the agency. 9. During an interview on 8/12/2021, the administrator stated the regulations allow for discharge without notice if they are unsafe and needed extended care and the patient was a danger to themselves. 10. During an interview on 8/16/2021 at 3:43 p.m. with the administrator and alternator administrator, when asked if the patient's financial situation had been assessed, or if they had made a referral as the patient clearly needed help and had no caregiver the alternate administrator stated they had previously called adult protective services on other patients and the patient's families would get angry and call them (the agency) so the agency would leave it up to the physician. When informed there's no documentation of the medical doctor being notified the patient hadn't eaten in days, appeared neglected, and was acutely ill, the administrator stated the physician would receive a copy of the discharge summary when the summary was ready. Findings include: 1. A document titled "Patient Discharge Process" was provided by the alternate administrator on 8/10/2021 at 10:00 a.m. The document indicated but was not limited to; "Agency staff will provide the patient with a 15-day notification of the impending discharge ... Upon discharge to self-care, the patient will receive verbal/written information regarding community services, medication use, any procedures/treatments to be performed, and follow-up visits for physician care ... To avoid charges of 'abandonment' at the time of discharge agency documentation will include the following: a. Evidence that the decision was not made unilaterally. The patient, family, and the physician participated in the decision to discharge the patient from the agency. b. Evidence that the patient no longer qualifies for home care services. c. If there are unmet needs and the agency is no longer able to meet those needs documentation that appropriate notice was given (verbal and written) and referrals made as indicated." 2. A document titled "Care Plans" was provided by the administrator on 8/10/2021 at 10:37 a.m. The document indicated but was not limited to; "The Care Plan shall be reviewed, evaluated, and revised ... based upon the patient's health status and/or environment, ongoing patient assessments, caregiver support systems, and the effectiveness of the interventions in achieving progress toward goals." 3. The Center for Medicaid and Medicare State Operations Medicare Benefit Policy Manual Chapter 7 indicates but is not limited to; "As part of the certification of patient eligibility for the Medicare home health benefit, a face-to-face encounter with the patient must be performed by the certifying physician or allowed practitioner himself or herself, a physician or allowed practitioner that cared for the patient in the acute or post-acute care facility (with privileges who cared for the patient in an acute or post-acute care facility from which the patient was directly admitted to home health) or an allowed non-physician practitioner (NPP). Timeframe Requirements ... The encounter must occur no more than 90 days prior to the home health start of care date or within 30 days after the start of care." 4. The complete clinical record for patient 13 was reviewed on 8/10/2021 and evidenced the following: A document titled F2F (face-to-face) Encounter signed by non-employee G, nurse practitioner. The document included "Date of In-Person Visit: 04/27/2021" signed on 4/27/2021. A document titled "Home Health Change of Care Notice (HHCCN) indicated that starting on 6/11/2021 the agency would discharge the patient if they did not have a face-to-face visit with a physician within 30 days of admission due to insurance nonpayment. The document stated, "Your doctor's orders for your home care have changed." The HHCCN was signed on admission 5/13/2021 prior to care being delivered and prior to any physician changes having occurred. A document titled "Patient Communication" dated 5/27/2021 signed by employee E, Office Manager, indicated but was not limited to "Spoke with patients mother as well as patient. Patient has not showed up for past 2 md (medical doctor) appts (appointments) that was scheduled. Patient has an appt set up for 6/10/21 and was told to make sure he makes the appointment." A document titled "Patient Communication" dated 6/10/2021 signed by employee E, Office Manager, that indicated, but was not limited to "Md office called to inform that patient missed F2F appt this date. Could not get him rescheduled by 6/11/2021. Called and informed patients mother and patient that services would be stopped effective 6/11/21 due to not showing up for F2F." A document titled "Discharge Summary" dated 6/11/2021 signed by employee F, Registered Nurse. "The document indicated, but was not limited to, "Reason for discharge ... Noncompliant ... Information Provided for Continuing Needs/Specific Discharge Instructions? ..."The RN failed to document who the information was provided to on the discharge assessment. 