Every finding on record at Indianapolis Home Care Inc.

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR §484.102 Survey Dates: 03/31, 04/01, and 04/02/2025. Active Census: 62 At this Emergency Preparedness survey, Interim Healthcare of Indianapolis was found to be in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR §484.102. QR completed by Area 3 on 4/04/2025.

This visit was for a Federal Recertification and State Re-Licensure survey of a Home Health Provider. Survey Dates: 03/31/2025, 04/01/2025, and 04/02/2025. 12-Month Unduplicated Skilled Admissions: 117 Partially Extended on 04/01/2025 at 3:35 PM. This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Abbreviations: PT Physical Therapist HHA Home Health Aide RN Registered Nurse CM Clinical Manager POC Plan of Care SOC Start of Care ROC Resumption of Care QR completed by Area 3 on 4-04-2025.

HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator's name, business address, and business phone number in order to receive complaints. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patient received the name and contact information for the Administrator to be able to file a complaint for 1 of 1 (Patient: #1) home visits for patients receiving physical therapy. Findings Include: 1. A review of a dated 04/02/2021, Interim HealthCare policy titled “Contents of the Patient/Client Record” indicated but wasn’t limited to, “ … Contents of An In-Home Presentation Pocket Folder … The following paper forms … are found in the in home presentation Pocket folder … Patient information letter …Name and contact information of the clinical manager … ” 2. During a home visit on 04/01/2025 at 11:46 AM, at Patient #1’s residence, Person 4, the family member/caregiver for Patient #1, provided the agency pocket folder for review. Upon examining the folder, noted it did not include the name or contact information of the agency’s Administrator. When I asked Patient #1 and Person 4 if they knew who the Administrator was and how to contact them in case, they had complaints or concerns, they indicated they were unaware. PT 1 reviewed the agency pocket folder and confirmed the agency pocket folder lacked the Administrator’s name and contact details. PT 1 confirmed Patient #1's SOC date of 02/24/2025.

State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patient received the Indiana state toll-free home health hotline contact information to be able to file a complaint to 1 of 1 (Patient: #1) home visits for patients receiving physical therapy. Findings Include: 1. A review of a dated 04/02/2021, Interim HealthCare policy titled “Contents of the Patient/Client Record” indicated but wasn’t limited to, “ … Contents of An In-Home Presentation Pocket Folder … The following paper forms … are found in the in home presentation Pocket folder … Patient information letter …Name and contact information of the clinical manager … Patient Rights and Responsibilities … ” 2. During a home visit at Patient #1’s residence on April 1, 2025, at 11:46 AM, Person 4, the family member/caregiver for Patient #1, provided the patient’s agency's pocket folder for review. A review of the agency pocket folder noted the Indiana state toll-free hotline phone number and information missing. When asked Patient #1 and the caregiver how they knew to contact the Indiana state hotline for complaints, they indicated they did not know. PT 1 reviewed the agency pocket folder and confirmed that the folder did not include the sticker on the front that should provide the hotline information and number for the Indiana state toll-free complaint hotline. PT 1 further confirmed Patient #1's SOC date of 02/24/2025. 410 IAC 17-12-3(b)(2)(B)

