Every finding on record at Interim Healthcare of SE Indiana Inc

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR §484.102. Survey Dates: 07/22/2025 - 07/25/2025 Active Census: 326 At this Emergency Preparedness survey, Interim Healthcare of SE Indiana was found to be in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR §484.102. QR on 08/04/2025 by A4

This visit was for a Federal Recertification and State Re-Licensure survey of a Home Health Provider in conjunction with 2 complaints. Survey Dates: 07/22/2025 - 07/25/2025 Complaint #: 116461 with related and unrelated deficiencies cited 116468 with related and unrelated deficiencies cited 12-Month Unduplicated Skilled Admissions: 194 Partially Extended on 07/25/2025 at 1:09 PM This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Refer to State Form for additional State Findings. Abbreviations: RN Registered Nurse MD Medical Doctor POC Plan of Care SN Skilled Nurse OASIS Outcome and Assessment Information Set

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to promptly alert relevant physicians and revise the POC in response to a change in patient condition for 1 of 3 closed records reviewed (Patient #8). Findings include: A review of a policy titled "Contents of the Patient/Client Record" indicated but was not limited to: "…Purpose…b) Provide a current and accurate account of the care/services provided to each patient/client…d) Support communication among employees providing, supervising, and managing care/services, and collaboration with other health care providers involved in the delivery of the patient's/client's care/service including the physician or allowed practitioner (e.g., NP, PA, CNS)…" A review of a policy titled "Coordination of Care/Services" indicated but was not limited to: "Policy Interim HealthCare maintains regular communication with the patient/client and with others providing patient/client care/services. Actions and goals of Interim HealthCare services are complimentary and reflect cooperative care planning…Procedure…7. The designated Clinical Manager regularly confers with the patient/client/caregiver, the patient's/client's physician or allowed practitioner (e.g., NP, PA, CNS) as appropriate, and with other health care team members providing care/service to the patient/client. a) The designated employee contacts the physician or allowed practitioner (e.g., NP, PA, CNS) when any of the following events occurs: i) The patient's/client's condition changes; ii) The patient's/client's response to care/treatments or medications is not as expected…" The Clinical Record for Patient #8, Certification Period 03/14/2025 - 05/12/2025, evidenced a POC signed and returned by MD 1 (referring doctor) on 03/25/2025 with all the required elements included and specific treatment for wound care on the lateral side of the right foot (Wound #1) for which the patient was admitted to the home health agency. On 03/24/2025, an emergency room visit note indicated 14 staples were administered to a curved laceration (a tear or split in the skin and underlying tissues, often caused by sharp objects or blunt force) on the anterior (refers to the front of the body in anatomical terms) right leg (Wound #2) that showed some bruising with minimal bleeding and the right foot warm with appropriate capillary refill intact. MD 4 (Emergency Medicine) gave discharge instructions for the patient to make an appointment with MD 3 (Primary Care) to have the staples removed. On 03/27/2025, a skilled nursing visit occurred. In the visit summary, RN 2 indicated the wound dressing for Wound #2 was "changed yesterday, no orders for it". RN 2 wrote an order to increase nursing visits to three (3) times a week starting 04/05/2025 - 04/25/2025. The order was sent to MD 1 on 03/27/2025, signed and returned on 04/08/2025. The record failed to evidence RN 2 communicated wound assessment or request for wound orders for Wound #2 with MD 1 or MD 3. Nursing notes dated 03/31/2025, 04/04/2025, and 04/07/2025 indicated RN 2 assessed Wound #2 and noted no wound orders in each note. The record failed to evidence RN 2 communicated wound assessment or request for wound orders for Wound #2 with MD 1 or MD 3. On 04/03/2025, a case conference note indicated RN 2 discussed the patient with the home health team and Wound #2 "still has no orders for treatment" and reported there were no signs or symptoms of infection. The record failed to evidence RN 2 communicated with MD 1 or MD 3 for wound care orders. On 05/09/2025, a general note indicated MD 1's office called and left a message at the home health agency. The patient had complaints of pain in the leg wound. RN 2 noted there was no redness or drainage from Wound #2. The record failed to evidence communication with the physician to report change in patient wound. During an interview on 07/25/2025 at 10:39 AM, RN 2 indicated Patient #8 was referred to the home health agency by MD 1, a podiatrist, for a foot wound that had been present for a year and was not healing. After