Every finding on record at Indiana Signal Health Group Skilled Inc

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102. Survey Dates: September 17th, 18th, 19th, 20th, and 23rd of 2024 Active Census: 37 At this Emergency Preparedness survey, Indiana Signal Health Group Skilled was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 484.102. QR Completed on 10/01/2024 by A4

This visit was for a Federal Recertification and State Re-Licensure survey of a Home Health Provider. Survey Dates: September 17th, 18th, 19th, 20th, and 23rd of 2024 12-Month Unduplicated Skilled Admissions: 37 A partially extended survey was announced on 09/18/2024 at 11:00 AM. This deficiency report reflects State Findings cited in accordance with 410 IAC 17.

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 notify the physician of missed skilled nursing visits for 1 of 3 wound care patients reviewed. (Patient #1) Findings Include: 1. A policy titled, "Interruption of Services/Missed Visits" indicated but was not limited to, "If the Agency misses visits or services as required by the plan of care, the Agency must notify the responsible physician of the missed visit if there is any potential for clinical impact upon the patient. The physician will determine whether the patient visit may be skipped or additional intervention is required by the Agency due to the impact on the patient. All documentation will be filed in the patient chart". 2. A document titled, "Communication Note" was sent to the physician on 09/18/2024 by the Administrator. The note indicated dates of missed visits. 08/15/2024, 08/19/2024, 08/20/2024, 08/22/2024, 08/23/2024, 08/29/2024, 09/02/2024, 09/05/2024, and 09/12/2024. 3. The clinical record for Patient #1 evidenced missed visits by skilled nursing regarding wound care on 08/15/2024, 08/19/2024, 08/20/2024, 08/22/2024, 08/23/2024, 08/29/2024, 09/02/2024, 09/05/2024, and 09/12/2024. The agency failed to notify the physician of the missed visits until the surveyor identified them. 4. During an interview on 09/18/2024 at 10:35 AM, the Administrator indicated that all missed visits should be sent to physicians for notification. The Scheduler typically sends them all at once every 2-4 weeks. The missed nursing visits for Patient #1 were not sent to the physician and he plans to send them now. The Administrator, indicated, after a discussion with the Scheduler, that he has only sent home health aide missed visits to the physician. Nursing missed visits are to be sent by the Administrator. 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 ensure that all medical equipment in the home was listed on the Plan of Care for 3 of 3 home visits completed. (Patient #1, #2, & #9) Findings Include: 1. A policy titled, "Plan of Care (POC)" indicated but was not limited to, "Required to include ... supplies and equipment required ...". 2. During a home visit observation for Patient #1 on 09/18/2024 at 1:00 PM, the surveyor observed a glucometer (used to assess blood glucose levels), a Dexcom (device worn to assess continuous blood glucose level monitoring), and a Continuous Positive Airway Pressure (CPAP) machine (a device used to keep airways open while sleeping) in the home. The Clinical Record/POC for Patient #1, Certification Period 09/13/2024--11/11/2024, failed to include a glucometer, a Dexcom, and a CPAP. 3. During a home visit observation for Patient #2 on 09/20/2024 at 9:30 AM, the surveyor observed a glucometer in the home. The Clinical Record/POC for Patient #2, Certification Period 08/11/2024--10/09/2024, failed to include a glucometer. 4. During a home visit observation for Patient #9 on 09/20/2024 at 10:00 AM, the surveyor observed hearing aides, a bedside commode, and a urinal in the home. The Clinical Record/POC for Patient #9, Certification Period 07/28/2024--9/25/2024, failed to include hearing aides, a bedside commode, and a urinal. 5. During an interview on 09/19/2024 at 9:56 AM, the Administrator indicated that all durable medical equipment in the home should be on the plan of care. 410 IAC 17-13-1 (a)(1)(C)(ii)

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to follow physician orders for wound care in 3 of 3 wound care patients reviewed. (Patient #1, #2, #3) Findings Include: 1. A policy titled "Verbal Orders" indicated but was not limited to: "Conformance with Physician Orders: ... Drugs and treatments are administered by the Agency staff only as ordered by the physician." 2. A record review for Patient #1, Certification Period 08/11/2024–10/09/2024, evidenced the following: An 08/01/2024 physician wound care order for Patient #1's coccyx indicated but was not limited to, Cleanser: Soap and water, two times per day for 30 days. Primary dressing: Wet to dry, two times per day for 30 days. Secondary dressing: Telfa Island 4x4 (a soft non-woven dressing that conforms around the wound and seals on all four sides), two times per day for 30 days. An 08/12/2024 Skilled Nursing Visit Note: Treatment performed: Skilled nurse performed pressure ulcer care to the coccyx, cleansing/irrigating the wound with Normal Saline (NS), applying a wet-to-dry dressing, and covering and securing with foam dressing using an aseptic technique. The skilled nurse was also to teach the patient/caregiver to perform wound care. LPN 1 failed to cleanse the wound with soap and water and apply a Telfa Island 4x4 dressing twice daily as ordered. An 08/13/2024 Skilled Nursing Visit Note: Treatment performed: Skilled nurse performed pressure ulcer care to the coccyx, cleansing/irrigating the wound with NS, applying a wet-to-dry dressing, and covering and securing with foam dressing using an aseptic technique. The skilled nurse may teach the patient/caregiver to perform wound care. LPN 1 failed to cleanse the wound with soap and water and apply a Telfa Island 4x4 dressing twice daily as ordered. An 08/14/2024 Skilled Nursing Visit Note: Treatment performed: Cleansed wound with NS, patted dry, applied wet to dry dressing, covered and secured with an island dressing using an aseptic technique. The Administrator failed to cleanse the wound with soap and water twice daily as ordered. An 08/15/2024 physician wound care order for Patient #1's coccyx indicated but was not limited to, Cleanser: Soap and water, two times per day for 30 days. Primary dressing: Dry gauze, two times per day for 30 days. Secondary dressing: Telfa Island 4x4, two times per day for 30 days. An 08/16/2024 Skilled Nursing Visit Note: Treatment performed: Cleansed wound with NS, patted dry, applied wet to dry dressing, covered and secured with an island dressing using an aseptic technique. The Administrator failed to cleanse the wound with soap and water and apply dry gauze twice daily as ordered. An 08/21/2024 Skilled Nursing Visit Note: Treatment performed: Cleansed wound with soap and water, patted dry, applied wet to dry dressing, and covered and secured with a 4x4 island dressing using an aseptic technique. The Administrator failed to apply dry gauze twice daily as ordered. A 09/06/2024 physician wound care order for Patient #1's coccyx indicated but was not limited to, Cleanser: Soap and water, once per day for 30 days. Primary dressing: Silver 4x4 Melgisorb AG (absorbent calcium alginate dressing with silver), once per day for 30 days. Secondary dressing: Telfa Island 4x4, once per day for 30 days. A 09/06/2024 Skilled Nursing Visit Note: Treatment performed: Cleansed wound with NS, applied silver 4x4 Melgisorb AG, covered and secured with Optifoam dressing using aseptic technique. LPN 1 failed to cleanse the wound with soap and water and apply Telfa Island 4x4 dressing daily as ordered. A 09/09/2024 Skilled Nursing Visit Note: Treatment performed: Cleansed wound with NS, applied silver 4x4 Melgisorb AG, covered and secured with Optifoam dressing using aseptic technique. LPN 1 failed to cleanse the wound with soap and water and apply Telfa Island 4x4 dressing daily as ordered. A 09/10/2024 Skilled Nursing Visit Note: Treatment performed: Cleansed wound with NS, applied silver 4x4 Melgisorb AG, covered and secured with Optifoam dressing using aseptic technique. LPN 1 failed to cleanse the wound with soap and water and apply Telfa Island 4x4 dressing daily as ordered. 3. A record review for Patient #2, Certification Period 09/13/2024–11/11/2024, evidenced the following: A 09/10/2024 physician wound care order for Patient #2’s right lateral lower leg indicated but was not limited to, Cleanser: Soap and water, one time per day for 30 days. Primary Dressing: Silver 4x4 Melgisorb AG, one time per day for 30 days. Secondary Dressing: Kerlix (bandage roll providing wicking action, aeration, and absorbency), one time per day for 30 days. Compression Wrap: Ace Wrap, one time per day for 30 days. A 09/14/2024 Skilled Nursing Visit Note: The following treatment was performed: Skilled nurse performed wound care for the right lower leg venous ulcer, cleansing the wound with soap and water, rinsing, patting dry, applying Melgisorb AG, and covering and securing the dressing with an ACE bandage, using aseptic technique. The Administrator failed to apply Kerlix as ordered. A 09/16/2024 Skilled Nursing Visit Note: The following treatment was performed: Skilled nurse performed wound care for the right lateral leg venous ulcer, cleansing the wound with soap and water, rinsing, patting dry, applying Melgisorb AG, and covering and securing the dressing with an ACE bandage, using aseptic technique. LPN 1 failed to apply Kerlix as ordered. 4. A record review for Patient #3, Certification Period 08/31/2024–10/29/2024, evidenced the following: An 08/12/2024 physician wound care order for Patient #3’s left ischial pressure wound (buttock) indicated but was not limited to, Applying antifungal powder once every other day. A 09/05/2024 Skilled Nursing Visit Note: The following treatment was performed: The skin around the wound was cleansed with soap and water, rinsed with water, and patted dry. The wound was cleaned with a sterile cotton-tipped applicator and sterile gauze, and a scant amount of ground Metronidazole (500 mg antibiotic tablet) was applied to the wound bed. Prisma (used to optimize wound healing) was loosely placed in the wound, and the area was covered with 3x3 gauze and secured with a cover roll. LPN 1 failed to apply antifungal powder once every other day and failed to obtain updated physician wound orders. A 09/09/2024 Skilled Nursing Visit Note: The following treatment was performed: The skin around the wound was cleansed with soap and water, rinsed, and patted dry. The wound was cleaned with a sterile cotton-tipped applicator and sterile gauze, and a scant amount of ground Metronidazole 500 mg tablet was applied to the wound bed. Prisma was loosely placed in the wound, and the area was covered with 3x3 gauze and secured with a cover roll. LPN 1 failed to apply antifungal powder once every other day and failed to obtain updated physician wound orders. A 09/12/2024 Skilled Nursing Visit Note: The following treatment was performed: The skin around the wound was cleansed with soap and water, rinsed, and patted dry. The wound was cleaned with a sterile cotton-tipped applicator and sterile gauze, and a scant amount of ground Metronidazole 500 mg tablet was applied to the wound bed. Prisma was loosely placed in the wound, and the area was covered with 3x3 gauze and secured with a cover roll. LPN 1 failed to apply antifungal powder once every other day and failed to obtain updated physician wound orders. A 09/16/2024 Skilled Nursing Visit Note: The following treatment was performed: The skin surrounding the wound was cleansed with soap and water, rinsed, and patted dry. The wound was cleaned with a sterile cotton-tipped applicator and sterile gauze, and a scant amount of ground Metronidazole 500 mg tablet was applied to the wound bed. Prisma was loosely placed in the wound, and the area was covered with 3x3 gauze and secured with a cover roll. LPN 1 failed to apply antifungal powder once every other day and failed to obtain updated physician wound orders. 5. During an interview on 09/17/2024 at 3:13 PM, the Administrator indicated that physician orders for wound care were not followed for Patient #1. The Administrator further indicated that Patient #1’s orders change frequently and should be followed at all times. The Administrator was unable to change wound orders on the Plan of Care and could not figure out how to do so within the Electronic Medical Record (EMR) system. The Administrator also indicated that caregivers, specifically the grandson and niece, performed wound care in the evening or when a visit was missed by the nurse. The Administrator was unable to find or provide documentation showing that the caregivers were trained on wound care initially or with each wound care order change. The wound care completed by the caregivers was not documented or tracked, and the Administrator only knew it was completed because Patient #1 reported it. 6. During an interview on 09/17/2024 at 4:20 PM, Patient #1 indicated that a friend completes wound care in the absence of the nurse. Patient #1 communicates any new wound care orders to their friend, who then performs the care. Patient #1 did not recall the agency nurses training their friend on how to complete wound care but indicated satisfaction with the current services received from the home health agency. 7. During an interview on 09/18/2024 at 9:05 AM, the Administrator acknowledged being aware that Patient #1’s caregivers had not been trained on wound care and planned to schedule a date and time for the training. 8. During an interview on 09/18/2024 at 10:35 AM, the Administrator indicated that physician orders for wound care were not followed for Patient #2, and Kerlix was not included in the wound orders on the Plan of Care. 9. During an interview on 09/18/2024 at 1:30 PM, the Director of Marketing was asked to provide wound care orders for Patient #3. Wound care orders from January 2024 were provided. The Director denied having any further notes or orders from the wound center for review. The Director indicated that Patient #3’s wound orders had not changed but requested an update from the wound center. New orders were provided, which were noted to be significantly different from the current treatment being provided. The most recent wound order was dated 08/12/2024. 410 IAC 17-13-1(a)

Patients receive education and training CFR(s): 484.60(d)(5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to provide initial and on-going wound care training/education to the caregiver for wound care that was to be provided in the absence of agency nursing staff in 1 of 3 wound care patients reviewed. (Patient #1) Findings Include: 1. A policy titled, "Admission Documentation/Patient Education" indicated but was not limited to, "Patient/Family Education: Starting with the admission visit, Agency staff will provide education to the patient and caregiver related to: Infection prevention & control... Treatments/care/services ... Such education may be oral or written educational materials sourced from the Agency or any other agency/authority in the topic, and documented in the permanent clinical record that information was provided". 2. A policy titled, "Wound Care" indicated but was not limited to, "a. Wound care education will be provided to each patient/caregiver as applies ... c. All education on wound care will include, but not be limited to: ... Self wound care ... Dressings to be utilized in wound care ... Symptoms to report to your nurse or physician ... d. All wound care education is to be documented in nursing notes". 3. The Clinical Record for Patient #1, Certification Period 08/11/2024--10/09/2024, failed to include documentation demonstrating that the caregiver received initial and ongoing education/training on wound care to be completed in the absence of the agency nurse. Caregiver infection prevention & control was also absent from the clinical record. 4. During an interview on 09/17/2024 at 3:13 PM, the Administrator indicated that the caregivers complete wound care in the absence of agency nursing staff. Caregivers include a grandson and a niece. Agency nursing staff complete home visits once a day, Monday-Friday. The caregivers provide wound care each evening as ordered and on the weekends. 5. During an interview on 09/17/2024 at 4:20 PM, Patient #1 indicated that a friend completes wound care in the absence of nursing staff. Cannot recall a friend receiving training/education on wound care initially or ongoing. Patient #1 tells a friend what the wound doctor's orders are and he/she completes wound care. 6. During an interview on 09/19/2024 at 9:05 AM, the Administrator indicated that documentation of caregivers' training and education regarding Patient #1's wound care was not found in the clinical record, neither initial or ongoing. Wound care has been and will continue to be provided by the caregiver in the absence of nursing staff. The agency plans to set up a date/time for the caregivers to be trained. 7. During an interview on 09/20/2024 at 12:09 PM, the Administrator indicated that the caregiver was trained today on wound care/infection control. 410 IAC 17-14-1 (a)(1)(G)

Aides are members of interdisciplinary team CFR(s): 484.80(g)(4) Home health aides must be members of the interdisciplinary team, must report changes in the patient's condition to a registered nurse or other appropriate skilled professional, and must complete appropriate records in compliance with the HHA's policies and procedures. This ELEMENT is not met as evidenced by: Based on record review and interview the Home Health Aide (HHA) failed to report a change in condition to the Registered Nurse in 1 of 3 active records reviewed with HHA services. (Patient #4) Findings Include: 1. A document titled, "Job Title: Home Health Aide (HHA)" indicated but was not limited to, "Reports any changes in the patient's status or home situation immediately to the supervisor, staff nurse, or aide supervisor, including recognizing & reporting skin changes". 2. A document dated 09/13/2024 titled, "Client Notes Report" indicated that HHA #2 noted that Patient #4 had a couple of "open spots" on his/her backside, and "cream" was applied. HHA 2 failed to notify the nurse of the change in condition. 3. During an interview on 09/20/2024 at 12:49 PM, the Administrator was reviewing Patient #4's clinical record with the surveyor and read aloud the note entered by HHA #2 and indicated that she was not made aware of these open spots and confirmed that the documentation did not include a note indicating any nurse was made aware. She stated the expectation is for the HHA to notify the nurse of any changes in condition. 4. During an interview on 09/23/2024 at 3:30 PM, HHA #2 indicated that Patient #4 did have new open spots identified on his/her bottom on 09/13/2024. She indicated that this was an ongoing thing with Patient #4 and was not uncommon. Surveyor clarified with HHA #2 that these were new open spots and HHA #2 confirmed they were. HHA #2 further indicated that if they were "really open and raw" the nurse would be notified. HHA #2 indicated that the open spots had not cleared to date and planned to notify the Administrator later today.