5. The clinical record failed to evidence documentation related to reasoning patient 13 missed MD appointments, interventions implemented to remove any barriers to attending appointments and the outcome of those interventions, failed to evidence documentation evidencing patient and family was informed when missing the visits that services would be discontinued, failed to evidence a 15-day discharge notice, and failed to evidence a safe and appropriate transfer to another agency that provided skilled nursing, or any follow-up care set up for the patient. 6. During an interview on 8/12/2021 at 11:31 a.m., the alternate administrator stated the face-to-face was not received until after the patient was discharged when the office manager went to the nursing home to obtain the document so that they would be paid for the care provided. 7. During an interview on 8/16/2021 with the administrator when asked why they waited until after the patient was discharged to obtain the face-to-face the administrator stated they wanted the patient to see a doctor to update medications

Integrate all orders CFR(s): 484.60(d)(2) Integrate orders from all physicians or allowed practitioners involved in the plan of care to assure the coordination of all services and interventions provided to the patient. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to integrate all orders in the plan of care and failed to assure coordination of care for all services required for 2 of 5 discharged patients reviewed. (Patient 13 and Patient 16). 8. The complete clinical record for Patient 16, start of care 02/13/2021, was reviewed on 08/10/2021 and evidenced the following: A document dated 02/11/2021, signed by Non-employee C on 02/12/2021, titled F2F (Face 2 Face). The document indicated, but was not limited to, “ ... Home Health Services PT (physical therapy), OT (occupational therapy), NSG (nursing), HHA (home health aide) ... ” A document dated 02/13/2021, signed by Employee G, titled Physician Order, indicated but was not limited to, “This patient has been admitted to skilled home health services for the following disciplines: PT (physical therapy)/OT (occupational therapy)/SN (skilled nursing) ... Skilled Nursing warranted due to active surgical wound … Fall prevention … Assess environment for personal safety hazards … Gait and balance exercises ... ” The document failed to include orders for a home health aide, specific orders for wound care, frequency, and duration of visits for skilled nursing, and orders for OT. A 02/17/2021 document, signed by Employee I, titled Patient Communication. The document indicated, but was not limited to, “ ... pt slurring ... words … hadn’t eaten ... would be contacting authorities to do a welfare check ... SN notified 911 at this time ... ” The document failed to evidence that the physician was made aware of changes in the patient’s status, need for emergency services, or that the plan of care may need to be altered. A 2/18/2021 document titled PTA Visit indicated that during the PTA (physical therapy assistant) visit, the patient declined all intervention except laying supine due to weeping from a liver laceration wound, and the need for food and water. The PTA stated the patient was supposed to be changing his liver bandage every day but ran out of pads and has been using a towel. The document failed to evidence that the physician was made aware of the patient’s status or that the plan of care may need to be altered. A 02/22/2021 document, signed by Employee E, titled Patient communication indicated, but was not limited to, “SN called MD (medical doctor) office to notify of patient noncompliant with care ... advise patient to go to ER.” The document failed to evidence that the physician was made aware of the patients poor living conditions or the safety of the patient and why the patient was advised to go to the emergency room. 9. During an interview on 8/16/2021 at 3:43 p.m. with the administrator and alternator administrator, when informed there's no documentation of the physician being notified the patient hadn't eaten in days, appeared neglected, and was acutely ill, the administrator stated the physician would receive a copy of the discharge summary when the summary was ready. 10. The home health agency failed to provide home health aide services, or adequate wound care services resulting in a decline in the patient's condition due to an infection. The clinical record failed to evidence that the physician was made aware of the patient's living conditions or decline in condition. Findings include: 1. A policy titled "Care Plan" was provided by the administrator on 8/12/2021 at 10:37 a.m. The document indicated but is not limited to, "Each patient will have a care plan on file that addresses their identified needs ... the care plan shall include ... a list of specific interventions with plans for implementation ... " 2. A policy titled "Clinical Documentation" was provided by the alternate administrator on 8/10/2021 at 10:00 am. The document indicated but was not limited to, "Telephone or other communication with patients, physicians, families, or other members of the health care team will be documented in clinical progress notes or other interagency communication forms." 