the patient was admitted to the agency for a couple of weeks, the patient was walking out onto the porch and the storm door "sliced" Patient #8's right lower leg open and the patient was taken to the ER. Staples were used to close the leg wound (Wound #2) and the leg was wrapped. RN 2 indicated after Patient #8 returned from the Emergency Department, he/she was unable to visualize Wound #2 due to the dressing/wrap that was present. RN 2 indicated when the patient returned from the ER after the leg injury, a granddaughter was changing the dressing for Wound #2 until RN 2 received wound care orders. RN 2 indicated he/she communicated with MD 1 who admitted the patient for Wound #1, to obtain orders for Wound #2 as well, however orders were not received right away for Wound #2. During an interview on 07/25/2025 at 1:13 PM, the Director of Clinical Services indicated when the change in condition is related to a wound, the nurse is expected to assess the wound no matter what unless orders are received from a doctor to not remove a dressing. When there are no orders, the nurse should take off the dressing, assess and measure it, then re-dress it with a dry dressing. At that time, the doctor would receive report, and new orders would be requested for treatment of a new wound. The nurse is expected to continue communications and document all changes that occur with the patient's condition at any time there is a change and ensure all documentation is complete and accurate. 410 IAC 17-13-1(a)(2)

Communication with all physicians CFR(s): 484.60(d)(1) Standard: Coordination of Care. The HHA must: (1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to coordinate care and communicate changes in patient condition with all physicians involved in the POC for 1 of 3 closed records reviewed (Patient #8). Findings include: A review of a policy titled "Coordination of Care/Services" indicated but was not limited to: "Policy Interim HealthCare maintains regular communication with the patient/client and with others providing patient/client care/services. Actions and goals of Interim HealthCare services are complimentary and reflect cooperative care planning…Procedure…7. The designated Clinical Manager regularly confers with the patient/client/caregiver, the patient's/client's physician or allowed practitioner (e.g., NP, PA, CNS) as appropriate, and with other health care team members providing care/service to the patient/client. a)The designated employee contacts the physician or allowed practitioner (e.g., NP, PA, CNS) when any of the following events occurs: i) The patient's/client's condition changes; ii) The patient's/client's response to care/treatments or medications is not as expected…" The Clinical Record for Patient #8, Certification Period 03/14/2025 - 05/12/2025, evidenced a POC signed and returned by MD 1 (referring doctor) on 03/25/2025 with all the required elements included and specific treatment for wound care on the lateral side of the right foot (Wound #1) for which the patient was admitted to the home health agency. On 03/24/2025, an emergency room visit note indicated 14 staples were administered to a curved laceration (a tear or split in the skin and underlying tissues, often caused by sharp objects or blunt force) on the anterior (refers to the front of the body in anatomical terms) right leg (Wound #2) that showed some bruising with minimal bleeding and the right foot warm with appropriate capillary refill intact. MD 4 (Emergency Medicine) gave discharge instructions for the patient to make an appointment with MD 3 (Primary Care) to have the staples removed. A nursing note on 03/25/2025 indicated RN 2 failed to coordinate the care of Wound #2 with MD 3. Nursing notes on 3/27/2025, 03/31/2025, 03/31/2025, 04/04/2025, 04/07/2025, 04/16/2025, 04/18/2025, 04/19/2025, 04/21/2025, 04/30/2025, 05/07/2025, 05/09/2025, 05/15/2025 indicated RN 2 provided skilled nursing services related to Wound #2 for the patient and failed to evidence coordination of care and communication with all physicians involved in patient’s care. Case Conference notes on 03/27/2025, 04/17/2025, and 04/24/2025 indicated RN 2 reported updates related to Wound #2 and failed to evidence coordination of care and communication with all physicians involved in patient’s care. On 04/07/2025, a medical assistant note in the patient’s record, indicated during an encounter with the patient, MD 2 (primary care office group physician with MD 3) was asked to assess Wound #2. MD 2 removed three (3) Steri-strips (thin, sticky bandages that cover small cuts and some surgical incisions; can apply them across the cut running in the opposite direction to help the two sides of the skin stay tightly closed) along with four (4) staples and observed a very red and swollen right lower leg. MD 2 indicated the patient suffered from a possible allergic reaction to Tegaderm used a day or so prior and advised the medical assistant and patient to only use Bactroban ointment with non-adherent pads secured with