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 obtain a signed physician order for services in 1 of 3 new admissions reviewed. (Patient #6) Findings Include: 1. A policy titled, "Orders: Signed in 30 Days", indicated but was not limited to, "Orders are signed by the physician within time frames established by state/federal regulations and our Agency policy, but at least within 30 days. All plans of care, verbal orders, and changes in orders will be signed by the certifying physician in 30 days and filed in the patient's clinical file. Every effort will be made to ensure the order is signed within the timeframe, including refaxing and in person visit to the MD office. All efforts to obtain the MD signature will be documented". 2. A policy titled, "Verbal Orders", indicated but was not limited to, "Verbal orders must be authenticated and dated by the physician in accordance with applicable state laws and regulations, and Agency policy". 3. A policy titled, "Plan of Care (POC)" indicated but was not limited to, "Must be signed by the attending medical professional acting within the boundaries of all applicable state laws and regulations". 4. A Clinical Record for Patient #6, Start of Care 07/29/2024, Certification Period 07/29/2024--09/26/2024 failed to include a signed physician order for services. Services included a start of care skilled nursing visit one time and Physical Therapy services once weekly for 1 week, then twice weekly for 8 weeks. 5. During an interview on 09/20/2024 at 12:09 PM, the Administrator indicated starting care for Patient #6. The expectation is to obtain a signed physician order for services and typically does this, however, this one got missed. The Plan of Care was signed by the physician on 09/17/2024 with orders for skilled nursing for the start of care and physical therapy but agreed this signature was not obtained in the Agency timeframe expectation, of 30 days.

This visit was for a Federal/State Complaint Survey (95557) that was fully extended. Survey Dates: January 25th, 26th, 27th, 30th, 31st and February 1st of 2023. Provider Number: 157681 Census: 44 At this survey, Indiana Signal Health Group Skilled Inc. found in compliance with 42 CFR 484.102 in regards to Emergency Preparedness Federal regulations. QR Completed 2/13-14/2023 A4

This visit was for a complaint investigation survey. Complaint #: 95557; substantiated with findings. Survey Dates: January 25th, 26th, 27th, 30th, 31st, and February 1st of 2023. A fully extended survey was announced on 1/26/2023 at 9:30 a.m. · These deficiencies reflect State Findings cited in accordance with 410 IAC 17. Refer to state form for additional state findings. An immediate jeopardy related to 484.80 Home Health Aide Services was identified and announced on 1/26/2023 at 9:30 a.m. and 484.55 Comprehensive Assessment of Patients was identified and announced on 1/30/2023 at 4:17 p.m. The agency's immediate jeopardy removal of immediacy plan and actions were determined to have removed the immediacy component of the immediate jeopardy on 2/1/2023 at 4:07 p.m. Based on the Condition-level deficiencies identified during the 1/25/2023 - 2/1/2023 survey, Indiana Signal Health Group Skilled Inc., your home health agency was subject to an extended survey pursuant to section 1891(c)(2)(D) of the Social Security Act, on 1/26/2023 at 9:30 a.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 home health aide training and/or competency evaluation program for two years beginning 2/1/2023 and continuing through 1/31/2025.

Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient's eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This CONDITION is not met as evidenced by: An Immediate Jeopardy related to 484.55 Comprehensive Assessment of Patients was identified and announced on 1/30/2023 at 4:17 p.m. The agency's second immediate jeopardy removal of immediacy plan and actions were determined to have removed the immediacy component of the immediate jeopardy on 2/1/2023 at 4:07 p.m. The Immediate Jeopardy began on 11/25/2023 when the nurse completed the recertification assessment date 11/25/2022--1/23/2023, This assessment appeared to be copied and pasted from the previous recertification assessment dated 9/26/2022--11/24/2022 as it read exactly the same, word for word. An additional recertification assessment to begin on 1/24/2023, completed on 1/19/2023 was copied and pasted from the resumption of care assessment completed on 1/16/2023. The nurse indicated that the assessment for the resumption of care was completed in-person with an up-to-date assessment, however, admitted that the recertification assessment to begin on 1/24/2023 that was completed 1/18/2023 was copied and pasted and not in-person, not up to date. 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 the Condition of Participation 42 CFR 484.55 Comprehensive Assessment. Based on record review and interview, the agency failed to ensure that an updated, in-person, patient-specific, comprehensive nursing assessment reflecting the patient's current health status was completed for 1 of 7 patients reviewed (Patient 1) (See G0518 and G0544), resulting in an Immediate Jeopardy finding at 484.55 Comprehensive Assessment of Patients. Based on record review and interview, the agency failed to ensure the registered nurse completed an initial assessment within 48 hours of the physician's ordered service (See G0514). In regards to G0510, findings Include: A policy titled, " Assessments," dated 7/2020 was provided by the Director of Indiana Signal Health Group Inc. on 1/25/2023 at 11:00 a.m. The policy indicated, but was not limited to, "All patients referred to our Agency will receive a patient-specific, comprehensive assessment according to the Physician services ordered, to determine the immediate care and support needs of the patient" ... "Update of the Comprehensive Assessment: will be performed the last 5 days of every 60 days beginning with the start-of-care date (day 56-60)." ... "The Comprehensive Assessment must accurately reflect the patient's status and must include: 1. Current health, psychosocial, functional, & cognitive status/diagnosis. 2. Vital signs 3. Identification of additional health problems or pertinent health history 4. Data items collected at an in patient facility admissions or discharges only." ... "Follow- up (recertification) Assessments require a new plan of care, updated goals, reviewed medication sheet and revised HHA (home health aide) care plan (if applicable)." ... "Every skilled visit will have a physical assessment and routine assessment of patient's home for potential safety issues done and documented." ... "A comprehensive assessment is completed at recertification, post hospitalization, discharge, transfer, and readmission, and as a significant change in patient/patient's condition warrants." An interview was completed on 1/26/2023 at 10:48 a.m. with the Clinical Supervisor. The Clinical Supervisor agreed that the Plan of Care from recertification period 9/26/2022--11/24/2022 & the Plan of Care from the recertification period 11/25/2022--1/23/2023 appeared to be copied and pasted from one assessment to the next as it read word for word exactly the same in the nursing narrative note (60 day summary). The recertification period dated 11/25/2022--1/23/2023 nursing note indicated that the patient denied any infections, ER visits or hospitalizations during this certification period when in fact, the patient was admitted to the hospital from 1/12/2023--1/14/2023 for Hypoxia, Influenza A, COPD (chronic obstructive pulmonary disease) exacerbation, and hypertension. An interview was completed on 1/30/2023 at 11:00 a.m. with RN (registered nurse) A. RN A indicated not being present, in the home of Patient 1 when completing the comprehensive assessment on 1/19/2023 for the next recertification period starting 1/24/2023. Indicated being present in the home with Patient 1 on 1/16/2023 completing the ROC (Resumption of Care) post hospitalization assessment and used that information to complete the recertification assessment for the next recertification period on 1/19/2023. Indicated she had only been in the home once the month of January, on 1/16/2023. The patient passed away in the home on 1/22/2023.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure the RN (registered nurse) completed an initial assessment within 48 hours of the physician's ordered service in 1 of 7 records reviewed (Patient 5). Findings Include: A policy titled, "Assessments," dated 7/2020 provided by the Director of Indiana Signal Health Group on 1/25/2023 at 11:00 a.m., indicated but was not limited to, "The initial assessment will be performed by a RN for patients receiving nursing only services or nursing and therapy (unless therapy only case), within 48 hours of the patient's referral...". On 1/27/2023, Patient 5's clinical record revealed a referral from the physician on 10/27/2022 with the initial/comprehensive assessment completed on 11/1/2022. An interview with the clinical supervisor was completed on 1/27/2023 at 2:30 p.m. The clinical supervisor agreed that an initial assessment is to be completed within 48 hours of receiving the physician order. 410 IAC 17-14-1(a)(1)(A)

Completion of the comprehensive assessment CFR(s): 484.55(b) Standard: Completion of the comprehensive assessment. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to ensure that an updated, in-person, patient-specific, comprehensive nursing assessment reflecting the patient's current health status was completed in 1 of 7 patients reviewed (Patient 1). Findings Include: A policy titled, " Assessments," dated 7/2020 was provided by the Director of Indiana Signal Health Group Inc. on 1/25/2023 at 11:00 a.m. The policy indicated, but was not limited to, "All patients referred to our Agency will receive a patient-specific, comprehensive assessment according to the Physician services ordered, to determine the immediate care and support needs of the patient" ... "Update of the Comprehensive Assessment: will be performed the last 5 days of every 60 days beginning with the start-of-care date (day 56-60)." ... "The Comprehensive Assessment must accurately reflect the patient's status and must include: 1. Current health, psychosocial, functional, & cognitive status/diagnosis. 2. Vital signs 3. Identification of additional health problems or pertinent health history 4. Data items collected at an in patient facility admissions or discharges only." ... "Follow- up (recertification) Assessments require a new plan of care, updated goals, reviewed medication sheet and revised HHA (home health aide) care plan (if applicable)." ... "Every skilled visit will have a physical assessment and routine assessment of patient's home for potential safety issues done and documented." ... "A comprehensive assessment is completed at recertification, post hospitalization, discharge, transfer, and readmission, and as a significant change in patient/patient's condition warrants." An interview was completed on 1/26/2023 at 10:48 a.m. with the Clinical Supervisor. The Clinical Supervisor agreed that the Plan of Care from recertification period 9/26/2022--11/24/2022 & the Plan of Care from the recertification period 11/25/2022--1/23/2023 appeared to be copied and pasted from one assessment to the next as it read word for word exactly the same in the nursing narrative note (60 day summary). The recertification period dated 11/25/2022--1/23/2023 nursing note indicated that the patient denied any infections, ER visits or hospitalizations during this certification period when in fact, the patient was admitted to the hospital from 1/12/2023--1/14/2023 for Hypoxia (low oxygen level), Influenza A (viral infection), COPD (chronic obstructive pulmonary disease) exacerbation, and hypertension. An interview was completed on 1/30/2023 at 11:00 a.m. with RN (registered nurse) A. RN A indicated not being present, in the home of Patient 1 when completing the comprehensive assessment on 1/19/2023 for the next recertification period starting 1/24/2023. Indicated being present in the home with Patient 1 on 1/16/2023 to complete the ROC (Resumption of Care) post hospitalization assessment and used that information to complete the recertification assessment for the next recertification period to start on 1/24/2023. Indicated only been in the home once in the month of January, 1/16/2023. The patient passed away in the home on 1/22/2023.

Update of the comprehensive assessment CFR(s): 484.55(d) Standard: Update of the comprehensive assessment. The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient's condition warrants due to a major decline or improvement in the patient's health status, but not less frequently than- This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to ensure that an updated, in-person, patient-specific, comprehensive nursing assessment reflecting the patient's current health status was completed in-person in 1 of 7 records reviewed (Patient 1). Findings Include: A policy titled, " Assessments," dated 7/2020 was provided by the Director of Indiana Signal Health Group Inc. on 1/25/2023 at 11:00 a.m.. The policy indicated, but was not limited to, "All patients referred to our Agency will receive a patient-specific, comprehensive assessment according to the Physician services ordered, to determine the immediate care and support needs of the patient" ... "Update of the Comprehensive Assessment: will be performed the last 5 days of every 60 days beginning with the start-of-care date (day 56-60)." ... "The Comprehensive Assessment must accurately reflect the patient's status and must include: 1. Current health, psychosocial, functional, & cognitive status/diagnosis. 2. Vital signs 3. Identification of additional health problems or pertinent health history 4. Data items collected at an in patient facility admissions or discharges only." ... "Follow- up (recertification) Assessments require a new plan of care, updated goals, reviewed medication sheet and revised HHA (home health aide) care plan (if applicable)." ... "Every skilled visit will have a physical assessment and routine assessment of patient's home for potential safety issues done and documented." ... "A comprehensive assessment is completed at recertification, post hospitalization, discharge, transfer, and readmission, and as a significant change in patient/patient's condition warrants." An interview was completed on 1/26/2023 at 10:48 a.m. with the Clinical Supervisor. The Clinical Supervisor agreed that the Plan of Care from recertification period 9/26/2022--11/24/2022 & the Plan of Care from the recertification period 11/25/2022--1/23/2023 appeared to be copied and pasted from one assessment to the next as it read word for word exactly the same in the nursing narrative note (60 day summary). The recertification period dated 11/25/2022--1/23/2023 nursing note indicated that the patient denied any infections, ER visits or hospitalizations during this certification period when in fact, the patient was admitted to the hospital from 1/12/2023--1/14/2023 for Hypoxia, Influenza A, COPD (chronic obstructive pulmonary disease) exacerbation, and hypertension. An interview was completed on 1/30/2023 at 11:00 a.m. with RN A. RN A indicated not being present, in the home of Patient 1 when completing the comprehensive assessment on 1/19/2023 for the next recertification period starting 1/24/2023. Indicated being present in the home with Patient 1 on 1/16/2023 completing the ROC (Resumption of Care) post hospitalization assessment and used that information to complete the recertification assessment for the next recertification period to start on 1/24/2023. Indicated only being in the home once the month of January, 1/16/2023. Patient 1 passed away in the home on 1/22/2023. 410 IAC 17-14-1 (a)(1)(B)