3. A policy titled "Standard Infection Control Procedures for Home Care" was provided by the administrator on 8/12/2021 at 10:37 a.m. The document indicated but was not limited to, "In the event of insect or rodent infestation noted by agency staff, the agency will be immediately notified, and the agency staff will begin making arrangements with the patient/family to seek professional treatment for the infestation ..." 4. The complete clinical record for patient 13, start of care 5/13/2021, was reviewed on 8/11/2021. The record evidenced the following: A document titled "Home Health Certification and Plan of Care" indicated but was not limited to, a diagnosis of neuromuscular dysfunction of the bladder, unspecified and paraplegia. The document included the following orders and treatments, " SN (skilled nursing) 1x9 (1 time a week times 9 weeks) ... Patient has or is at risk for having pressure ulcers-risk for infection ... SN to assess skin for breakdown every visit ..." A document titled, "RN-Skilled Nursing Visit" for 5/20/2021 signed by employee I, Registered Nurse. The document indicated but was not limited to, "Skin ... WNL (within normal limits) ... A document titled, "RN-Skilled Nursing Visit" for 5/24/2021 signed by employee C, Registered Nurse. The document indicated but was not limited to, "Skin ... Dry ... Warm ... Good/Elastic ... Assessment ... provided [sic] has no open areas or wounds at this time ..." A document titled, "LPN/LVN-Skilled Nursing Visit" for 6/02/2021 signed by employee D, Licensed Practical Nurse. The document indicated but was not limited to, "Skin ... Dry ... Warm ... Good/Elastic ... Assessment ... Medication Changes … No " 5. The hospital record for patient 13 was provided by entity B on 8/10/2021. The document indicated but was not limited to, an emergency room visit on 6/2/2021 related to an open wound. The patient was discharged with a follow-up order for wound care with the local wound and ostomy clinic and prescriptions for 2 new antibiotics. 6. Documentation from the personal services agency providing care for patient 13 received on 8/17/2021 evidenced a document titled "Incident Report" dated 5/27/2021 for patient 13 that indicated, but was not limited to, "I was cleaning him [patient 13] up and noticed a rash on the front right leg and a fluid pocket on the back of his right leg underneath his butt." The family was notified at 7:44 p.m. signed by non-employee A. A picture of the wound was attached. A second document titled "Activity" evidenced an entry from non-employee B stated the personal care agency was notified of emergency room admission on 6/2/2021 for patient 13 and that patient would receive oral antibiotics. The non-employee also documented non-employee A had reported that the wound had worsened. 7. The home health agency failed to coordinate care with patient 13’s personal service agency and patient 13’s caregiver resulting in the agency not being aware of the wound identified on 5/27/2021, hospital admission on 6/2/2021, and new antibiotics and wound care orders prescribed on 6/2/2021.

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to coordinate care for 2 of 2 patients discharged for noncompliance. (Patient 13 and Patient 16) 11. The complete clinical record for Patient 16, start of care 02/13/2021, was reviewed on 08/10/2021 and evidenced the following: A document dated 02/13/2021, signed by Employee G, titled Physician Order, indicated but was not limited to, “This patient has been admitted to skilled home health services for the following disciplines: PT (physical therapy)/OT (occupational therapy)/SN (skilled nursing) ... Skilled Nursing warranted due to active surgical wound … Fall prevention … Assess environment for personal safety hazards … Gait and balance exercises ... ” The document failed to include orders for a home health aide, specific orders for wound care, frequency, and duration of visits for skilled nursing, and orders for OT. A 02/17/2021 document, signed by Employee I, titled Patient Communication. The document indicated, but was not limited to, “SN (skilled nurse) received phone call from pt (patient) emergency contact ... expressed concern that ... unable to reach pt for the last 24-48 hours ... SN notified supervisors at this time ... pt slurring ... words … hadn’t eaten and was walking … to get food ... SN informed emergency contact ... would be contacting authorities to do a welfare check ... SN notified 911 at this time ... ” The document failed to evidence that the physician was made aware of changes in the patient’s status and the need for emergency services. The clinical record failed to evidence that any follow up from the agency after emergency services were summoned. A 2/18/2021 document titled PTA Visit indicated that during the PTA (physical therapy assistant) visit, the PTA documented the patient declined all intervention except laying supine due to weeping from a liver laceration wound. The PTA documented the patient needed food and water; the PTA reached the emergency contact who stated they were unable to provide food