surgical tape. The wound was redressed while in the office and MD 2 educated patient on bathing and care instructions while at home. On 05/09/2025, RN 2 wrote an order for changes applied to recertification of the patient for 05/13/2025 - 07/11/2025. The orders indicated skilled nursing to assess and change dressing to right foot and leg three (3) times weekly, an updated goal for the patient to be able to remain in the home and achieve optimal well-being prior to discharge from home services, and the plan was discussed with MD 1. The order was sent to MD 1 on 05/13/2025, signed and returned on 05/14/2025. The record failed to evidence RN 2 added MD 3 to the patient’s POC and failed to evidence coordination of care and communication between all physicians involved in patient's care. During an interview on 07/25/2025 at 10:39 AM, RN 2 indicated he/she probably forgot to document when the staples were taken out of Patient #8's right leg wound. RN 2 indicated being pretty sure a primary care physician removed the staples. After reviewing Patient #8's clinical record, RN 2 indicated MD 2 is who removed the staples per the patient's clinical record. The RN indicated MD 2 is in a physicians group with MD 3. RN 2 indicated he/she communicated with MD 1 who admitted the patient for the right foot wound (Wound #1), to obtain orders for the right leg wound (Wound #2) as well, however orders were not received right away for Wound #2. The RN indicated he/she couldn't be for sure if it was MD 1 who removed the staples from Wound #2. RN 2 then indicated actually not being sure who Patient #8's primary care physician was and indicated MD 2 was who sent the progress note to the agency after the staples were removed from Wound #2. RN 2 indicated he/she did not communicate with MD 2 to follow up after the staples were removed, and instead reached out to MD 1 because that is who was overseeing the orders for Wound #1. During an interview on 07/25/2025 at 1:13 PM, the Director of Clinical Services indicated the referring physician is often who the nurse primarily communicates. Ideally, if the referring physician is a specialist, the primary care physician would be looped into care for updates. The Director of Clinical Services indicated the expectation for nurses who are providing care that if there is a change in condition then the referring physician is contacted regarding the update to determine if new orders need to be implemented. If the referring physician is not willing to provide orders for the condition change, then the primary care physician should be contacted, updated and orders requested for care. Also, all physicians related to patient care should be on the Plan of Care to ensure total coordination of care. 410 IAC 17-14-1(a)(1)(G)

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the clinical record contained complete and accurate clinical notes for 1 of 3 closed records reviewed (Patient #8). Findings include: A review of a policy titled "Entries into the Patient/Client Record," indicated but was not limited to: "Entries into the patient/client record include at least the following: …Accurate and pertinent data regarding patient/client: i. Assessment; ii. Care/Services delivered; iii. Outcomes and responses to care/services…" On 03/24/2025, an emergency room visit note indicated 14 staples were administered to a curved laceration (a tear or split in the skin and underlying tissues, often caused by sharp objects or blunt force) on the anterior (refers to the front of the body in anatomical terms) right leg that showed some bruising with minimal bleeding and the right foot warm with appropriate capillary refill intact. Nursing notes dated 03/25/2025, 03/27/2025, 03/31/2025, 04/04/2025, indicated RN 2 performed a skilled nursing visit and assessed Wound #2. The record failed to evidence documentation of staples present to Wound #2. On 04/07/2025, a medical assistant note indicated during an encounter with the patient, MD 2 (primary care office group physician with MD 3) was asked to assess Wound #2. MD 2 removed three (3) Steri-strips (thin, sticky bandages that cover small cuts and some surgical incisions; can apply them across the cut running in the opposite direction to help the two sides of the skin stay tightly closed) along with four (4) staples and observed a very red and swollen right lower leg. On 04/07/2025, a skilled nursing visit occurred. RN 2 indicated Wound #2 was observable with light serosanguineous drainage, no odor, pink tissue with closed/hyperkeratotic wound edges visualized, and that an "abdominal pad covered with a clear dressing, No orders, dressing is clean dry and intact no visible s/s of infection noted". The visit summary indicated possible changes in treatment or doctor based on what MD 1 decided at the upcoming appointment for the week. The record failed to evidence documentation of change in Wound #2, removal of staples. On 04/16/2025, RN 2 measured Wound #2 at 13 cm long X 4 cm wide X 0.3 cm deep, light serosanguinous