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to ensure that physician orders were followed in 1 of 7 records reviewed (Patient 6). Findings Include: A document titled, "Home Health Certification and Plan of Care," for the recertification period 12/21/2022 to 2/18/2023 was provided by the clinical supervisor on 1/27/2023 at 11:59 a.m.. The document indicated, but was not limited to, "Orders for Discipline and Treatments: Home Health Aide" ... "5-8 hours/day, 5-7 days/week x 60 days to assist with ADL's and IADL's." The complete medical record for Patient 6 was reviewed on 1/27/2023 and indicated the following HHA (Home Health Aide) visits: 12/21/2022 3 hour HHA visit 12/22/2022 4 hour HHA visit 12/23/2022 Missed HHA visit due to HHA car problems 12/25/2022--12/28/2022 Missed visits due to patient being out of town 12/29/2022 4 hour HHA visit 12/30/2022 4 hour HHA visit 1/2/2023 4 hour HHA visit 1/3/2023 4 hour HHA visit 1/4/2023 4 hour HHA visit 1/5/2023 4 hour HHA visit 1/6/2023 4 hour HHA visit 1/9/2023 Missed visit due to HHA illness 1/10/2023 4 hour HHA visit 1/11/2023 4 hour HHA visit 1/12/2023 4 hour HHA visit 1/13/2023 4.75 hour HHA visit 1/16/2023 5 hour HHA visit 1/17/2023 4 hour HHA visit 1/182023 4 hour HHA visit 1/19/2023 4 hour HHA visit 1/20/2023 4 hour HHA visit 1/23/2023 4 hour HHA visit 1/24/2023 4 hour HHA visit 1/25/2023 4 hour HHA visit 1/26/2023 4 hour HHA visit 1/27/2023 3 hour HHA visit 1/30/2023 4 hour HHA visit An interview with the Scheduling Supervisor on 1/31/2023 at 10:38 a.m. indicated that Patient 6 was not receiving 5-7 hours of HHA services by choice. The aide is only available for 4 hours a day and refuses any other HHA's services. This has been an ongoing concern of not meeting physician ordered services for greater than 1 year.

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 basic infection control standards were met during home visits completed by the RN (registered nurse) in 1 of 2 home visits completed (Patient 2). Findings Include: A policy titled, "Hand Washing," dated 7/2020 was provided by the Director of Indiana Signal Health Group Inc, on 1/303/2023 at 4:03 p.m. The policy indicated, but was not limited to, "Current CDC Hand Hygiene Guidelines:" ... " d. Clean hands before and after patient care and with each glove change." ... "Employees providing care/service in the homme will wash their hands at least:" ... " c. After touching inanimate object on or near the patient. d. After handling bed pans, urinals, catheters, linens. e. Before gloves are put on and after gloves are taken off." During a home visit on 1/30/2023 completed by RN A on Patient 2, surveyor observed a Foley catheter (urinary catheter) change assisted by HHA (Home Health Aide) B. A drape was placed under the patient's buttocks with no gloves on. The RN then donned new clean gloves without washing and/or sanitizing hands. The existing Foley catheter was removed and discarded. The RN then removed the dirty gloves and donned sterile gloves without performing hand hygiene. Supplies were opened and a new Foley catheter was inserted with bright yellow/orange colored urine observed draining from new Foley catheter. The sterile gloves were then removed, no hand hygiene completed and the dirty supplies were then discarded with no gloves on. The RN then sanitized her hands and secured the catheter collection bag to the patient's lower thigh. An interview with both the RN A and HHA B was completed on 1/30/2023 at 10:35 a.m.. Both the RN and the HHA B indicated that this patient frequently gets UTI's (urinary tract infections). HHA B indicated that the patient gets UTI's "all the time". RN A indicated that the UTI's have been contributed to the patient not wiping correctly post bowel movement so the family is now assisting the patient with this task. An interview with the patient's family was completed on 1/30/2023 at 10:45 a.m. The family indicated that the patient frequently gets UTI's and was hospitalized approximately one month ago for this. He noticed this week that Patient 6 was sleeping more than usual, a sign that the patient has another UTI, so he had taken her to the emergency room to be evaluated. Patient 6 was found to have a UTI and put on an antibiotic and antifungal medication to treat. 410 IAC 17-12-1(m)

Home health aide services CFR(s): 484.80 Condition of participation: Home health aide services. All home health aide services must be provided by individuals who meet the personnel requirements specified in paragraph (a) of this section. This CONDITION is not met as evidenced by: An Immediate Jeopardy related to 484.80 Home Health Aide Services was identified and announced on 1/26/2023 at 9:30 a.m. The agency's immediate jeopardy removal of immediacy plan and actions were determined to have removed the immediacy component of the immediate jeopardy on 1/27/2023 at 2:30 p.m.. The Immediate Jeopardy began on 1/8/2023 when the HHA (home health aide) N failed to notify the RN (registered nurse) of the change of Patient 1's health status. On 1/22/2023 HHA N found Patient 1 deceased in the home. Based on record review and interview the agency failed to ensure that HHA N reported a change in the patient's health condition to the RN that could have contributed to the patient's death resulting in an Immediate Jeopardy finding at 484.80 Home Health Aide Services, announced on 1/26/2023 at 9:30 a.m. in 1 of 1 agency reviewed (See G0750); failed to ensure training and competency evaluations for home health aides were completed by a contracted registered nurse (See G0788); failed to ensure the home health aide reported changes in patient's health condition (See G0804); and failed to ensure the home health aide provided quality care (See G0822). The cumulative effect of these systemic problems has resulted in the home health agency's inability to ensure provision of quality health care in a safe environment for the condition of participation 42CFR 484.80 Home Health Aide Services. In regards to G0750 findings Include: A document titled, "Job Title: Home Health Aide (HHA)," undated was provided by the Director of Indiana Signal Health Group Inc. on 1/25/2023 at 11:00 a.m. The document indicated but was not limited to, "Responsibilities/Essentials Functions" ... " Reports any changes in the patient's status or home situation immediately to the supervisor, staff nurse, or aide supervisor, including recognizing & reporting skin changes." Patient 1's clinical record was reviewed and HHA N documented the following notes that indicated, but was not limited to: 1/8/2023 ER visit last night for throat tightness. Found to have stricture. Given Hydroxyzine that helped & appointment with ENT. 1/9/2023 Trouble swallowing 1/10/2023 Cataract surgery this morning. Went well. Can see much better. Tired. 1/11/2023 Low grade fever. eye surgeon said anesthesia can cause low grade fevers sometimes. Tongue swelling, throat pain, ear pain, & headache. On call nurse called, awaiting call back. 1/12/2023--1/14/2023 Hospital admission for Hypoxia, Influenza A, COPD exacerbation, hypertension. 1/18/2023 Low grade fever and not feeling well. 1/19/2023 Fever. Low oxygen level. Appointment with doctor soon.. 1/20/2023 Very tired today. Took a nap, woke up very confused, unsure of where she was, lasted approximately 5 minutes. Complaining of pain in right ear. Scheduled appointment with Primary Care Physician next week. 1/21/2023 Fever free today. Still very weak and tired. Complaining of soreness in neck/shoulders. Muscles are very tight. Extremely weak and tired. Hasn't eaten much in a few days. The RN had not been contacted regarding the change in health status and symptoms on any of the days listed above except on 1/11/2023, however, no documentation was found noting where the RN called the patient or the HHA back on this day. A document titled, Discharge Summary" provided by the clinical manager on 1/25/2023 at 4:20 p.m., completed by RN A on 1/22/2023 indicated but was not limited to, "Patient found by HHA on floor and had passed away at some point before the HHA arrived. HHA had no indication of what had happened. Stated she was fine when she saw her last night." An interview was completed with the RN A on 1/25/2023 at 3:07 p.m.. RN A indicated that she had not been notified by HHA N of Patient 1's declining health status. Unaware of documented changes by HHA N of confusion, weakness, fever, pain, difficulty breathing, tongue swelling, pain, and not eating. Indicated that Patient 1 had a history of telling the HHA N one thing regarding her health, but then telling the RN something different, not consistent with health concerns. RN A was aware that Patient 1 was seen by a pain management physician on 1/19/2023, the day of the home visit for resumption of care, post hospitalization 1/12/2023--1/14/2023. An interview was completed with the Clinical Supervisor on 1/25/2023 at 1:15 p.m. During a interview, the Clinical Supervisor indicated that a message had been sent to HHA A asking if the RN had been notified of the changes in the patient's health status. HHA A had not responded to this message. The clinical supervisor indicated that HHA N and Patient 1 are mother and daughter. An interview was completed with the Clinical Supervisor on 1/26/2023 at 11:50 a.m. indicating that the Scheduling Supervisor had reached out to HHA N and was asked if the RN had been notified of the change in the Patient 1's health status. HHA N indicated that the RN was not notified. An interview was completed with HHA A on 1/27/2023 at 7:55 a.m.. HHA A indicated that all changes in the patient's health condition are reported to the RN. An interview was completed with HHA B on 1/30/2023 at 10:43 p.m.. HHA B indicated that any changes in the patient's health status, including falls, injuries, and changes in condition are reported to the RN.

Org. had partial/extended survey CFR(s): 484.80(f)(3) Was subjected to an extended (or partially extended) survey as a result of having been found to have furnished substandard care (or for other reasons as determined by CMS or the state); or This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure training and competency evaluations for HHA's (home health aides) were completed by the contracted RN (registered nurse) hired by the agency, as a result of condition level findings on the previous Federal and State survey dated 3/21/2022, in 1 of 1 agency reviewed. Findings Include: A survey on 3/21/2022 indicated but was not limited to, "Indiana Signal Health Group Skilled Inc is precluded from conducting a home health aide training or competency evaluation program for a period of two years beginning 3/21/2022 through 3/20/2024 for being out of compliance with §484.70 Condition of participation: Infection prevention and control and §484.105 Condition of participation: Organization and administration of services." Personnel records reviewed on 1/31/2023 indicated the following HHA's that received competency evaluations completed by the administrator of Indiana Signal Health Group Inc.: HHA C on 1/6/2023 HHA D on 1/18/2023 HHA E on 1/18/2023 HHA F on 10/4/2022 HHA G on 1/19/2023 HHA R on 1/9/2023 HHA H on 1/3/2023 HHA I on 1/19/2023 HHA J on 1/16/2023 Personnel records reviewed on 1/31/2023 indicated the following HHA's that received competency evaluations completed by the clinical supervisor of Indiana Signal Health Group Inc.: HHA B, date not documented on competency check list, however, hire date provided by agency indicates 5/1/2022. An interview with the Director of Indiana Signal Health on 1/25/2023 at 9:40 a.m. was completed. The Director of Signal Health indicated that the agency was not completing competency trainings on home health aide staff, only providing support if an aide is struggling with a task. An interview with the Director of Indiana Signal Health on 1/25/2023 at 10:44 a.m. was completed. The Director of Signal Health indicated that RN D (registered nurse) is still contracted by the agency to complete HHA competencies and that the administrator is only assisting HHA's that may need additional assistance. An interview with the Clinical Supervisor on 1/31/2023 at 2:47 p.m. was completed. Indicated that the understanding was that the agency could complete new hire competencies if the HHA is already registered with the State (active HHA). Indicated the agency owner also understood it this way.

Aides are members of interdisciplinary team CFR(s): 484.80(g)(4) Home health aides must be members of the interdisciplinary team, must report changes in the patient's condition to a registered nurse or other appropriate skilled professional, and must complete appropriate records in compliance with the HHA's policies and procedures. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure that the HHA N (home health aide) reported a change in the patient's health condition to the RN (registered nurse) that could have contributed to the patient's death in 1 of 1 agency reviewed. Findings Include: A document titled, "Job Title: Home Health Aide (HHA)," undated was provided by the Director of Indiana Signal Health Group Inc. on 1/25/2023 at 11:00 a.m. The document indicated but was not limited to, "Responsibilities/Essentials Functions" ... " Reports any changes in the patient's status or home situation immediately to the supervisor, staff nurse, or aide supervisor, including recognizing & reporting skin changes." Patient 1's clinical record was reviewed and HHA N documented the following notes that indicated, but was not limited to: 1/8/2023 ER visit last night for throat tightness. Found to have stricture. Given Hydroxyzine that helped & appointment with ENT. 1/9/2023 Trouble swallowing 1/10/2023 Cataract surgery this morning. Went well. Can see much better. Tired. 1/11/2023 Low grade fever. eye surgeon said anesthesia can cause low grade fevers sometimes. Tongue swelling, throat pain, ear pain, & headache. On call nurse called, awaiting call back. (No documentation found that the nurse called Patient 1 or HHA N back). 1/12/2023--1/14/2023 Hospital admission for Hypoxia, Influenza A, COPD exacerbation, hypertension. 1/18/2023 Low grade fever and not feeling well. 1/19/2023 Fever. Low oxygen level. Appointment with doctor soon.. 1/20/2023 Very tired today. Took a nap, woke up very confused, unsure of where she was, lasted approximately 5 minutes. Complaining of pain in right ear. Scheduled appointment with Primary Care Physician next week. 1/21/2023 Fever free today. Still very weak and tired. Complaining of soreness in neck/shoulders. Muscles are very tight. Extremely weak and tired. Hasn't eaten much in a few days. A document titled, Discharge Summary" provided by the clinical manager on 1/25/2023 at 4:20 p.m., completed by RN A on 1/22/2023 indicated but was not limited to, "Patient found by HHA on floor and had passed away at some point before the HHA arrived. HHA had no indication of what had happened. Stated she was fine when she saw her last night." An interview was completed with the RN A on 1/25/2023 at 3:07 p.m. RN A indicated that she had not been notified by HHA N of Patient 1's declining health status. Unaware of documented changes by HHA N of confusion, weakness, fever, pain, throat pain, tongue swelling, and not eating. Indicated that Patient 1 had a history of telling the HHA N one thing regarding her health, but then telling the RN something different, not consistent with health concerns. RN A was aware that Patient 1 was seen by a pain management physician on 1/19/2023, the day of the home visit for resumption of care, post hospitalization 1/12/2023--1/14/2023. An interview was completed with the Clinical Supervisor on 1/26/2023 at 11:50 a.m. indicating that the Scheduling Supervisor had reached out to HHA N and was asked if the RN had been notified of the change in the Patient 1's health status. HHA N indicated that the RN was not notified. An interview was completed with the Clinical Supervisor on 1/25/2023 at 1:15 p.m. During a record review, the Clinical Supervisor indicated that a message had been sent to HHA N asking if the RN had been notified of the changes in the patient's health status. HHA N had not responded to this message. An interview was completed with HHA A on 1/27/2023 at 7:55 p.m. HHA A indicated that all changes in the patient's health condition are reported to the RN. An interview was completed with HHA B on 1/30/2023 at 10:43 p.m. HHA B indicated that any changes in the patient's health status, including falls, injuries, and changes in condition are reported to the RN.