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure patient clinical records included information about the services the patient received from other agencies and failed to ensure they coordinated care delivery to meet the patient's needs for 2 of 2 (Patients #2 and 4), active patient records reviewed of patients receiving outside personal care services. Findings include: 1. A review of a dated 04/02/2021, Interim HealthCare policy titled “Coordination of Care/Services” indicated but wasn’t limited to, “ …Interim Healthcare maintains regular communication with the patient/client and with others providing patient/client care/services …. Interim HealthCare coordinates care delivery to meet the patient’s needs … ” 2. During a home visit on 04/01/2025 at 10:12 AM, Person 1, caregiver/family member for Patient #2, repositioned Patient #2 for RN 2. Person 2 indicated they provided 23 hours a day for Patient #2 through Entity 2, a personal care agency. Person 2 further specified their care schedule, providing attendant care from 1:00 AM to 8:00 PM, and HHA care from 8:00 PM to 12:00 PM. A review of the clinical record for Patient #2 SOC 03/30/2024, contained a ROC dated 03/18/2025, which failed to evidence the patient was receiving services from Entity 2. A review of a recertification comprehensive assessment dated 03/12/2025, failed to evidence the patient was receiving services from Entity 2. A review of the plan of care for the recertification period 03/15/2025 to 05/13/2025, failed to evidence Patient #2 was receiving services from Entity 2. A review of the care coordination notes dated 03/30/2024 to 04/01/2025, failed to evidence the patient was receiving services from Entity 2. During an interview on 04/02/2025 at 2:15 PM, when queried regarding the process and location of the documentation for coordinating care with other services Patient #2 had been receiving with Entity 2, RN 2 indicated they were aware of Entity 2, they did not contact the other agency, and the process should have been to document coordination of care between the two agencies in the care coordination notes. 3. A review of the clinical record for Patient #4 SOC 09/01/2023, contained a recertification comprehensive assessment dated 02/19/2024, failed to evidence Patient #4 was receiving services from Entity 3. A review of the plan of care for the recertification period 02/22/2025 to 04/22/2025, failed to evidence Patient #4 was receiving services from Entity 3. A review of the care coordination notes dated 01/01/2025 to 04/01/2025, failed to evidence the patient was receiving services from Entity 3. A review of dated 04/02/2025, document titled “Census Activity Report” provided by Entity 3, a personal care agency, listed Patient #4 SOC date 09/01/2023, receiving waiver services. During an interview on 04/01/2025 at 1:10 PM, Patient #4 confirmed they received attendant care services from Entity 3 and had been for years. During an interview on 04/02/2025 at 9:37 AM, RN 3 indicated they were unaware they needed to coordinate care between agencies if the agency was the personal care agency affiliated with the home care agency. RN 3 indicated they needed to start doing that. During an interview on 04/02/2025 at 3:01 PM, the CM indicated they could not provide care coordination notes for Patient #4 regarding care coordinated between the agency and Entity 3, until they added it today. 410 IAC 17-14-1(a)(1)(F)

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patient had been provided a medication schedule to 1 of 1 (Patient: #1) home visits for patients receiving physical therapy. Findings Include: 1. A review of a dated 04/02/2021, Interim HealthCare policy titled “Contents of the Patient/Client Record” indicated but wasn’t limited to, “ … Contents of An In-Home Presentation Pocket Folder … The following paper forms … are found in the in home presentation Pocket folder … Written information to the patient that includes: Patient medication schedule/instructions … ” 2. During a home visit on 04/01/2025 at 11:46 AM, at Patient #1’s residence, Person 4, the caregiver/family member for Patient #1, provided the agency pocket folder for review. The agency pocket folder contained a document titled “Medication Profile” which was blank. When queried regarding a medication list being provided, the patient and Person 4, regarding a medication list, indicated they had only received the medication list from Entity 5, the skilled nursing facility Patient #1 had stayed before returning home. During an interview on 04/01/2025 at 12: PM, when queried regarding Patient #1’s medication profile being blank, PT 1 indicated they had not completed a medication profile/schedule for Patient #1, and thought the agency would mail the plan of care from the office later. A review of the clinical record for Patient #1, SOC 02/24/2025, contained an initial comprehensive assessment dated 02/24/2025, and electronically signed by PT 1. The comprehensive assessment contained a section titled “Clinical Visit Summary.” The clinical visit summary revealed PT 1 reviewed the agency admission book, medication actions, and side effects with Patient #1 and the caregiver. During an interview on 04/02/2025 at 2:00 PM, the CM confirmed a medication list should be provided to the patients.

Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patient received the name and contact information for the CM to 1 of 1 (Patient: #1) home visits for patients receiving physical therapy. Findings Include: 1. A review of a dated 04/02/2021, Interim HealthCare policy titled “Contents of the Patient/Client Record” indicated but wasn’t limited to, “ … Contents of An In-Home Presentation Pocket Folder … The following paper forms … are found in the in home presentation Pocket folder … Patient information letter …Name and contact information of the clinical manager … ” 2. During a home visit on 04/01/2025 at 11:46 AM, at Patient #1’s residence, Patient #1’s family member/caregiver, Person 4 provided the agency pocket folder for review. A review of the agency pocket folder failed to contain the name and contact information for the agency’s CM. When queried if Patient #1 and Person 4 knew who the CM was and how to contact them, they indicated they were not aware. PT 1 confirmed the agency pocket folder provided had not contained the CM name and contact information. PT #1 further confirmed Patient #1's SOC date of 02/24/2025.