for the patient. The PTA stated the patient was supposed to be changing his liver bandage every day but ran out of pads and has been using a towel. The document failed to evidence that the physician was made aware of the patient’s status or the need for wound care and supplies. A 02/19/2021 document titled OT (occupational therapist) Evaluation, signed by Employee H, indicated that the patient had no assistance, the patient lived on the 3rd floor and there was clutter and garbage scattered throughout. There was an insect/rodent infestation present. The patient was sleeping with a mattress on the floor with no sheets. The document failed to indicate that the physician was made aware of the patient’s living conditions. A 02/22/2021 document, signed by Employee E, titled Patient communication indicated, but was not limited to, “SN called MD (medical doctor) office to notify of patient noncompliant with care and meds. Advise patient to go to ER.” The document failed to indicate that the patient was being discharged from the agency. A 02/22/2021 document, signed by Employee E, titled Physician Order indicated, but was not limited to, “This patient may be discharged ... The reason for the discharge is pt is noncompliant ... was seen for the discipline of SN for the following interventions Assessment, vs (vital signs), oxygen saturation, education. The outcome of this intervention has led to pt DC (discharge) ... ” The document was faxed to Non-employee D on 02/23/2021. The document was signed and returned to the agency on 02/24/2021, two days after the patient was discharged from the agency. The clinical record failed to evidence that the agency adequately coordinated care with the physician regarding orders, changes in the patient’s condition, patient needs, and patient safety. The clinical record failed to evidence that the agency attempted to coordinate care with other businesses such as an exterminator or meal delivery business. 12. During an interview on 8/16/2021 at 3:43 p.m. with the administrator and alternator administrator, when informed there's no documentation of the physician being notified the patient hadn't eaten in days, appeared neglected, and was acutely ill, the administrator stated the physician would receive a copy of the discharge summary when the summary was ready. Findings include: 1. POLICY 2. The complete clinical record for patient 13, the start of care 5/13/2021, was reviewed on 8/11/2021. The record evidenced the following: A document titled "Patient Communication" dated 5/20/2021 signed by employee E, Office Manager, indicated, but was not limited to "Spoke with patients mother Teresa and informed her that patient needed set up with his PCP (primary care physician) by 6/11/2021." A document titled "Patient Communication" dated 5/27/2021 signed by employee E, Office Manager, indicated but was not limited to "Spoke with patients mother as well as patient. Patient has not shown up for the past 2 MD (medical doctor) appts (appointments) that was scheduled. Patient has an appt set up for 6/10/21 and was told to make sure he makes the appointment." A document titled "Patient Communication" dated 6/10/2021 signed by employee E, Office Manager, indicated, but was not limited to "Md office called to inform that patient missed F2F appt this date. Could not get him rescheduled by 6/11/2021. Called and informed patients, mother, and patient, that services would be stopped effective 6/11/21 due to not showing up for F2F." A document titled, "LPN/LVN-Skilled Nursing Visit" for 6/02/2021 was signed by employee D, Licensed Practical Nurse. The document indicated but was not limited to, "Skin ... Dry ... Warm ... Good/Elastic ... Assessment ... " A document titled "Discharge Summary" dated 6/11/2021 signed by employee F, Registered Nurse. "The document indicated, but was not limited to, "Reason for discharge ... Noncompliant ... Information Provided for Continuing Needs/Specific Discharge Instructions? ..."The RN failed to document who the information was provided to on the discharge assessment. A document titled "F2F (face to face) Encounter" dated 4/27/2021. The document indicated but is not limited to, "Date of In-Person Visit: 04/27/2021" signed by Non-Employee A, Nurse Practitioner. 3. Hospitalization records for patient 13 were received on 8/13/2021 for patient 13. The records indicated but were not limited to an emergency room visit dated 6/1/2021. The clinical impression documented by the medical provider indicated an open wound, 4cm by 5cm ulceration with central eschar on the proximal posterior right thigh. The wound was cultured, and the results indicated evidenced heavy growth of Proteus mirabilis, heavy growth of Pseudomonas aeruginous, and heavy growth of Providencia stuartii. The patient received IV antibiotics and was prescribed oral antibiotics for home. 6. During an interview on 8/16/2021 the administrator stated the LPN (licensed practice nurse) who performed the visit on 6/2/202,1 the day after the hospital admission, would have documented an ER visit had she known and that maybe she rolled the patient to one side, therefore, missing the wound. The administrator stated the patient also had a responsibility to report the visit and the agency can’t take full responsibility when they didn’t know. The patient was discharged with no wound care services or other receiving agencies. 