Ensuring the overall quality of care provided CFR(s): 484.80(h)(5)(i) Ensuring the overall quality of care provided by an aide; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure HHA (home health aide) N provided quality care due to the HHA failed to report a change in the patient's health condition to the RN (registered nurse) that could have contributed to the patient's death in 1 of 1 agency reviewed. Findings Include: A document titled, "Job Title: Home Health Aide (HHA)," undated was provided by the Director of Indiana Signal Health Group Inc. on 1/25/2023 at 11:00 a.m. The document indicated but was not limited to, "Responsibilities/Essentials Functions" ... " Reports any changes in the patient's status or home situation immediately to the supervisor, staff nurse, or aide supervisor, including recognizing & reporting skin changes." Patient 1's clinical record was reviewed and HHA N documented the following notes that indicated, but was not limited to: 1/8/2023 ER visit last night for throat tightness. Found to have stricture. Given Hydroxyzine that helped & appointment with ENT. 1/9/2023 Trouble swallowing 1/10/2023 Cataract surgery this morning. Went well. Can see much better. Tired. 1/11/2023 Low grade fever. eye surgeon said anesthesia can cause low grade fevers sometimes. Tongue swelling, throat pain, ear pain, & headache. On call nurse called, awaiting call back. (No documentation found of RN's call back to Patient 1 or HHA N). 1/12/2023--1/14/2023 Hospital admission for Hypoxia, Influenza A, COPD exacerbation, hypertension. 1/18/2023 Low grade fever and not feeling well. 1/19/2023 Fever. Low oxygen level. Appointment with doctor soon.. 1/20/2023 Very tired today. Took a nap, woke up very confused, unsure of where she was, lasted approximately 5 minutes. Complaining of pain in right ear. Scheduled appointment with Primary Care Physician next week. 1/21/2023 Fever free today. Still very weak and tired. Complaining of soreness in neck/shoulders. Muscles are very tight. Extremely weak and tired. Hasn't eaten much in a few days. A document titled, Discharge Summary" provided by the clinical manager on 1/25/2023 at 4:20 p.m., completed by RN A on 1/22/2023 indicated but was not limited to, "Patient found by HHA on floor and had passed away at some point before the HHA arrived. HHA had no indication of what had happened. Stated she was fine when she saw her last night." An interview was completed with the RN (registered nurse) A on 1/25/2023 at 3:07 p.m. RN A indicated that she had not been notified by HHA A of Patient 1's declining health status. Unaware of documented changes by the HHA of confusion, weakness, fever, pain, difficulty swallowing, tongue swelling, and not eating. Indicated that Patient 1 had a history of telling the HHA N one thing regarding her health, but then telling the RN something different, not consistent with health concerns. RN A was aware that Patient 1 was seen by a pain management physician on 1/19/2023, the day of the home visit for resumption of care, post hospitalization 1/12/2023--1/14/2023. An interview was completed with the Clinical Supervisor on 1/25/2023 at 1:15 p.m. During a record review, the Clinical Supervisor indicated that a message had been sent to HHA N asking if the RN had been notified of the changes in the patient's health status. HHA N had not responded to this message. An interview was completed with the Clinical Supervisor on 1/26/2023 at 11:50 a.m. indicating that the Scheduling Supervisor had reached out to HHA N and was asked if the RN had been notified of the change in the Patient 1's health status. HHA N indicated that the RN was not notified.

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102. Survey Dates: March 8th, 9th, 10th, 11th, 14th, 15th, 16th, 17th, 18th, and 21st of 2022. Census for last 12 months: 287 At this Emergency Preparedness survey, Indiana Signal Health Group Skilled Inc. was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 484.102. QR Completed 4/7/2022 A4

This visit was for a federal complaint investigation, recertification, and re-licensure of a Home Health Agency. Fully Extended Survey Announced: 3/9/2022 at 11:54 a.m.Complaint 61807 - substantiated with findingsFacility #: 013593Dates of Survey: 3/8/2022--3/21/2022 These deficiencies reflect State Findings cited in accordance with 410 IAC 17 Indiana Signal Health Group Skilled Inc is precluded from conducting a home health aide training or competency evaluation program for a period of two years beginning 3/21/2022 through 3/20/2024 for being out of compliance with §484.70 Condition of participation: Infection prevention and control and §484.105 Condition of participation: Organization and administration of services.

Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure that an updated comprehensive assessment was completed in 4 of 15 patients reviewed. (Patient 2, 6, 10, and 13) Findings Include: 1. A policy titled, "Assessments," dated 7/2020 was provided by Employee D at 1:00 p.m. The policy indicated, but was not limited to, "A comprehensive assessment is completed at recertification, post-hospitalization, discharge, transfer, and readmission and as a significant change in patient/patient's condition warrants." ... "Assessment is completed within time frame consistent with CMS regulations." 2. Record review completed on Patient 2, Certification Period 2/6/2022--4/6/2022 evidenced an incomplete comprehensive assessment (unsigned) dated 2/2/2022 by Employee C. 3. Record review completed on Patient 6, Certification Period 1/23/2022--3/23/2022 evidenced no comprehensive assessment was completed for this certification period. 4. Record review completed on Patient 10, Certification Period 6/20/21--8/18/2021 evidenced no comprehensive assessment was completed after this certification period. Patient 10 was not discharged until 10/7/2021, last visit in the home by a home health aide was on 9/17/2021. The record evidenced no comprehensive assessment/POC (plan of care) after 8/18/2021. 5. Record Review completed on Patient 13, Certification Period 12/25/2021--2/22/2022 evidenced no comprehensive assessment was completed after this certification period. 6. During an interview on 3/18/2022 at 10:00 a.m., Employee D indicated she was not surprised regarding the missing comprehensive assessments. No additional information was provided. 7. During an interview on 3/18/2022 at 1:10 p.m. Employee J was asked about the missing comprehensive assessments to which no further information was provided. 410 IAC 17-14-1(a)(1)(B)

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure a physician order was obtained for home health services in 1 of 14 patients reviewed. (Patient 11) Findings Include: 1. A policy titled, "Records: Clinical," dated 7/2020 was provided by Employee D on 3/21/2022 at 1:40 p.m. The policy indicated but was not limited to, "5. Clinical Record Contents" ... "j. All involved physicians' orders, verbal and written, including DNR's (Do Not Resuscitate) and any changes." 2. A document titled, "Discharge Announcement and Planning," dated 12/20/2021 was provided by Employee D on 3/18/2022 at 12:23 p.m. The summarized document was a handwritten plan for Patient 11 to receive home health services after discharge from the facility. No services were checked (ie., skilled nursing, physical therapy, occupational therapy, home health aide) and this form clearly stated "Please contact physician to obtain discharge order and any other orders checked below". 3. Record Review completed for Patient 11 on 3/17/2022: Certification Period 12/28/2021--2/25/2022. SOC (start of care) 12/28/2021. No authenticated physician order was obtained by the agency for SOC home health services. 4. An interview was completed with Employee D on 3/18/2022 at 12:23 p.m. Employee D provided a document titled, "Discharge Announcement and Planning" which indicated this was the physician order for services. Employee D indicated there were no specific services ordered on this document and was not an actual authenticated physician order. 410 IAC 17-13-1(a)

Infection prevention and control CFR(s): 484.70 Condition of Participation: Infection prevention and control. The HHA must maintain and document an infection control program which has as its goal the prevention and control of infections and communicable diseases. This CONDITION is not met as evidenced by: Based on record review and interview, the agency failed to ensure all staff were fully vaccinated and/or had religious exemptions authenticated/authorized by the Administrator and/or Clinical Manager (see G0687) and failed to ensure that direct care staff were provided with personal protective equipment and supplies (see G0682). The cumulative effect of these systemic problems resulted in the agency's inability to ensure quality health care in a safe environment for the Condition of Participation 484.70 Infection Prevention and Control.

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 and interview, the agency failed to ensure staff were supplied with appropriate PPE (personal protective equipment) to prevent the transmission of infectious agents in 1 of 1 agency. Findings Include: 1. A policy titled, "Recommended Equipment for Home Care (PPE)," was provided by Employee B on 3/11/2022 at 3:49 p.m. The policy indicated but was not limited to, "Personal protective equipment, which would be provided to employees by the home health care agency, as appropriate, includes: Disposable, nonsterile gloves and utility gloves. Disinfectants. Chemical germicides that are approved for use as hospital disinfectants and are tuberculocidal when used at recommended dilutions. Products registered by the Environmental Protection Agency (EPA) as being effective against human immunodeficiency virus (HIV) with an accepted HIV label. A solution of 5.25% sodium hypochlorite (household bleach) diluted to 1:10 with water. Mix a fresh supply of bleach every day (twenty-four (24) hours). Masks, cardiopulmonary resuscitation (CPR) masks, air-purifying masks, goggles, moisture-proof aprons/gowns, shoe covers, and caps. Leak-proof and puncture-proof specimen containers. Sharps containers. Liquid soap, soap towelettes, dry hand disinfectants (alcohol-based), sodium hypochlorite wipes, or dry bleach. Paper towels." 2. During an observation in the agency on 3/14/2022 at 11:49 a.m. A staff member entered the agency to obtain gloves. The interim administrator advised employee that she did not have access to the supply room to provide needed PPE. No other employees were present at the agency. The interim administrator advised the employee that Employee D would be in the office later in the afternoon and could obtain gloves at that time. Employee stated that gloves were needed now. The interim administrator offered to provide gloves stored in her car. 3. During an interview with the Clinical Manager on 3/8/2022 at 10:52 a.m., the clinical manager was unsure of how staff obtained needed supplies such as gloves, facemasks, etc. Suggested staff may come into the agency to pick up or supplies may be shipped to staff members' home but was unsure of the process. 4. A confidential interview was completed on 3/8/2022 at 11:49 p.m. The confidential interviewee indicated staff members were not being provided PPE. Some staff members in areas of greater distance to the agency did not have access to supplies. If staff members came into the agency to pick up supplies, they were given minimal supplies. For example, not given an entire box of gloves, instead provided with 6-8 pairs of gloves. Indicated that several staff members have complained regarding this practice. The confidential interviewee was advised that due to the high turnover rate of staff, providing full boxes of PPE was not cost-effective. 5. An interview was completed with Employee H on 3/9/2022 at 12:54 p.m. Employee H indicated there have been times when PPE was unavailable when needed. Employee H had to purchase masks on his/her own, both N95 masks & surgical masks. Typically supplies were delivered to staff members' homes or the patient's homes, usually by the marketers. No longer have marketers. 6. An interview was completed with Employee J on 3/9/2022 at 4:00 p.m. Employee J denied that staff members were not being provided appropriate PPE to complete their jobs. Advised of staff interviews suggesting otherwise. Indicated that these claims were not true. 410 IAC 17-12-1 (m)