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 infection control practices were followed to prevent transmission of infection in the use of hand hygiene and gloving during 1 of 1 home visits (Patient: #3) observed with Peripherally Inserted Central Cather (PICC) (a thin, soft flexible tube used for administering medication treatments) care being provided. Findings include: 1. A review of a of dated 12/19/2022, Interim HealthCare policy titled “Engineering Control and Worl Practices” indicated but wasn’t limited to, “ … Employees wash their hands: d) Immediately before applying gloves …. E) Immediately after removal of gloves … ” 2. A review of an undated agency procedure titled “Peripherally inserted Central Catheter Use” indicated but was not limited to, “ … Performing a PICC dressing change … Perform hand hygiene. Put on gloves … Remove existing dressing … Remove and discard your gloves. Perform hand hygiene. Put on sterile gloves … ” 3. During a home visit at Patient #3’s residence on 04/01/2025 at 9:05 AM, RN 1 was observed performing a PICC dressing change. RN 1 removed the PICC dressing from Patient #3’s right upper arm and discarded the dressing and gloves into the trash receptacle. Afterward, RN 1 donned the sterile gloves and cleansed the PICC site with Chloraprep swabsticks (a swabstick with a sterile skin antiseptic solution). RN 1 failed to perform hand hygiene after discarding the old PICC dressing and before donning the sterile gloves. During an interview on 04/01/2025 at 9:25 AM, when queried regarding the agency policy for hand hygiene and gloving during a PICC dressing change, RN 1 indicated when gloves were removed or prior to gloving. When questioned regarding hand hygiene after removing the old PICC dressing RN 1 stated," No, I did not perform hand hygiene after discarding the dressing and before donning sterile gloves. I didn’t even have it on the table when I set up my barriers.” 410 IAC 17-12-1(m)

An unannounced Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.22. Survey Dates: June 1, 2, 3; 2022 Facility Number: 006364 Provider Number: 157259 Census: 198 Interim Healthcare of Indianapolis was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 484.22. QR by Area 3 on 6-21-2022

This visit was for a Federal Recertification and State Re-licensure Survey of a Home Health agency. Survey Dates: 06-01, 06-02, 06-03-2022 Census: 198 QR by Area 3 on 6-21-2022

Information to patient CFR(s): 484.50(a)(1) Provide the patient and the patient's legal representative (if any), the following information during the initial evaluation visit, in advance of furnishing care to the patient: This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure a patient had a copy of their plan of care, medication profile, and visit schedule in accordance with agency policy for 1 of 5 active patients. (Patient #3) The findings include: 1. On 06-03-2022 at 11:09 AM, the Administrator, Employee #1 provided an April, 2021 Interim HealthCare policy titled, "Contents of An In-Home Presentation Pocket Folder". The policy indicated but was not limited to, "...The following standardized paper forms or their equivalent are found in the in-home presentation...Medication Profile...Patient Rights...Written information to the patient that includes visit schedule, including the frequency of care...patient medication schedule...any other pertinent instruction related to the patient's care and treatments that the HHA will provide ..." 2. On 06-02-2022 at 8:00 AM, a home visit was completed for Patient #3. The In-Home Packet did not include a medication profile, the plan of care or the visit schedule. 3. On 06-02-2022 at 9:45 AM, the Clinical Manager, Employee #2 was queried about the contents of the In-Home Packet. Employee #2 indicated that the In-Home Packet should include a current plan of care and schedule.

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 facility failed to ensure the follow up comprehensive assessment started was completed in the last 5 days of the certification period and available for care planning for 1 of 5 active records reviewed. (Patient # 3) The findings include: 1. On 06-01-2022 at 1:00 PM, a review of the clinical record with the Clinical Manager, Employee #2, for Patient #3 indicated the comprehensive assessment was for the certification period of 03-15-2022 to 05-16-2022. The recertification comprehensive assessment for the next recertification period was not finished and available in the clinical record for care planning prior to the expiration of the certification period on 05-16-2022. 2. On 06-01-2022 at 1:00 PM, Employee #2 indicated the process for completing the recertification was to complete it prior to the expiration of the current certification period. Employee #2 indicated that Registered Nurse #1 was a new employee and had not completed the assessment in the correct time frame according to the regulation. 410 AC 17-14-1(a)(1)(B)