7. Documentation from the personal services agency providing care for patient 13 received on 8/17/2021 evidenced a document titled "Incident Report" dated 5/27/2021 for patient 13 that indicated, but was not limited to, "I was cleaning him [patient 13] up and noticed a rash on the front right leg and a fluid pocket on the back of his right leg underneath his butt." The family was notified at 7:44 p.m. signed by non-employee A. A picture of the wound was attached. A second document titled "Activity" evidenced an entry from non-employee B stated the personal care agency was notified of emergency room admission on 6/2/2021 for patient 13 and that patient would receive oral antibiotics. The non-employee also documented non-employee A had reported that the wound had worsened. 8. Hospitalization records for patient 13 received on 8/13/2021 indicated the patient returned to the emergency room on 6/22/2021. The patient was admitted for "multiple right lower extremity wounds and the wound to the right hip had increased in size to golf ball size ... The right heel had purulent drainage and a foul smell." The patient was diagnosed with sepsis related to an unknown organism. The right heel had purulent drainage and a foul smell. 9. During an interview on 8/11/2021 with the patient’s caregiver, the caregiver stated patient 13 was found to have maggots on his wound on the right hip area and was potentially losing his right foot from wounds and infection found on the heel. 10. The agency failed to coordinate care between the Hospital, the Personal Care Services Agency, and the patient’s caregiver. 11. During the entrance conference on 8/9/2021 at 12:15 p.m. the administrator stated the agency coordinates care with other agencies every 60 days. 12. During an interview on 8/16/2021 at 3:04 p.m. the administrator stated the patient shouldn’t get a hall pass, the patient didn’t tell the agency he had a wound or a visit to the emergency room and so he shouldn’t be just given a pass and we can’t just blame it on him being bipolar.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure staff was following acceptable standards of practice by actively documenting the absence of illness or signs/symptoms of COVID-19 and failing to screen all patients for COVID-19 prior to performing home visits for 1 of 1 agency reviewed. 3. During an interview with the administrator and the alternate administrator on 08/09/2021 at 11:11 a.m., a document titled “COVID-19 Focused Infection Control Survey Tool: Acute and Continuing Care” was used. The interview indicated, but was not limited to, “Does the facility have a screening process ... No ... How is staff monitored for compliance? Peer-to-peer reporting, trusting our staff, and staff education ... The facility has established/implemented a surveillance plan, based on facility assessment, for identifying, tracking, monitoring, and/or reporting fever, respiratory illness, or other signs/symptoms of COVID-19? No ... ” 4. During a home visit on 08/12/2021 at 9:00 a.m., Employee J failed to screen the patient for COVID-19 symptoms upon arrival to the patient’s home. When asked if the employees were required to conduct any type of self-screening, Employee J stated they were not required to self-screen or track symptoms or lack of symptoms. 5. During an interview with the administrator on 08/12/2021 at 11:23 a.m., when asked if employees had been required to track COVID-19 symptoms, or lack of symptoms, at any point since the start of the pandemic, the administrator stated the employees were not required to do any symptom tracking. 6. During an interview with the alternate administrator on 08/16/2021 at 3:25 p.m., the alternate administrator stated the employees were not required to track their symptoms, or lack of symptoms, and should be calling the patients ahead of time to screen the patients for COVID-19 symptom; they agency stopped tracking symptoms when the mask mandate was lifted. Findings include: 1. A 3/23/2020 CMS Infection Control Covid-19 questionnaire tool indicated, but was not limited to, "Is the facility screening all staff at the beginning of their shift for fever and signs/symptoms of illness? Is the facility actively taking their temperature and documenting the absence of illness (or signs/symptoms of COVID-19 as more information becomes available)?" Ref: QSO 20-20-All 2. A 12/20/2020 CMS Memorandum Ref: QSO-21-08-NLTC indicated but was not limited; “Education, Monitoring, and Screening of Staff. Does the facility have a screening process for all staff to complete prior to or at the beginning of their shift that reviews for exposure to others with known or suspected COVID-19, signs/symptoms of illness, and includes whether fever is present (screened upon arrival or self-reported absence of fever)? Is there evidence the provider has educated staff on SARS-CoV?"