COVID-19 Vaccination of Home Health Agency staff CFR(s): 484.70 (d)-(d)(3)(i-x) § 484.70 Condition of Participation: Infection Prevention and Control. (d) Standard: COVID-19 Vaccination of Home Health Agency staff. The home health agency (HHA) must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. For purposes of this section, staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for COVID-19 is defined here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine. (1) Regardless of clinical responsibility or patient contact, the policies and procedures must apply to the following HHA staff, who provide any care, treatment, or other services for the HHA and/or its patients: (i) HHA employees; (ii) Licensed practitioners; (iii) Students, trainees, and volunteers; and (iv) Individuals who provide care, treatment, or other services for the HHA and/or its patients, under contract or by other arrangement. (2) The policies and procedures of this section do not apply to the following HHA staff: (i) Staff who exclusively provide telehealth or telemedicine services outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section; and (ii) Staff who provide support services for the HHA that are performed exclusively outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section. (3) The policies and procedures must include, at a minimum, the following components: (i) A process for ensuring all staff specified in paragraph (d)(1) of this section (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the HHA and/or its patients; (ii) A process for ensuring that all staff specified in paragraph (d)(1) of this section are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations; (iii) A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19; (iv) A process for tracking and securely documenting the COVID-19 vaccination status of all staff specified in paragraph (d)(1) of this section; (v) A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC; (vi) A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law; (vii) A process for tracking and securely documenting information provided by those staff who have requested, and for whom the HHA has granted, an exemption from the staff COVID-19 vaccination requirements; (viii) A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws, and for further ensuring that such documentation contains (A) All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and (B) A statement by the authenticating practitioner recommending that the staff member be exempted from the HHA's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications; (ix) A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and (x) Contingency plans for staff who are not fully vaccinated for COVID-19. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure all employees were either fully vaccinated for COVID-19 or had an authorized religious or medical exemption on file in 1 of 1 agency reviewed. This had the potential to affect all agency patients. Findings Include: 1. A policy titled, "COVID-19 Vaccine Mandate," dated 1/2022 was adopted by the governing body on December 17th, 2021. This policy was provided by Employee B on 3/10/2022 at 12:00 p.m. The policy indicated, but was not limited to, "Indiana Signal Health Group Skilled requires all employees to provide proof of their initial COVID-19 vaccine status by Monday, February 14, 2022 (2/14/2022), and the second dose by Tuesday, March 15, 2022 (3/15/2022), or submit a valid exemption, medical for religious, per CMS rule. Employees are defined as direct hire, contracted staff, office staff, and volunteers." ... "The only exceptions allowed will be a medical exemption or an exemption for a sincerely held religious belief, please see the COVID-19 Vaccine Exemptions Policy P:67 for further detail. Documentation will be given to the Administrator and/or Director of Nursing, who will then ensure the documentation is logged and filed in the confidential health information portion of the Personnel file. Religious exemptions are only approved by the Administrator and/or Director of Nursing per the Vaccine Exemption policy." ... "If employees do not provide evidence of their vaccinated status or have an exemption approved by the Administrator and/or DON (director of nursing) on file by February 14, 2022 (2/14/2022), and the second dose by March 15, 2022 (3/15/2022), they will be required to be reassigned where no client contact, office contact, or any contact with the agency is possible." ... "Clinical considerations will include: 1. PPE for all employees. All staff will be required to wear surgical masks when in the office and providing patient care and/or when patient contact is occurring. Unvaccinated staff will wear a surgical mask that is NIOSH-approved N95 or equivalent or higher level respirator for source control at all times of patient contact. 2. Daily screening log by all direct care workers which will show temperature, any symptoms. 3. Frequent testing of unvaccinated employees. a. Acceptable evidence for continuous testing will be either i. Antigen (testing 2x's weekly) ii. molecular (PCR testing 1x weekly) b. Testing will be one to two times weekly." ... "Unvaccinated direct care workers may not provide care to: a patient diagnosed with COVID-19, unvaccinated patients, immunocompromised patients." 2. A policy titled, "COVID-19 Exemptions," dated 1/2022 was approved by the governing body on December 17, 2021. This policy was provided by Employee B on 3/10/2022 at 12:00 p.m. The policy indicated, but was not limited to, The Administrator/Director of Nursing approves and signs the Religious Exemption Form." ... "2. A religious exemption may be accepted based on the following criteria: A complete Religious Exemption Form is filled out and signed by the staff member." 3. A document titled, "Governing Body Meeting Minutes," dated December 17, 2021, was provided by RN C on 3/21/2022 at 11:50 a.m. The document indicated, but was not limited to, "There was a special meeting held today with President and Governing Body. The purpose was to discuss Covid-19 policy. Meeting called to enforce Covid Vaccine mandate policy. All staff must be either vaccinated or provide religious or medical exemption by 12/31/21." 4. A document titled, "COVID-19 Vaccination Religious Exemption Request Form" was provided by Employee B on 3/10/2022 at 12:00 p.m. The summarized form was the form developed to be used to submit all religious exemptions that include the employee's name, job title, supervisor, documentation of religious belief, and employee signature. Office Use Only section contains date received, approval, alternate safety precautions taken including PPE (personal protective equipment) and testing, along with staff approval signature, title, date." 5. A complete personnel record review was completed on all direct care staff, contracted staff, office staff, and volunteers which was a total of 75 staff members. 40 of the 75 staff members (53%) were either unvaccinated or had a religious exemption on file that was not approved by the Administrator or Director of Nursing. Thirty-seven (37) employees submitted a religious exemption to the agency that was not authorized by the Administrator or Director of Nursing. Two (2) employees had only received the first dose in a two-dose series and one (1) employee had no documentation of any vaccinations on file. Personnel Record Reviews evidenced the following: Unvaccinated Staff: Employee BB, Employee CC, Employee DD Unauthorized Religious Vaccinations: Employee AA, Employee EE, Employee FF, Employee GG, Employee HH, Employee II, Employee JJ, Employee KK, Employee LL, Employee MM, Employee NN, Employee Q, Employee OO, Employee PP, Employee P, Employee QQ, Employee RR, Employee SS, Employee TT, Employee UU, Employee VV, Employee WW, Employee XX, Employee YY, Employee ZZ, Employee AAA, Employee BBB, Employee CCC, Employee DDD, Employee EEE, Employee FFF, Employee GGG, Employee V, Employee S, Employee SSS, Employee III, and Employee JJJ. 6. On 3/15/2022 at 9:33 a.m., Employee D was provided a list of items still needed to complete the survey process, including employee COVID-19 Vaccination/Exemption records. 7. On 3/15/2022 at 11:00 a.m., Employee D was advised all requested information, including employee COVID-19 Vaccination/Exemption records, be provided by tomorrow morning (3/16/2022). 8. On 3/15/2022 at 12:29 p.m., advised the owner all requested information be provided by tomorrow morning (3/16/2022). 9. During an interview on 3/16/2022 at 9:20 a.m., Employee D indicated he/she was still working on COVID-19 vaccination/exemption list and would provide in one hour. 10. An email was sent to Employee D on 3/17/2022 requesting COVID-19 vaccination/exemption information. 11. A phone interview was completed with Employee D on 3/17/2022. Indicated a list of COVID-19 vaccinations/exemptions for staff members had been sent via email. Still working on scanning vaccination cards and exemptions. Did not have a vaccination card for Employee E or Employee F. Attempting to contact both employees to obtain vaccination cards. 12. During a phone interview on 3/17/2022 at 3:09 p.m., Employee D indicated information sent on staff vaccine list was not current staff information. 13. During a phone interview with the owner on 3/17/2022 at 3:20 p.m., advised the COVID-19 vaccination/exemption list was not current and still not available. 14. A phone interview was completed with the owner on 3/17/2022 at 3:40 p.m. Indicated owner would email the current list of staff with vaccinations/exemptions in 20 minutes. 15. Received an email from the owner with a copy of all staff vaccinations/exemptions. Employee E did not have a vaccine card on file. Indicated this was missed. Owner attempting to contact Employee E to obtain information. 16. On 3/18/2022 at 2:15 p.m. received a message on phone from the owner stating that the personnel list with COVID-19 vaccinations/exemptions provided was the incorrect list. Stated it was pulled from her corporate office dropbox which includes other agencies that she owns. Stated that the 15 staff members that were not vaccinated are employed elsewhere. 17. On 3/21/2022 at 11:45 a.m. owner provided a new list of employees with COVID-19 vaccinations/exemptions. Indicated that all employees should have a vaccination or exemption on file. 410 IAC 17-12-1(m)

Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA's policies and procedures. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure that employees were knowledgeable of and had access to P & P (policies and procedures) in 1 of 1 agency. Findings Include: 1. A policy titled, "Policy and Procedure Development Process," dated 7/2020 was provided by Employee D on 3/16/2022 at 9:20 a.m. The policy indicated, but was not limited to, "2. The Policy and Procedure manual will be available to physicians, staff, patients, visitors, family members, and third-party agencies upon request. 3. The Policy and Procedures manual will be made available for ongoing staff education and orientation." 2. During an interview on 3/8/2022 at 10:52 a.m., the Clinical Manager indicated that P & P's were available on "drop-box", and online application, however, she did not know how to navigate the site to obtain needed policies & procedures. Unsure where the printed P & P's are kept, but indicated they are in binders. Unsure if staff had access to P & P in "dropbox" or know where the binders are kept. 3. During a confidential interview on 3/8/2022 at 11:49 a.m., the confidential interviewee advised there are multiple policy binders due to several agency name changes, and staff did not know which policies to follow. Indicated the policies were supposed to be accessed in the "drop-box", an online edition, however, staff either do not have access to this option or do not know how to navigate it. Indicated there were three different employee handbooks and staff were unsure which one to provide to new hires. They were not required to sign upon receipt of the handbook provided. 4. During an interview on 3/8/2022 at 12:35 p.m., Employee T indicated newly hired staff were educated on certain policies, HIPPA (privacy), body mechanics, infection control, etc. upon hire and were provided a handbook that did not require obtaining employee signatures upon receipt of handbook. Not all policies were covered during orientation. 5. During an interview on 3/9/2022 at 4:00 p.m., the owner indicated there were updated policies and procedures located in "dropbox" which all employees have access to. The owner indicated all employees have access to and should know how to navigate the online option.

Org. had partial/extended survey CFR(s): 484.80(f)(3) Was subjected to an extended (or partially extended) survey as a result of having been found to have furnished substandard care (or for other reasons as determined by CMS or the state); or This ELEMENT is not met as evidenced by: Based on interview, the agency was subjected to an extended survey as a result of substandard care, (Lack of Administrator/Alternate Administrator & Clinical Manager/Alternate Clinical Manager) in 1 of 1 agency reviewed. Findings Include: 1. An interview was completed with the administrator and clinical manager on 3/8/2022 at 4:00 p.m. The administrator and clinical manager discussed their resignation effective immediately. The Administrator indicated the owner had already been notified of resignation. Felt the agency had too many issues, unable to fix. Struggled with the owner to make needed changes. Had to prove why things needed to change by showing owner regulations. The Clinical Manager indicated if the Administrator resigned, she would resign as well. The Administrator also served as the Alternate Clinical Manager and the Clinical Manager served as the Alternate Administrator. 2. An interview was completed with Employee D on 3/9/2022 at 9:20 a.m., upon entering the agency. Employee D indicated both the Administrator/Alternate Clinical Manager and the Clinical Manager/Alternate Administrator did not show up for work that day. They were not answering any phone calls. All equipment including work cell phones and computers were left at the agency yesterday. 3. An interview was completed with the owner on 3/9/2022 at 9:25 a.m. Advised by the owner that the Administrator and Clinical Manager were no longer working for the agency. Both resigned as of yesterday with no notice provided. Plan to hire a new Administrator and Clinical Manager but they cannot start for 3 weeks. Discussing with staff regarding appointing an Interim Administrator, a registered nurse, already employed with the agency. 6. An interview was completed with the owner on 3/9/2022 at 11:54 a.m. The owner was notified of an Extended Survey due to a lack of Administrator/Alternate Administrator & Clinical Manager/Alternate Clinical Manager. Indicated the governing body included self and CFO (Chief Financial Officer). The owner indicated she would be the point of contact for the survey, however, would only be available by phone, as she lives in [another state]. Indicated the CFO is unavailable for a few weeks as she is out of the state.

Deficiencies that endangered health/safety CFR(s): 484.80(f)(5) Was found to have compliance deficiencies that endangered the health and safety of the HHA's patients, and had temporary management appointed to oversee the management of the HHA; or This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the Administrator and Clinical Manager were available to oversee the management of the agency in 1 of 1 agency observed. Findings Include: 1. An interview was completed with the administrator and clinical manager on 3/8/2022 at 4:00 p.m. The administrator and clinical manager discussed their resignation effective immediately. The Administrator indicated the owner had already been notified of resignation. The Clinical Manager indicated if the Administrator resigned, she would resign as well. The Administrator also served as the Alternate Clinical Manager and the Clinical Manager served as the Alternate Administrator. 2. An interview was completed with Employee D on 3/9/2022 at 9:20 a.m., upon entering the agency. Employee D indicated both the Administrator/Alternate Clinical Manager and the Clinical Manager/Alternate Administrator did not show up for work that day. They were not answering any phone calls. All equipment including work cell phones and computers were left at the agency yesterday. 3. An interview was completed with the owner on 3/9/2022 at 9:25 a.m. Advised by the owner that the Administrator and Clinical Manager were no longer working for the agency. Both resigned as of yesterday with no notice provided. Plan to hire a new Administrator and Clinical Manager but they cannot start for 3 weeks. Discussing with staff regarding appointing an Interim Administrator, a registered nurse, already employed with the agency. 4. An interview was completed with the owner on 3/9/2022 at 11:54 a.m. The owner was notified of an Extended Survey due to a lack of Administrator/Alternate Administrator & Clinical Manager/Alternate Clinical Manager. The owner indicated the governing body includes self and CFO (Chief Financial Officer). The owner indicated she would be the point of contact for the survey, however, would only be available by phone, as she lives out of state. Indicated that CFO was unavailable due to out of state for the next few weeks.

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 record review and interview, the agency failed to ensure home health aide visits were completed per physician order in 3 of 14 records reviewed. (Patient 6, 7, 9) Findings Include: 1. A policy titled, "Interruption in Services/Missed Visits," dated 7/2020 was provided by Employee D on 3/21/2022 at 1:00 p.m. The policy indicated but was not limited to, "Missed Visit Process: When a missed visit occurs, a 'missed visit' form is completed to clarify/explain why visits have not occurred. It does not apply to a one-time missed visit occurrence when the visit was rescheduled for another day in the same week the visit was to occur. When an interruption occurs due to a missed visit, the following procedures will be followed: a. Complete the 'Missed Visit' form, including the explanation why visit did not occur per the POC (plan of care) or must be temporarily halted (ie Hospitalization) and anticipated length of hold, if known. b. If the Agency misses visits or services as required by the plan of care, the Agency must notify the responsible physician of the missed visit if there is any potential for clinical impact upon the patient."... "c. All documentation will be filed in the patient chart." 2. Medical Record reviewed for Patient 6 on 3/16/2022: Certification Period 1/23/2022--3/23/2022. Physician order as follows: HHA 1-2 hours a day, 5-7 days a week. One missed visit the week of 1/2/2022--1/29/2022. One missed visit the week of 3/6/2022--3/12/2022. 3. Medical Record reviewed for Patient 7 on 3/16/2022: Certification Period 1/15/2022--3/15/2022. Physician order as follows: HHA 1 hour a day, 3 days a week AND HHA 2 hours a day, 1 day a week. During the week of 1/16/2022--1/22/2022, only one 2 hours HHA visit was completed. During the week of 1/23/2022--1/29/2022, no HHA visits were completed. 4. Medical Record reviewed for Patient 9 on 3/9/2022: Certification Period 1/7/2022--3/10/2022. Physician order as follows: HHA 13 hours a day, 7 days a week AND 8 hours a day, 5 days a week (unless patient in school). Missed visits were found on 1/10/2022--1/16/2022, 1/24/2022--1/30/2022, 2/7/2022--2/13/2022, 2/21/2022--2/27/2022, 3/1/2022, 3/6/2022--3/8/2022. 5. During an interview on 3/18/2022 at 9:08 a.m. Employee D indicated there was a missed visit binder with every patient included, however, this information was not always placed in the patient's electronic medical record.

Aides are members of interdisciplinary team CFR(s): 484.80(g)(4) Home health aides must be members of the interdisciplinary team, must report changes in the patient's condition to a registered nurse or other appropriate skilled professional, and must complete appropriate records in compliance with the HHA's policies and procedures. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure HHA's (home health aides) completed documentation of tasks and authenticated services provided in 3 of 14 records reviewed. (Patient 3, 7, and 10) Findings Include: 1. A policy titled, "Records: Clinical, " dated 7/2020 was provided by Employee D on 3/21/2022 at 1:40 p.m. The policy indicated but was not limited to, "Clinical Record Documentation: Entry Basics: All record entries into the clinical record, by all disciplines, are written at the time of the service rendered, by the primary person providing the care/service and shall be incorporated into the patent's clinical record within 7 days of the delivery of service." ..."Documentation standards include: a. Entries that are legible, clear, complete, concise, appropriately authenticated (must include a signature and title, or a secured computer entry by a unique identifier or a primary author who has reviewed and approved the entry)." ... "General: Clinical records are:" ... "Used as a legal document that is descriptive of care and services provided." 2. Record review was completed on 3/14/2022 for Patient 3: Certification Period 2/8/2022--4/8/2022. Missing Home Health Aide Signatures on tasks completed were found from 2/9/2022 through 3/14/2022. 3. Record review was completed on 3/16/2022 for Patient 7: Certification Period 1/15/2022--3/15/2022. Missing Home Health Aide Signatures on tasks completed were found on 1/17/2022, 1/31/2022, 2/1/2022, 2/2/2022, 2/7/2022, 2/8/2022, 2/9/2022, 2/11/2022, 2/14/2022, 2/15/2022, 2/16/2022, 2/18/2022, 2/21/2022, 2/22/2022, 2/23/2022, 2/25/2022, 2/28/2022, 3/1/2022, 3/2/2022, 3/4/2022, 3/7/2022, 3/8/2022, 3/9/2022, 3/11/2022, 3/14/2022 and 3/15/2022. 4. Record review was completed on 3/17/2022 for Patient 10: Certification Period 6/20/2021--8/18/2021. Home Health Aide (individual tasks) were found to be not documented on the weeks of 6/21/2021--6/25/2021, 6/28/2021--7/2/2021, 7/5/2021--7/9/2021, 7/12/2021--7/16/2021, 7/19/2021--7/23/2021, 7/26/2021--7/30/2021, 8/2/2021--8/6/2021, 8/9/2021--8/13/2021, and 8/16/2021--8/18/2021. 5. An interview was completed on 3/15/2022 at 11:47 p.m. Employee D indicated HHA is not signing daily documentation after completing tasks. Could not provide a reason for missing signatures. 7. During an interview on 3/18/2022 at 10:00 a.m., Employee D was asked about Patient 10's home health aide tasks not completed. No further information was provided.