Improvements are sustained CFR(s): 484.65(c)(3) The HHA must take actions aimed at performance improvement, and, after implementing those actions, the HHA must measure its success and track performance to ensure that improvements are sustained. This ELEMENT is not met as evidenced by: Based on record review and interview, the facility failed to ensure the Quality Assessment and Performance Improvement (QAPI) plan was tracking performance as indicated in 1 of 1 Performance Improvement Plans (PIP's). Findings include: 1. On 06-03-2022 at 11:09 AM, the Administrator, Employee #1, provided a January 2018 Interim HealthCare Policy titled, "Quality Assessment and Performance Improvement (QAPI). The policy indicated but was not limited to, "...The results of the QAPI program, including specific performance improvement projects, are documented and evaluated at least annually with the expectation of measurable improvement...Interim HealthCare measures analyzes and tracks quality indicators...to assess process of care, services and operations..." 2. On 06-02-2022 at 1:55 PM, the Interim HealthCare QAPI meeting minutes were reviewed with Employee #1. A review of the October-28-2021, Tri-State Regional QAPI Minutes indicated that Interim HealthCare offices, "...would hold monthly QAPI meetings as they have daily updates on data and are able to evaluate trends before they become problems..." 3. On 06-02-2022 at 1:55 PM, the February 17, 2022, Indianapolis Interim HealthCare QAPI meeting minutes were reviewed. The PIP for Medication Reconciliation plan was initiated. The plan indicated that Medication Management audits would begin on 02-20-2022. A review of 10% of charts for medication accuracy monthly using the audit tool would begin. A review of reconciliation would include 25% review of records for Quarter 1, 50% for Quarter 2, 75% for Quarter 3 and 100% for the 4th Quarter. A review of the March and May 2022 Indianapolis Interim HealthCare QAPI meeting minutes indicated that audits have not been completed. 4. On 06-02-2022 at 1:55 PM, Employee #1 was queried on the data needed to ensure they were tracking the data for the Medication Reconciliation PIP. Employee #1 indicated the audits have not been completed. 410 AC 17-12-2(a)

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 and interview, the Administrator failed to ensure they were responsible for the day to day operation of the home health agency in regards to failure to update the plan of care at least every 60 days; failure to ensure all patients had a copy of their plan of care, medication profile, and visit schedule in the home; failure to maintain complete data tracking for the Quality Assessment Performance Improvement Program (QAPI), failed to ensure a comprehensive assessment was completed and in the clinical record prior to expiration of the certification period; and failed to ensure the organizational chart was updated for accuracy and in accordance with federal regulations. Findings Include: 1. The administrator failed to ensure all patients had been given a copy of their plan of care, medication profile, and visit schedule (See G 410.) 2. The Administrator failed to ensure the comprehensive assessment was updated and available for care planning for the next certification period plan of care. (See G 546.) 3. The Administrator failed to ensure performance improvement projects contained the required data to track their performance to ensure improvements were achieved (See G 656). 4. The Administrator failed to ensure that the Organizational Chart for Interim Healthcare of Indianapolis was updated and accurately reflected the Administrator reported to the Governing Body and included lines of authority down to the Patient level. A review of an agency document dated 2021, titled, “Organizational Chart Interim Healthcare of Indianapolis,” was provided by the Administrator on 06-01-2022 at 4:05 PM. The document failed to be updated with the correct information of who the Administrator reported to (Governing Body,) and failed to include the patients on the organizational chart. During an interview on 06-01-2022, at 3:50 PM, the administrator and alternate administrator, when queried regarding the organization chart confirmed the administrator should report directly to the Governing body and needed to be updated. 410 IAC 17-12-1(a)(1)

Protection of records CFR(s): 484.110(d) Standard: Protection of records. The clinical record, its contents, and the information contained therein must be safeguarded against loss or unauthorized use. The HHA must be in compliance with the rules regarding protected health information set out at 45 CFR parts 160 and 164. This STANDARD is not met as evidenced by: Based on record review and observation the home health agency failed to ensure patient's personal health information was stored in a locked and secure area in 1 of 1 home health agency. The findings include: 1. On 06-03-2022 at 12:51 PM, the agency Administrator, Employee #1, provided an August 2013 policy titled, "Safeguarding Protected Health Information (PHI) - continued. The policy indicated but was not limited to, "...Paper Records, Protected health information maintained on paper, when not in use, is stored in a: Designated fire-resistant file cabinet(s) equipped with a lock, or A secured room that is locked when the Office is closed for the business day. 2. On 06-01 and 06-02 the conference room stored the following 11 white cardboard boxes labeled as discharged patients: Box #1 labeled Jan- Mar 2019, Box #2- 2019, Box #21- 2020, Box #22- 2020, Box #23 2020, Box #24 2020, Box #25 2020, Box #26- 2020, Box #27- 2019, Box #28- 2018. One brown cardboard box without a lid held patient PHI. The conference room did not have a lock on the door. 3. On 06-01-2022 during the entrance conference, Employee #1 indicated that all records were kept locked in the "Bull Pen." On 06-02-2022 during the daily conference, Employee #1 indicated that the records should be kept in a locked area. 410 AC 17-15-1(c)