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to ensure all clinical documents were properly authenticated for 1 of 5 closed records reviewed. (Patient 13). A policy titled "Clinical Documentation" was provided by the alternate administrator on 8/10/2021 at 10:00 am. The document indicated but was not limited to, “A separate note shall be completed for each visit/shift and signed and dated … telephone or other communication with patients, physicians, families, or other members of the health care team will be documented …” A job description titled “Registered Nurses” was provided by the alternate administrator on 8/10/2021 at 10:00 a.m. The document indicated but was not limited to “Essential Functions/Areas of Accountability … documents legibly and according to Agency documentation guidelines and standards.” The complete clinical record for patient 13, the start of care 5/13/2021, was reviewed on 8/11/2021. The record evidenced the following: A document titled "Home Health Change of Care Notice (HHCCN) indicated that starting on 6/11/2021 the agency would discharge the patient if they did not have a face-to-face visit with a physician within 30 days of admission due to insurance nonpayment. The document stated, "Your doctor's orders for your home care have changed." The HHCCN was signed on admission 5/13/2021 prior to care being delivered and prior to the doctor changing the patient’s orders and prior to the agency having any verbal or signed orders from the physician. A document titled “Hoosier Homecare Services: Notice of Medicare Non-coverage” for patient 13 indicated “The effective date coverage of your home health services services will end:” The agency failed to enter a date identifying when services when end. The document signature is illegible and fails to evidence a date the document was signed. During an interview on 8/12/2021 at 11:31 a.m., the alternate administrator stated the undated/illegible document titled Notice of Medicare Non-coverage was the 15-day notice given to patient 13.

Licensed Practical (Vocational) Nurse CFR(s): 484.115(e) Standard: Licensed practical (vocational) nurse. A person who has completed a practical (vocational) nursing program, is licensed in the state where practicing, and who furnishes services under the supervision of a qualified registered nurse. This STANDARD is not met as evidenced by: Based on record review and interview the Licensed Practical Nurse failed to provide an accurate skin assessment for 1 of 2 closed records with wounds reviewed. (Patient 13). Findings include: A job description titled “Licensed Practical Nurse” was provided by the alternate administrator on 8/10/2021 at 10:00 a.m. The document indicated but was not limited to “Provides professional nursing care as defined in the nurse practice act … follows the care plan established by the registered nurse … recognizes and reports changes in client condition … participates in the coordination of home care services.” The complete clinical record for patient 13, the start of care 5/13/2021, was reviewed on 8/11/2021 and evidenced the following: A document titled "Home Health Certification and Plan of Care" indicated but was not limited to, a diagnosis of neuromuscular dysfunction of the bladder, unspecified and paraplegia. The document included the following orders and treatments, " SN (skilled nursing) 1x9 (1 time a week times 9 weeks) ... Patient has or is at risk for having pressure ulcers-risk for infection ... SN to assess skin for breakdown every visit ..." A document titled, "LPN/LVN-Skilled Nursing Visit" for 6/02/2021 was signed by employee D, Licensed Practical Nurse. The document indicated but was not limited to, "Skin ... Dry ... Warm ... Good/Elastic ... Assessment ... " Documentation from the personal services agency providing care for patient 13 received on 8/17/2021 evidenced a document titled "Incident Report" dated 5/27/2021 for patient 13 that indicated, but was not limited to, "I was cleaning him [patient 13] up and noticed a rash on the front right leg and a fluid pocket on the back of his right leg underneath his butt." The family was notified at 7:44 p.m. signed by non-employee A. A picture of the wound was attached. A second document titled "Activity" evidenced an entry from non-employee B stated the personal care agency was notified of emergency room admission on 6/2/2021 for patient 13 and that patient would receive oral antibiotics. The non-employee also documented non-employee A had reported that the wound had worsened. Hospitalization records for patient 13 received on 8/13/2021 indicated the patient returned to the emergency room on 6/22/2021. The patient was admitted for "multiple right lower extremity wounds and the wound to the right hip had increased in size to golf ball size ... The right heel had purulent drainage and a foul smell." The patient was diagnosed with sepsis related to an unknown organism. The right heel had purulent drainage and a foul smell. During an interview on 8/16/2021, the administrator stated the LPN (licensed practice nurse) who performed the visit on 6/2/2021 the day after the hospital admission, would have documented an ER visit had she known and that maybe she rolled the patient to one side, therefore, missing the wound. The administrator stated the patient also had a responsibility to report the visit and the agency can’t take full responsibility when they didn’t know. The patient was discharged with no wound care services or other receiving agencies. The administrator stated, “I’m not arguing about the wound the nurse obviously missed it but the patient has some responsibility.”