drainage, no odor, closed/hyperkeratotic wound edges with pink surrounding tissue, no signs of infection with collagen and xeroform applied with a gauze dressing per the new order. The visit summary indicated the patient removed dressings from wounds to take a shower and reports no pain. RN 2 wrote an order to apply collagen and xeroform with sterile gauze to Wound #2. The order was sent to MD 1 on 04/21/2025, signed and returned on 04/22/2025. The record failed to evidence documentation of change in Wound #2, removal of staples. On 05/12/2025, a follow-up visit note with MD 1 after a scheduled MRI test was completed, indicated the wounds on the right lateral foot and the lower tibial region of the right leg had worsened. The MRI showed early acute osteomyelitis. MD 1 noted the patient sustained a laceration to the lower right leg that had 14 staples used to close the wound, then two (2) weeks later, the staples were removed by MD 3. MD 1 reported "fairly large eschar remained present without active drainage or signs of infection". MD 1 indicated the patient called on 05/09/2025 due to worsening pain with the wounds, so an appointment was scheduled for 05/12/2025 in the wound clinic for evaluation and debridement. During an interview on 07/25/2025 at 10:39 AM, RN 2 indicated being unable to recall when the staples were removed from the right leg wound. The RN indicated he/she probably forgot to document when the staples were taken out of Patient #8's right leg wound. During an interview on 07/25/2025 at 1:13 PM, the Director of Clinical Services indicated that when the change in condition is related to a wound, the nurse is expected to assess the wound no matter what unless orders are received from a doctor to not remove a dressing. When there are no orders, the nurse should take off the dressing, assess and measure it, then re-dress it with a dry dressing. At that time, the doctor would receive report and new orders would be requested for treatment of a new wound. The nurse is expected to continue communications and document all changes that occur with the patient's condition at any time there is a change and ensure all documentation is complete and accurate. 410 IAC 17-14-1(a)(1)(E)

This visit was for a Federal and State Licensure complaint investigation of a home health agency. Complaint 31975: Substantiated, federal deficiencies related to the allegation were cited. Survey Date: October 18th of 2021 Facility Number: 003257 QR completed 10/26/2021 A4

Document efforts to resolve problems CFR(s): 484.50(d)(5)(iv) (iv) Document the problem(s) and efforts made to resolve the problem(s), and enter this documentation into its clinical records; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to document efforts to resolve problems in 4 of 5 records reviewed. (Patient 1, 3, 4, 5) Findings include: 1. An admission packet was provided by Employee A on 10/18/21. The packet contained a 2018 policy titled "Statement of Patient’s/Client's Rights". The policy indicated, but was not limited to, "2. Receive all services outlined in your care plan." 2. A 04/02/2021 policy titled "Variances from the Plan of Care/Service Plan" was provided by Employee B on 10/18/21 at 1:03 p.m. The policy indicated, but was not limited to, "2. If the office is unable to fill the visit/shift/hour requirement of a patient/client, then ... contacts the patient/client/caregiver to reschedule the visit/shift to comply with the physician's ... orders or service plan ... c) If alternative means cannot be identified and the visit/shift/hours are not filled but ... do not put the patient/client at risk ... does not have a potential for clinical impact ... the communication is documented as such. d) If alternative means cannot be identified and the patient/client will be put at risk by not filling the visit/shift/hour ... notifies all parties including any ordering physician ... The physician ... decides whether the patient visit may be skipped, or addition intervention is required ... 3. The Visit/Shift Variance Report form ... is completed ... for each missed visit/shift ... Care/Service Variance 1. The care manager ... provides on-going monitoring to determine that care/service plans are being followed as written ... d) Documents actions taken in the patient's/client's record ... " 3. A 10/2017 revised job description titled "Home Health Aide-Home Care Job Description" was provided by Employee A on 10/18/21 at 4:10 p.m. The job description indicated, but was not limited to, " ... Document observations, activities and services provided in an accurate, complete and timely manner ... " 4. A 10/2017 revised job description titled "Registered Nurse-Home Care Job Description" was provided by Employee A on 10/18/21 at 4:10 p.m. The job description indicated, but was not limited to, " ... Completes timely and accurate clinical notes ... " 5. A 10/2017 revised job description titled "RN Case Manager-Home Care Job Description" was provided by Employee A on 10/18/21 at 4:10 p.m. The job