Non-skilled direct observation every 60 days CFR(s): 484.80(h)(2) If home health aide services are provided to a patient who is not receiving skilled nursing care, physical or occupational therapy, or speech-language pathology services, the registered nurse must make an on-site visit to the location where the patient is receiving care no less frequently than every 60 days in order to observe and assess each aide while he or she is performing care. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure HHA (home health aide) supervisory visits were completed by the RN (registered nurse) every 60 days when skilled services were not provided in 8 of 15 records reviewed. (Patient 1, 2, 3, 5, 6, 9, 13, and 15) Findings Include: 1. A policy titled, "Supervision: Clinical Staff," dated 7/2020 was provided by Employee G on 3/8/2022 at 2:06 p.m. The policy indicated, but was not limited to, "Non-skilled Cases: For a patient not receiving skilled services, supervision by an on-site visit: At least every 60 days by a RN (registered nurse). The staff member will be present during the visit." 2. Record Reviews on the following patients confirmed missing HHA supervisory visits: Patient 1, Certification Period Reviewed 1/30/2022--3/29/2022 HHA Supervisory visits were not completed in January or February of 2022. Patient 2, Certification Period Reviewed 12/8/2021--2/5/2022 HHA Supervisory visits were incomplete in February 2022 (incomplete/unsigned documentation). Patient 3, Certification Period Reviewed 1/9/2022--3/9/2022 HHA Supervisory visits were not completed in February 2022. Patient 5, Certification Period Reviewed 2/1/2022--4/2/2022 HHA Supervisory visits were not completed in March 2022. Patient 6, Certification Period Reviewed 11/24/2021-1/22/2022 & 1/23/2022--3/23/2022 HHA Supervisory visits were not completed in January 2022. Patient 9, Certification Period Reviewed 1/7/2022--3/10/2022 HHA Supervisory visits were not completed in February and March of 2022. Patient 13, Certification Period Reviewed 12/25/2021--2/22/2022 HHA Supervisory visits were not completed in February or March of 2022. Patient 15, Certification Period Reviewed 1/15/2022--3/15/2022 HHA Supervisory visits were not completed in January, February, March of 2022. 3. During an interview on 3/8/2022 at 10:52 a.m., Employee G indicated supervisory visits with home health aide services only are to be completed every 30 days, while supervisory visits with skilled services are to be completed every 14 days. Unaware of any supervisory visits not being completed. Indicated most supervisory visits are being completed via phone due to the COVID-19 pandemic. 4. A confidential interview was completed on 3/8/2022 at 11:49 a.m. The confidential interviewee indicated supervisory visits were not being completed per policy, especially for patients residing in the outlying areas. 5. During an interview on 3/9/2022 at 4:00 p.m., the owner indicated staff was hired to oversee supervision as she lives in [name of state] and they failed to follow through with this requirement. 410 IAC 17-14-1(n)

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: Based on observation, record review, and interview the agency failed to ensure an Administrator/Alternate Administrator and Clinical Manager/Alternate Clinical Manager were on staff to oversee and manage all employees and patient care and services (see G0944);the administrator failed to report to the governing body (see G0946); administrator failed to be responsible for all day to day operations (see G0948); administrator failed to ensure the clinical manager was available during all operating hours (see G0950); administrator failed to ensure qualified personnel was hired (see G0952); administrator failed to ensure in his/her absence a qualified, pre-designated person assumed administrator role (see G0954); administrator failed to ensure availability of administrator or pre-designated person was available during all operating hours (see G0956); the Clinical Manager failed to ensure oversight of all patient care services and employees (see G0958); clinical manager failed to ensure patient and personnel assignments were completed (see G0960); clinical manager failed to ensure patient care was coordinated (see G0962); clinical manager failed to ensure referrals were coordinated (see G0964; clinical manager failed to ensure patients' needs were continually assessed (see G0966); and the clinical manager failed to ensure the development, implementation, and updates of the plan of care (see G0968). The cumulative effect of these systemic problems resulted in the agency’s inability to ensure the provision of quality health care in a safe environment for the Condition of Participation 484.105 Organization and administration of services.

Administrator must: CFR(s): 484.105(b)(1) Standard: Administrator. The administrator must: This STANDARD is not met as evidenced by: Based on record review and interview, the administrator failed to complete all responsibilities/obligations within the agency in 1 of 1 agency reviewed. Findings Include: 1. A policy titled, "Administrator/Alternate Administrator," dated 7/2020 was provided by Employee B on 3/10/2022 at 1:50 p.m. The policy indicated but was not limited to, "Administrator: responsibilities include, but are not limited to: Planning, organizing, directing and evaluating day to day agency operations to ensure the provision of adequate and appropriate care/services. Maintain ongoing communication between the Governing Body and staff. Ensure the clinical manager is available during all hours of operation. Complying with applicable laws and regulations. Ensuring that the following are made available to the Commissioner upon request: Reports, records, minutes, documentation, information, and files (within 72 hours of request). Fiscal planning, budgeting (yearly), and management of operations in accordance with established fiscal parameters. Implementing Governing Body directives. Oversight of Agency personnel to include recruiting, employing, and retaining qualified personnel to maintain appropriate staffing levels, evaluations for direct reports, complaint resolution. Directing and monitoring organizational QA activities. Ensuring staff development including orientation, ongoing in-service education, continuing education, and evaluation of staff. Assuring that skilled nursing and other therapeutic services furnished are under the supervision and direction of a physician or registered nurse. Assuring appropriate staff supervision during all operating hours. Ensuring the accuracy of public information materials. Appointing a similarly qualified alternate (approved by Governing Body), if not appointed by Governing Body. Reviews/evaluates existing policies/procedures annually by means of the Agency Annual Evaluation. Acts as a Chairperson for the Advisory Committee or appoints same. Prepares reports/summaries on Agency activity for the Governing Body. Determines organization lines of authority/communication and fixes areas of responsibility. In regular contact with local, state, and nation associations/participates in meetings, conventions, etc. Cooperates with health and related agencies to increase/improve services to the community, developing an open positive rapport. Handles complaints not resolved at Clinical Manager level. Accommodates Federal, State, and regulatory personnel/surveyors during site visits. Acts as the Agency Privacy Officer. Serves as the Agency Disaster Coordinator. Serves as the agency Civil Rights/Section 1557 Coordinator. Other duties as assigned." 2. An interview was completed with the administrator and clinical manager on 3/8/2022 at 4:00 p.m. The administrator and clinical manager discussed their resignation effective immediately. The Administrator indicated the owner had already been notified of resignation. The Clinical Manager indicated if the Administrator resigned, she would resign as well. The Administrator also served as the Alternate Clinical Manager and the Clinical Manager served as the Alternate Administrator. 3. During an interview on 3/9/2022 at 9:20 a.m., upon entering the agency, Employee D indicated both the Administrator/Alternate Clinical Manager and the Clinical Manager/Alternate Administrator did not show up for work that day. They were not answering any phone calls. All equipment including work cell phones and computers were left at the agency yesterday. 4. During an interview on 3/9/2022 at 9:25 a.m., the owner indicated the Administrator and Clinical Manager were no longer working for the agency. Planned to hire a new Administrator and Clinical Manager but they could not start for 3 weeks. Discussed with staff regarding appointing an Interim Administrator, a registered nurse, already employed with the agency to fill in. 5. An interview was completed with the owner on 3/9/2022 at 11:54 a.m. The owner was notified of an Extended Survey due to a lack of Administrator/Alternate Administrator & Clinical Manager/Alternate Clinical Manager. Indicated the governing body includes self and CFO (Chief Financial Officer). The owner indicated she would be the point of contact for the survey, however, would only be available by phone, as she lived out of state. Indicated that CFO was unavailable for the next few weeks.

Administrator appointed by governing body CFR(s): 484.105(b)(1)(i) (i) Be appointed by and report to the governing body; This ELEMENT is not met as evidenced by: Based on record review and interview, the Administrator failed to report to the governing body in 1 of 1 agency reviewed. Findings Include: 1. A policy titled, "Administrator/Alternate Administrator," dated 7/2020 was provided by Employee B on 3/10/2022 at 1:50 p.m. The policy indicated but was not limited to, "Administrator: responsibilities include, but are not limited to:" ... "maintain ongoing communication between the Governing Body and staff." 2. An interview was completed with the administrator and clinical manager on 3/8/2022 at 4:00 p.m. The administrator and clinical manager discussed their resignation effective immediately. The Administrator indicated the owner had already been notified of resignation. 3. During an interview on 3/9/2022 at 9:20 a.m., upon entering the agency, Employee D indicated both the Administrator/Alternate Clinical Manager and the Clinical Manager/Alternate Administrator did not show up for work today. 4. During an interview on 3/9/2022 at 9:25 a.m., the owner indicated the Administrator and Clinical Manager were no longer working for the agency. Plan to hire a new Administrator and Clinical Manager but they cannot start for 3 weeks. 410 IAC 17-12-1(b)(1)

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on record review interview, the agency failed to ensure the day-to-day operations of the agency were met in 1 of 1 agencies observed. Findings Include: 1. A policy titled, "Administrator/Alternate Administrator," dated 7/2020 was provided by Employee B on 3/10/2022 at 1:50 p.m. The policy indicated, but was not limited to, "1. Administrator: responsibilities include: but are not limited to: Planning, organizing, directing, and evaluating day to day agency operations to ensure the provision of adequate and appropriate care/services." 2. An interview was completed with the administrator and clinical manager on 3/8/2022 at 4:00 p.m. The administrator and clinical manager discussed their resignation effective immediately. 3. During an interview on 3/9/2022 at 9:20 a.m., upon entering the agency, Employee D indicated both the Administrator/Alternate Clinical Manager and the Clinical Manager/Alternate Administrator did not show up for work today. They were not answering any phone calls. All equipment including work cell phones and computers were left at the agency yesterday. 4. During an interview on 3/9/2022 at 9:25 a.m., the owner indicated the Administrator and Clinical Manager were no longer working for the agency. Plan to hire a new Administrator and Clinical Manager but they cannot start for 3 weeks. 5. An interview was completed with the owner on 3/9/2022 at 11:54 a.m. who indicated the governing body includes self and CFO (Chief Financial Officer). The owner indicated she would be the point of contact for the survey, however, will only be available by phone, as she lived out of state. Indicated that CFO for the next few weeks. 410 IAC 17-12-1(b)(3)

Ensure clinical manager is available CFR(s): 484.105(b)(1)(iii) (iii) Ensure that a clinical manager as described in paragraph (c) of this section is available during all operating hours; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure a Clinical Manager was available during all operating hours in 1 of 1 agency observed. Findings Include: 1. A policy titled, "Clinical Manager/Alternate Clinical Manager," dated 7/2020 was provided by Employee B on 3/10/2022 at 1:50 p.m. The policy indicated, but was not limited to, "A Clinical Manager is available during all agency operating hours (all hours staff from the agency are providing services for patients)." 2. An interview was completed with the administrator and clinical manager on 3/8/2022 at 4:00 p.m. The administrator and clinical manager discussed their resignation effective immediately. 3. During an interview on 3/9/2022 at 9:20 a.m., upon entering the agency, Employee D indicated both the Administrator/Alternate Clinical Manager and the Clinical Manager/Alternate Administrator did not show up for work today. 4. An interview was completed with the owner on 3/9/2022 at 9:25 a.m. Advised by the owner the Administrator and Clinical Manager were no longer working for the agency. Plan in place to hire a new Administrator and Clinical Manager but they cannot start for 3 weeks. 5. An interview was completed with the owner on 3/9/2022 at 11:54 a.m. The owner indicated she would be the point of contact for the survey, however, would only be available by phone, as she lived out of state. The owner indicated the CFO (Chief Financial Officer) was unavailable for the next few weeks. 410 IAC 17-12-1(d)

Ensures qualified pre-designated person CFR(s): 484.105(b)(2) When the administrator is not available, a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator. The pre-designated person may be the clinical manager as described in paragraph (c) of this section. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure a qualified, pre-designated person was available to assume responsibility/obligations in his/her absence in 1 of 1 agency observed. Findings Include: 1. A policy titled, "Administrator/Alternate Administrator," dated 7/2020 was provided by Employee B on 3/10/2022 at 1:50 p.m. The policy indicated but was not limited to, "2. Alternate Administrator: The governing body/Administrator will appoint an Alternate Administrator, who will act as the Agency Alternate Administrator should the Administrator be absent from the Agency, and assume all the duties/responsibilities of the Administrator as well as be available during all operating hours of the Agency." 2. An interview was completed with the administrator and clinical manager on 3/8/2022 at 4:00 p.m. The administrator and clinical manager discussed their resignation effective immediately. The Administrator and Clinical Manager both step in as each others alternates. 3. During an interview on 3/9/2022 at 9:20 a.m., upon entering the agency, Employee D indicated both the Administrator/Alternate Clinical Manager and the Clinical Manager/Alternate Administrator did not show up for work today. 4. During an interview on 3/9/2022 at 9:25 a.m., the owner indicated the Administrator/Alternate Clinical Manager and Clinical Manager/Alternate Administrator were no longer working for the agency. Plan to hire a new Administrator/Alternate Clinical Manager and Clinical Manager/Alternate Administrator but they cannot start for 3 weeks. 410 IAC 17-12-1(c)(8)

Available during all operating hours CFR(s): 484.105(b)(3) The administrator or a pre-designated person is available during all operating hours. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the administrator was available during all operating hours in 1 of 1 agency reviewed. Findings Include: 1. A policy titled, "Administrator/Alternate Administrator," dated 7/2020 was provided by Employee B on 3/10/2022 at 1:50 p.m. The policy indicated but was not limited to, "It is the policy of the Agency for the Governing Body to designate in writing, a qualified professional to act as the Agency Administrator and for the Governing Body/Administrator, to select a pre-designated Alternate Administrator to act in the absence of the Agency Administrator. Both will be available during all operating hours." ... "The Governing Body/Administrator will appoint an Alternate Administrator, who will act as the Agency Alternate Administrator should the Administrator be absent from the Agency, and assume all the duties/responsibilities of the Administrator as well as be available during all operating hours of the Agency." 2. An interview was completed with the administrator and clinical manager on 3/8/2022 at 4:00 p.m. The administrator and clinical manager discussed their resignation effective immediately. The Administrator also serves as the Alternate Clinical Manager and the Clinical Manager serves as the Alternate Administrator. 3. During an interview on 3/9/2022 at 9:20 a.m., upon entering the agency, Employee D indicated both the Administrator/Alternate Clinical Manager and the Clinical Manager/Alternate Administrator did not show up for work that day. 4. An interview was completed with the owner on 3/9/2022 at 9:25 a.m. who indicated the Administrator and Clinical Manager were no longer working for the agency. Plan to hire a new Administrator and Clinical Manager but they cannot start for 3 weeks.

Clinical manager CFR(s): 484.105(c) Standard: Clinical manager. One or more qualified individuals must provide oversight of all patient care services and personnel. Oversight must include the following-- This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure a Clinical Manager provided oversight of all patient services and personnel in 1 of 1 agency observed. Findings Include: 1. A policy titled, "Clinical Manager/Alternate Clinical Manager," dated 7/2020 was provided by Employee B on 3/10/2022 at 1:50 p.m. The policy indicated but was not limited to, "Clinical Manager provides oversight for all patient care services and personnel. Oversight will include, but not limited to: Making patient & personnel assignments. Coordinating patient care. Coordinating referrals. Assuring patient needs are continually assessed. Assuring the development, implementation, & updates of the individualized plan of care. Respond to an emergency. Provide guidance to staff. Answer questions. Resolve issues; within a reasonable amount of time, given the emergency or issue that has been raised." 2. An interview was completed with the administrator and clinical manager on 3/8/2022 at 4:00 p.m. The administrator and clinical manager discussed their resignation effective immediately. The Administrator also served as the Alternate Clinical Manager and the Clinical Manager served as the Alternate Administrator. 3. During an interview on 3/9/2022 at 9:20 a.m., upon entering the agency, Employee D indicated both the Administrator/Alternate Clinical Manager and the Clinical Manager/Alternate Administrator did not show up for work today. 4. An interview was completed with the owner on 3/9/2022 at 9:25 a.m. who indicated the Administrator and Clinical Manager were no longer working for the agency. Plan to hire a new Administrator and Clinical Manager but they cannot start for 3 weeks. 410 IAC 17-12-1(d)

Make patient and personnel assignments, CFR(s): 484.105(c)(1) Making patient and personnel assignments, This ELEMENT is not met as evidenced by: Based on record review and interview, the Clinical Manager failed to ensure patient and personnel assignments were completed in 1 of 1 agency reviewed. Findings Include: 1. A policy titled, "Clinical Manager/Alternate Clinical Manager," dated 7/2020 was provided by Employee B on 3/10/2022 at 1:50 p.m. The policy indicated but was not limited to, "Oversight will include, but not limited to:" ... "Making patient & personnel assignments." 2. An interview was completed with the administrator and clinical manager on 3/8/2022 at 4:00 p.m. The administrator and clinical manager discussed their resignation effective immediately. The Administrator also serves as the Alternate Clinical Manager and the Clinical Manager serves as the Alternate Administrator. 3. During an interview on 3/9/2022 at 9:20 a.m., upon entering the agency, Employee D indicated both the Administrator/Alternate Clinical Manager and the Clinical Manager/Alternate Administrator did not show up for work today. 4. An interview was completed with the owner on 3/9/2022 at 9:25 a.m. who indicated the Administrator and Clinical Manager were no longer working for the agency. Plan to hire a new Administrator and Clinical Manager but they cannot start for 3 weeks. 419 IAC 17-14-1(a)(1)(K)

Coordinate patient care CFR(s): 484.105(c)(2) Coordinating patient care, This ELEMENT is not met as evidenced by: Based on record review and interview, the Clinical Manager failed to ensure the coordination of patient care in 1 of 1 agency observed. Findings Include: 1. A policy titled, "Clinical Manager/Alternate Clinical Manager," dated 7/2020 was provided by Employee B on 3/10/2022 at 1:50 p.m. The policy indicated but was not limited to, "Oversight will include, but not limited to:" ... "Coordination patient care." 2. An interview was completed with the administrator and clinical manager on 3/8/2022 at 4:00 p.m. The administrator and clinical manager discussed their resignation effective immediately. The Administrator also serves as the Alternate Clinical Manager and the Clinical Manager serves as the Alternate Administrator. 3. During an interview on 3/9/2022 at 9:20 a.m., upon entering the agency, Employee D indicated both the Administrator/Alternate Clinical Manager and the Clinical Manager/Alternate Administrator did not show up for work today. 4. An interview was completed with the owner on 3/9/2022 at 9:25 a.m. who indicated the Administrator and Clinical Manager were no longer working for the agency. Plan to hire a new Administrator and Clinical Manager but they cannot start for 3 weeks.

Coordinate referrals; CFR(s): 484.105(c)(3) Coordinating referrals, This ELEMENT is not met as evidenced by: Based on record review and interview, the Clinical Manager failed to coordinate referrals in 1 of 1 agency reviewed. Findings Include: 1. A policy titled, "Clinical Manager/Alternate Clinical Manager," dated 7/2020 was provided by Employee B on 3/10/2022 at 1:50 p.m. The policy indicated but was not limited to, "Oversight will include, but not limited to:" ... "Coordinating referrals." 2. An interview was completed with the administrator and clinical manager on 3/8/2022 at 4:00 p.m. The administrator and clinical manager discussed their resignation effective immediately. The Administrator also serves as the Alternate Clinical Manager and the Clinical Manager serves as the Alternate Administrator. 3. During an interview on 3/9/2022 at 9:20 a.m., upon entering the agency, Employee D indicated both the Administrator/Alternate Clinical Manager and the Clinical Manager/Alternate Administrator did not show up for work today. 4. An interview was completed with the owner on 3/9/2022 at 9:25 a.m. who indicated the Administrator and Clinical Manager were no longer working for the agency. Plan to hire a new Administrator and Clinical Manager but they cannot start for 3 weeks.

Assure patient needs are continually assessed CFR(s): 484.105(c)(4) Assuring that patient needs are continually assessed, and This ELEMENT is not met as evidenced by: Based on record review and interview, the Clinical Manager failed to ensure the needs of the patients were continually assessed in 1 of 1 agency observed. Findings Include: 1. A policy titled, "Clinical Manager/Alternate Clinical Manager," dated 7/2020 was provided by Employee B on 3/10/2022 at 1:50 a.m. The policy indicated but was not limited to, "Oversight will include, but not limited to:" ... "Assuring that patient needs are continually assessed." 2. An interview was completed with the administrator and clinical manager on 3/8/2022 at 4:00 p.m. The administrator and clinical manager discussed their resignation effective immediately. The Administrator also serves as the Alternate Clinical Manager and the Clinical Manager serves as the Alternate Administrator. 3. During an interview on 3/9/2022 at 9:20 a.m., upon entering the agency, Employee D indicated both the Administrator/Alternate Clinical Manager and the Clinical Manager/Alternate Administrator did not show up for work today. 4. An interview was completed with the owner on 3/9/2022 at 9:25 a.m. who indicated the Administrator and Clinical Manager are no longer working for the agency. Plan to hire a new Administrator and Clinical Manager but they cannot start for 3 weeks.

Assure implementation of plan of care CFR(s): 484.105(c)(5) Assuring the development, implementation, and updates of the individualized plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the Clinical Manager failed to assure the development, implementation, and update of the POC (Plan of Care) in 1 of 1 agency observed. Findings Include: 1. A policy titled, "Clinical Manager/Alternate Clinical Manager," dated 7/2020 was provided by Employee B on 3/10/2022 at 1:50 p.m. The policy indicated, but was not limited to, "Oversight will include, but not limited to:" ... "Assuring the development, implementation & updates of the individualized plan of care." 2. An interview was completed with the administrator and clinical manager on 3/8/2022 at 4:00 p.m. The administrator and clinical manager discussed their resignation effective immediately. The Administrator also serves as the Alternate Clinical Manager and the Clinical Manager serves as the Alternate Administrator. 3. During an interview on 3/9/2022 at 9:20 a.m., upon entering the agency, Employee D indicated both the Administrator/Alternate Clinical Manager and the Clinical Manager/Alternate Administrator did not show up for work today. 4. An interview was completed with the owner on 3/9/2022 at 9:25 a.m. who indicated the Administrator and Clinical Manager were no longer working for the agency. Plan to hire a new Administrator and Clinical Manager but they cannot start for 3 weeks. 410 IAC 17-14-1(a)(1)(c)

This visit was for a federal complaint investigation of a Home Health Agency.Complaint 61362 - substantiated with findingsFacility #: 013593Dates of Survey: 12/13/2021--12/14/2021 This deficiency reflects State Findings cited in accordance with 410 IAC 17. QR completed 1/3/2021 A4

HHA can no longer meet the patient's needs CFR(s): 484.50(d)(1) The transfer or discharge is necessary for the patient's welfare because the HHA and the physician or allowed practitioner, who is responsible for the home health plan of care agree that the HHA can no longer meet the patient's needs, based on the patient's acuity. The HHA must arrange a safe and appropriate transfer to other care entities when the needs of the patient exceed the HHA's capabilities; This ELEMENT is not met as evidenced by: Based on record review and interviews the agency failed to arrange a safe and appropriate transfer to other home health agencies in 1 of 5 records reviewed. (Patient 2) Findings Include: 1. A policy titled, “Discharge/Reduction in Services,” dated 7/2020 was provided by Employee B on 12/13/2021. The policy indicated but was not limited to, “e. Discharge instructions will be provided: i. Discharge planning will identify needs the patient may have. ii. Arrangements for such services will be coordinated by our Agency when applicable. For a patient requiring continued care, assistance will be provided to the patient and family/caregiver in order to manage continuing care needs after Agency services are discontinued, i.e., referrals for services.” 2. The clinical record for Patient 2 was reviewed on 12/13/2021 for the certification period 10/2/2021—11/30/2021, SOC (start of care) date 10/7/2020. The record indicated the following: A document titled, “Home Health Discharge Summary,” dated 10/25/2021 was provided by Employee C on 12/13/2021 at 2:33 p.m. The document indicated but was not limited to, “Narrative: Pt (patient) received SN (skilled nursing) visits for monthly foley cath (catheter used to collect urine inserted through the urethra and into the bladder) changes. Pt funding no longer covering services. Pts daughter who is an RN (registered nurse) lives with the patient and is able to assume responsibility.” A document titled, “Communication Note,” dated 10/22/2021 was provided by Employee C on 12/13/2021 at 2:33 p.m. The document indicated but was not limited to, “Called daughter Alexis explained that patient’s insurance is not covering home care services and that we have to discharge from care effective today. Private pay offered. Daughter will let us know if she is interested in private pay.” A document titled, “Communication Note,” dated 10/26/2021 was provided by Employee C on 12/13/2021 at 2:33 p.m. The document indicated but was not limited to, “Spoke with patient’s daughter/POA (power of attorney) and explained that insurance is rejecting her mother’s claim, I reviewed the insurance information with her and discussed her private pay options and quoted her prices, she stated she can not afford at this time.” 3. An interview was completed with Employee B on 12/13/2021 at 2:38 p.m. Employee B was unaware that discharged patients needing continued home health services require a referral to other home health agencies to continue services needed. Indicated that Patient 2 was offered private pay services. Indicated that Patient 5’s daughter lives with the patient, is a registered nurse who was previously employed with Indiana Signal Home Group, and would be taking over the urinary catheter changes needed monthly. 4. An interview was completed with Patient 2’s caregiver on 12/14/2021 at 9:55 a.m. Patient 2’s caregiver confirmed notice of discharge the same day of discharge, effective immediately via phone call. Denied referral to any other home health agency by Indiana Signal Health Group. Was offered private pay, unable to afford it. Indicated unable to complete Patient 2’s urinary catheter changes monthly due to inability to have supplies shipped to the home. Indicated Patient 2 has been transported to the Emergency Department monthly to have service completed.

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102. Survey Dates: October 18th, 19th, 20th, 21st, and 22nd of 2021 Provider: 157681 12-month unduplicated census: 160 At this Emergency Preparedness survey, Indiana Signal Health Group Skilled Inc., was found not in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 484.102. The requirement at 42 CFR, Subpart 484.102 is NOT MET as evidenced by: lack of Emergency Preparedness program.

Establishment of the Emergency Program (EP) CFR(s): 484.102 §403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must establish and maintain a [comprehensive] emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements: * (Unless otherwise indicated, the general use of the terms "facility" or "facilities" in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This CONDITION is not met as evidenced by: Based on record review and interview the agency failed to establish and maintain a comprehensive emergency preparedness program in 1 of 1 agency reviewed. This had the potential to affect all patients receiving services with the agency. Findings Include: 1. A policy titled, "Biennial Review: Emergency Preparedness Plan," dated 7/2020 was provided by the administrator on 10/22/2021 at 3:07 p.m. The policy indicated but was not limited to, "Policy: Our agency will be in compliance with CMS regulations & state/federal disaster preparedness standards by at least every other year with a review of our Emergency Preparedness Plan." 2. During an interview on 10/22/2021 at 1:30 p.m. the administrator was asked if she had an additional binder for EP (Emergency Preparedness) for the surveyor to review. The administrator confirmed that there were no additional binders. Advised the administrator that the only thing found in the binder were the EP policies. The administrator confirmed that she had just recently printed these policies and placed them in the binder in anticipation of a new administrator taking over next week. The administrator denied assistance with developing the plan. Denied a facility-based & community-based risk assessment using an all-hazards approach. Denied cooperation/collaboration with local, state, & federal EP officials. Denied policies being reviewed/updated annually. Denied individual emergency plans in EP program, however, noted on the plan of care for each patient reviewed during the survey process. Denied having a communication plan reviewed/updated at least annually. Denied contact information of staff, patients, physicians, and volunteers. Denied alternate means of communication available in an emergency. Denied EP testing program, reviewed at least annually. Denies conducting exercises to test the EP plan at least annually (at least one full-scale community-based exercise and either a second community-based exercise, facility-based exercise, or tabletop exercise). The administrator indicated that the EP program had been overlooked due to the workload and staff available to assist.

This survey was for a Federal recertification and State relicensure survey in conjunction with an infection control-focused COVID-19 survey. Survey Dates: October 18th, 19th, 20th, 21st, and 22nd of 2021. Provider: 157681 12-month unduplicated census: 160 Partially Extended Survey Announced 10/19/2021 at 1:18 p.m. Extended Survey Announced 10/22/2021 at 3:15 p.m. These deficiencies reflect State findings cited in accordance with 410 IAC 17. Refer to state form for additional state findings. Signal Home Health Group is precluded from conducting a home health aide training or competency evaluation program for a period of two years starting October 22, 2021 to October 21, 2023 for being out of compliance with 484.102, Condition of Participation Establishment of the Emergency Program.