description indicated, but was not limited to, "General Purpose: To assure quality patient/client care and services are provided to in home clients ... Participates in ongoing interdisciplinary assessment of the patient ... in the development and evaluation of the plan of care ... Provides services that are ordered by the physician as indicated in the plan of care ... Completes timely and accurate clinical notes ... Effectively communicates with other members of the interdisciplinary ... team providing care to promote coordination of ... care ... Communicates with all physicians involved ... related to the current plan of care ... Uses clinical decision making to efficient and effectively manage as assigned patient ... " 6. The complete clinical record for Patient 1, SOC (start of care) 08/16/2017, was reviewed on 10/18/2021. The record indicated, but was not limited to, the following: A document titled Plan of Care for the certification period from 08/22/2021-10/20/2021, signed on 09/03/2021, included orders for a SN (Skilled Nurse) once weekly for 9 weeks, and a HHA (Home Health Aide) 7 times a week for 9 weeks. The clinical record evidenced that there were 14 missed HHA visits during the certification period. Of the 14 missed visits, 11 visits had no documentation as to why the visits were missed, documentation of any efforts to find alternate staff or reschedule for another day, or communication to the MD. A document titled “Unable to Meet Visit Frequency”, dated 09/21/2021, indicated, but was not limited to, “Number of Visits for Week Prescribed 7 Actual 5 ... No staff available ... Physician Contacted ... Will FAX note to MD (medical doctor) office ...” The clinical record failed to evidence any communication with the MD about the missed visits, as well as evidence any further documentation regarding missed visits. During an interview with Employee C on 10/18/21 at 2:00 p.m. Employee C stated that Patient 1 previously only received care from HHA's, until the prior year when a pressure ulcer developed. 7. The complete clinical record for Patient 3, SOC 03/14/2019, was reviewed on 10/18/2021. The record indicated, but was not limited to, the following: A document titled Plan of Care for the certification period from 03/03/2021-05/01/2021, signed on 03/02/2021, included orders for a HHA up to 5 hours per day, 5 days per week. The clinical record evidenced that there were 40 missed HHA visits during the certification period. The clinical record failed to evidence documentation as to why the visits were missed, or documentation of any efforts to find alternate staff or reschedule for another day was available. A document titled Client Discharge, dated 08/26/2021, indicated that Patient 3 was discharged from the agency per patient choice. When asked if Employee C knew why the patient chose to discharge from the agency, Employee C stated, "I don't know, probably because we didn't have the staff." During an interview with Employee C on 10/18/2021 at 3:40 p.m., when asked at why there were so few visits during the certification period, Employee C stated that Patient 3 only liked certain staff members. When asked if Employee C could provide any kind of documentation of communication between the agency and Patient 3 about missed visits or the patient discharge, Employee C stated “(Patient 3) has a really small chart. That’s all I’ve got.” 8. The complete clinical record for Patient 4, SOC 06/11/2020, was reviewed on 10/18/2021. The record indicated, but was not limited to, the following: A document titled Plan of Care for the certification period from 08/25/2021-10/23/2021, included orders for a SN for 2 encounters every day, for 9 weeks and orders for a HHA 4 hours per day, 7 days per week for 9 weeks. The clinical record evidenced that there were 9 days with only one SN visit for the day and 14 days with no SN visits, and 22 missed HHA visits during the certification period. The clinical record failed to evidence documentation as to why the visits were missed, any effort to find alternate staff, or proof of communication to the MD. 9. The complete clinical record for Patient 5, SOC 08/13/2018, was reviewed on 10/18/2021. The record indicated, but was not limited to, the following: A document titled Plan of Care for the certification period from 07/28/2021-09/25/2021, included orders for a HHA 4 hours per day, 7 days per week. The clinical record evidenced that there were 14 missed visits during the certification period. The clinical record failed to evidence documentation as to why the visits were missed, any effort to find alternate staff, or proof of communication to the MD. 10. During an interview with Employee C on 10/18/2021 at 3:40 p.m., when asked at what point the agency would consider discharging a patient, or referring to another agency, if the agency wasn't able to fulfill the visits ordered in then plan of care, Employee C stated "I don't know. Some patients are ok with sporadic visits, or only want certain staff members, so it's hard to say."