Patient's or legal representative's signature CFR(s): 484.50(a)(2) Obtain the patient's or legal representative's signature confirming that he or she has received a copy of the notice of rights and responsibilities. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to obtain the patient's and/or patient's representative's signature confirming that he/she received a copy of the notice of rights and responsibilities in 2 of 7 patients reviewed. (Patient 4 and 5) Findings include: A policy titled, "Rights & Responsibilities of Patients Policy" dated 7/2020 was provided by the administrator on 10/22/2021 at 12:13 p.m. The policy indicated but was not limited to, "Signature of Receipt of Rights: Obtain the patient's/legal representative's signature confirming that they have received a copy of the notice of rights and responsibilities. (signature on the admission form 'Review of Admission Documents')". A review of Patient 5's record on 10/19/2021, indicated no evidence the agency obtained the patient's and/or patient's representative's signature confirming he/she received a copy of the notice of rights and responsibilities. A review of Patient 4's record on 10/21/2021, indicated no evidence the agency obtained the patient's and/or patient's representative's signature confirming he/she received a copy of the notice of rights and responsibilities. An interview with the administrator was completed on 10/22/2021 at 11:30 a.m. The administrator stated she is aware that a signature must be obtained confirming receipt of notice of rights and responsibilities. Indicated that with the new EMR (electronic medical record) system, these documents were not uploaded from the old EMR to the current EMR. Indicated she did not have access to the old EMR to provide a copy of receipt. Unable to provide documentation by end of survey. 17-12-3(a)(2)

Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to investigate and document all complaints, including the resolution, in 1 of 1 agency reviewed. Findings include: 1. A policy titled, "Grievance Policy: Patients," dated 7/2020, was provided by the administrator on 10/21/2021 at 2:06 p.m. The policy indicated, but was not limited to, "It is the policy of our Agency to have a formal Grievance Procedure/process, that is under the direct responsibility of the Agency/Administrator who will respond to and oversee investigation of every complaint/concern presented by a patient, caregiver or family member." ... "Grievance Process: 1. Our Agency must: Investigate complaints made by a patient, the patient's representative (if any), and the patient's caregiver" ... "Document both the existence of the complaint and the resolution of the complaint. Take action to prevent further potential violations, including retaliation, while the complainant is being investigated." ... "The administrator shall conduct a complete investigation of the complaint." 2. A document titled, "Report of Concern Summary Log for the Month of January 2020," was provided by the administration on 10/21/2021 at 2:06 p.m. The summarized document indicated the last complaint investigated and documented was on 1/23/2020. 3. An interview with the administrator on 10/19/2021 at 2:10 p.m. was completed with the administrator. The administrator confirmed that complaints have not been investigated or documented with resolutions since January of 2020. When asked who receives the complaints, the administrator indicated that the schedulers receive those calls. Indicated that most complaints are related to the home health aides and the schedulers resolve the complaints. Unable to provide documentation of complaints since January of 2020. Confirmed the schedulers do not complete a log for tracking, administrator would have to scan through all phone calls received to identify which calls were complaints. 17-12-3(c)(2)

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure that the initial assessment was completed within 48 hours of a referral in 4 of 7 patients reviewed. (Patient 2, 3, 4, and 5) Findings Include: 1. A policy titled, "Assessments," dated 7/2020 was provided by the administrator on 10/21/2021 at 11:38 a.m. The policy indicated but was not limited to, "The initial assessment will be performed by a RN (registered nurse) for patients receiving nursing only services or nursing and therapy (unless therapy case only), within 48 hours of the patient's referral, discharge from a facility to home or specific date specified by the MD (medical doctor). It will be completed timely, no later than 5 calendar days after the SOC (start of care)." 2. The clinical record for Patient 2 was reviewed on 10/19/2021 for certification period 9/22/2021--11/20/2021. SOC (start of care) date 9/22/2021. Referral date 9/9/2021. Initial/Comprehensive/OASIS assessment completed on 9/22/2021 at 9:00 a.m. 3. The clinical record for Patient 3 was reviewed on 10/20/2021 for certification period 9/30/2021--11/28/2021. SOC (start of care) date 9/30/2021. Referral date 9/8/2021. Initial/Comprehensive/OASIS assessment completed on 9/30/2021 at 12:45 p.m. 4. The clinical record for Patient 4 was reviewed on 10/21/2021 for the certification period 8/1/2017--9/29/2021. SOC date 6/23/2017. Referral date was unknown. Initial/Comprehensive/OASIS assessment completion date was unknown. 5. The clinical record for Patient 5 was reviewed on 10/19/2021 for the certification period 9/22/2021--11/20/2021. SOC date 10/13/2017. Referral date unknown. Initial/Comprehensive/OASIS assessment completion date is unknown. 6. During an interview on 10/22/2021 at 11:30 a.m. the administrator confirmed a late SOC date from the initial order received for services for Patient 3. Indicated delay due to awaiting insurance approval and confirmed that MD should have been notified and new order obtained. Indicated that Patient 4 and 5 had missing contents in the chart including missing referral orders from the physician as well as the initial assessment, the initial comprehensive assessment, and the initial OASIS assessments. Indicated that the three assessments are all incorporated into one assessment and are to be completed within 48 hours of referral. Indicated missing items were not uploaded from the old EMR (electronic medical record) to the new EMR and no longer has access to old EMR to obtain information needed. 17-14-1(a)(1)(A)

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to follow and clarify physician orders at the start of care in 1 of 7 patients reviewed. (Patient 1) Findings Include: 1. A policy titled, "Admission Policy/Approved Treatments," dated 7/2020 was provided by the administrator on 10/22/2021 at 12:13 p.m. The policy indicated, but was not limited to, "Incoming referrals where the ordered discipline(s) is not offered by the agency or unavailable shall be referred to other agencies." ... "Care/Service Limitations: Patient intakes will be reviewed on a case by case basis to determine if the needs of the patient can be met. If the needs of the patient cannot be met the patient will be referred to another agency that can provide the services." 2. A document titled, "Admission Record," was provided by the clinic manager on 10/22/2021 at 12:01 p.m., regarding Patient 1. The document indicated but was not limited to, "May discharge home with home care and PT(physical therapy)/OT (occupational therapy) evaluation and treatment. 3. An interview with the administrator was completed on 10/19/2021 at 10:52 a.m. The administrator indicated that OT services were not provided by the agency for Patient 1 and that the order received should have been clarified with the physician prior to admitting the patient. Confirmed that this was not done and that a new order for PT only was not obtained.

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 observations, record reviews, and interviews the agency failed to screen and document signs and symptoms of COVID-19 for patients, visitors, and staff members. This deficient practice had the potential to affect all patients. Findings include: 1. A policy titled, "Pandemic Infectious Disease Policy," was provided by the administrator on 10/19/2021 at 1:06 p.m. The policy indicated but was not limited to, "When making a home visit, organizations will identify patients at risk for having COVID-19 infections before or immediately upon arrival to the home. Organizations will ask the patients the following: A. Has the patient traveled internationally within the last fourteen (14) days to countries with sustained community transmission" ... "B. Does the patient have signs or symptoms of a respiratory infection? Clinical criteria for identifying patients with COVID-19 include: 1. Fever 2. Cough 3. Dyspnea 4. Sore throat 5. Other symptoms as recognized by the government" ... "C. In the past fourteen 14 days, has the patient had contact with someone who or is under investigation for COVID-19, or are ill with a respiratory illness? D. Does the patient reside in a community where community-based spread of COVID-19 is occurring?" 2. A policy titled, "COVID-19 Health Care Professional (HCP) Policy," updated 6/1/2020 was provided by the administrator on 10/19/2021 at 1:06 p.m. The policy indicated but was not limited to, "Home health aides are required to complete self-screen documentation in the Generations EMR (electronic medical record) mobile app--Telephony in order to be able to clock into each shift. Licensed clinical staff (RN-registered nurse, LPN-licensed practical nurse, PT-physical therapist, PTA-physical therapy assistant, OT--occupational therapist, OTA-occupational therapy assistant, and ST-speech therapist) will self screen daily and document using Axxess mobile app COVID Screening Tool." 3. During an observation on 10/18/2021 at 9:30 a.m. surveyor entered agency and was not screened for COViD-19. On 10/19/2021 at 9:30 a.m. surveyor entered agency, administrator pretended to take surveyor's temperature using a hand gesture and asked if I had symptoms of COVID-19. Noted COVID-19 documentation clipboard for visitors on table upon entry, but information was not documented. On 10/22/2021 at 11:30 a.m. upon entering agency no COVID-19 screening was completed. 4. During an interview on 10/20/2021 at 1:05 p.m. the administrator indicated that clinical staff are not always documenting a self-screen for COVID-19 prior to each shift. Indicated that home health aides are to screen in the app in Generations, the electronic medical record, prior to clocking in for each shift, however, at some point this feature was accidentally deactivated. Unsure of when this happened but appears to be greater than 1 month ago. The administrator was not notified by any home health aides that this feature was no longer available and this issue was addressed and resolved during the survey process. Licensed clinical staff (RN, LPN, PT) are to self-screen and record prior to each shift in Axxess, the electronic medical record. Confirmed that staff are not using this tool per policy, and not always recording symptoms of lack of symptoms prior to each shift. 5. During a home visit with Patient 1, an interview was completed with Employee B on 10/19/2021 at 4:50 p.m. Employee B confirmed that he did not screen for COVID-19 on Patient 1 because she has been vaccinated. Confirmed that he completes a self-screen for COVID-19 daily, however, this is not documented. He is aware of the screening tool in the electronic medical record and indicated that the nurses are responsible for filling it out. 17-12-1(m)

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 record review and interview the agency failed to complete physician ordered HHA (home health aide) visits in 2 of 7 patients reviewed. (Patient 4 and 5) Findings include: 1. A policy titled, “Interruption in Services/Missed Visits,” was provided by the administrator on 10/19/2021 at 12:33 p.m. The policy indicated, but was not limited to, “If the Agency admits patients with needs that require care or services to be delivered at specific times of parts of the day, the Agency shall ensure qualified staff in sufficient quantity are employed by the agency or have other effective back-up plans to ensure the needs of the patent is met.” … “Missed Visit Process: When a missed visit occurs, a missed visit form is completed to clarify/explain why visits have not occurred.” … “All documentation will be filed in the patient chart.” 2. Record review on 10/21/2021 for Patient 4, certification period of 8/1/2021—9/29/2021, SOC (start of care) date 6/23/2017 was reviewed. The physician ordered HHA visits 3 hours a day, once weekly. The document titled, “Schedules for Patient 4, visits by all Caregivers,” indicated a missed visit on 8/24/2021 by the HHA. During an interview with the administrator on 10/22/2021 at 11:35 a.m. documentation for missed HHA visit for Patient 4 on 8/24/2021 was requested. The administrator confirmed missed visit documentation was not present in the clinical record 3. Record review on 10/19/2021 for Patient 5, certification period of 9/22/2021—11/20/2021, SOC (start of care) date 10/13/2017 was reviewed. The physician ordered home health aide visits 12 hours a day, 7 days a week. The document titled, “Schedules for Patient 5, visits by all Caregivers,” indicated the following: On 9/25/2021, HHA visit x10 hours. (10:00 a.m.—8:00 p.m.) On 9/26/2021, HHA visit x10 hours. (10:00 a.m.—8:00 p.m.) On 9/27/2021, HHA visit x6 hours. (2:00 p.m.—8:00 p.m.) On 10/3/2021, HHA visit x11.25 hours. (8:45 a.m.—8:00 p.m.) On 10/5/2021, no HHA visit for the day. On 10/6/2021, no HHA visit for the day. On 10/8/2021, no HHA visit for the day. On 10/9/2021, no HHA visit for the day. On 10/10/2021, no HHA visit for the day. On 10/11/2021, no HHA visit for the day. On 10/12/2021, no HHA visit for the day. On 10/13/2021, no HHA visit for the day. On 10/14/2021, HHA visit x6 hours. (2:00 p.m.—8:00 p.m.) On 10/13/2021, no HHA visit for the day. On 10/17/2021, no HHA visit for the day. On 10/18/2021, no HHA visit for the day. On 10/19/2021, HHA visit x6 hours. (2:00 p.m.—8:00 p.m.) An interview with the administrator on 10/20/2021 at 2:33 p.m. indicated that there was a note in the clinical record on 10/7/2021 at 2:17 p.m. that indicated that the mother of the patient was notified that all the caregivers have been sick but can send someone out today. The mother refused, didn’t want this HHA to get sick. Agreed to clean the home before HHA’s return. The administrator agreed that no further note was put into the patient’s chart indicating when HHA services would resume. No hold orders except for the day of 10/7/2021.

Aides are members of interdisciplinary team CFR(s): 484.80(g)(4) Home health aides must be members of the interdisciplinary team, must report changes in the patient's condition to a registered nurse or other appropriate skilled professional, and must complete appropriate records in compliance with the HHA's policies and procedures. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure that HHA (home health aides) were documenting completed tasks as ordered by the physician in the plan of care for 3 of 7 records reviewed. (Patient 2, 4, and 5) Findings include: 1. A policy titled, "Home Health Aide: Documentation," was provided by the administrator on 10/22/2021 at 12:13 p.m. The policy indicated but was not limited to, "Policy: Home health aides will document care/services provided on the home health aide charting form. Purpose: To provide documentation of care performed by the home health aide on each visit. To provide documentation of the home health aide's observations on each visit and evidence of client progress towards goals. To provide documentation that will identify the ongoing need for the home health aide services. Special Instructions: The home health aide shall utilize the appropriate home health aide flow sheet or charting form to document services rendered to the client. The home health aide shall be responsible for reporting any changes in the client's condition or other pertinent observations to the supervising nurse/therapist. The designated Registered nurse/Therapist or designated person is responsible for reviewing the home health aide's charting before it is placed in the chart. The original documentation shall be filed in the clinical record within seven (7) days of the end of the recording period." 2. Record review for Patient 2 was completed on 10/18/2021, SOC (start of care) 9/22/2021, certification period 9/22/2021--11/20/2021. Missing and/or Incomplete home health aide documentation throughout the certification period found during record review. 3. Record review for Patint 4 was completed on 10/21/2021, SOC 6/23/2017, certification period 8/1/2021--9/29/2021. Missing and/or incomplete home health aide documentation throughout the certification period found during record review. 4. Record review for Patient 5 was completed on 10/19/2021, SOC 10/13/2017, certification period 9/22/2021--11/20/2021. Missing and/or incomplete home health aide documentation throughout the certification period found during record review. 5. During an interview on 10/21/2021 at 2:30 p.m., the administrator confirmed that there is frequent home health aide documentation not being completed per policy. Indicated that this feature was deactivated by accident by another staff member, not allowing home health aides to document tasks. Confirmed the timeframe of home health aide's inability to document tasks performed on patients is unknown as she was not aware of the problem until found with surveyor's record review, but is working to have this issue resolved. Denied neither the home health aide's bringing this issue to her attention nor the supervising nurse.