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to provide all services ordered in the plan of care for 4 of 5 records reviewed. (Patient 1, 3, 4, 5) Findings include: 1. An admission packet was provided by Employee A on 10/18/21. The packet contained a 2018 policy titled "Statement of Patient's/Client's Rights". The policy indicated, but was not limited to, "2. Receive all services outlined in your care plan." 2. A 04/02/2021 policy titled "Variances from the Plan of Care/Service Plan" was provided by Employee B on 10/18/21 at 1:03 p.m. The policy indicated, but was not limited to, "2. If the office is unable to fill the visit/shift/hour requirement of a patient/client, then ... contacts the patient/client/caregiver to reschedule the visit/shift to comply with the physician's ... orders or service plan ... c) If alternative means cannot be identified and the visit/shift/hours are not filled but ... do not put the patient/client at risk ... does not have a potential for clinical impact ... the communication is documented as such. d) If alternative means cannot be identified and the patient/client will be put at risk by not filling the visit/shift/hour ... notifies all parties including any ordering physician ... The physician ... decides whether the patient visit may be skipped, or addition intervention is required ... 3. The Visit/Shift Variance Report form ... is completed ... for each missed visit/shift ... Care/Service Variance 1. The care manager ... provides on-going monitoring to determine that care/service plans are being followed as written ... d) Documents actions taken in the patient's/client's record ... " 3. A 10/2017 revised job description titled "Home Health Aide-Home Care Job Description" was provided by Employee A on 10/18/21 at 4:10 p.m. The job description indicated, but was not limited to, " ... Document observations, activities and services provided in an accurate, complete and timely manner ... " 4. A 10/2017 revised job description titled "Registered Nurse-Home Care Job Description" was provided by Employee A on 10/18/21 at 4:10 p.m. The job description indicated, but was not limited to, " ... Completes timely and accurate clinical notes ... " 5. A 10/2017 revised job description titled "RN Case Manager-Home Care Job Description" was provided by Employee A on 10/18/21 at 4:10 p.m. The job description indicated, but was not limited to, "General Purpose: To assure quality patient/client care and services are provided to in home clients ... Participates in ongoing interdisciplinary assessment of the patient ... in the development and evaluation of the plan of care ... Provides services that are ordered by the physician as indicated in the plan of care ... Completes timely and accurate clinical notes ... Effectively communicates with other members of the interdisciplinary ... team providing care to promote coordination of ... care ... Communicates with all physicians involved ... related to the current plan of care ... Uses clinical decision making to efficient and effectively manage as assigned patient ... " 6. The complete clinical record for Patient 1, SOC (start of care) 08/16/2017, was reviewed on 10/18/2021. The record indicated, but was not limited to, the following: A document titled Plan of Care for the certification period from 08/22/2021-10/20/2021, signed on 09/03/2021, included orders for a SN (Skilled Nurse) once weekly for 9 weeks, and a HHA (Home Health Aide) 7 times a week for 9 weeks. The clinical record evidenced that there were 14 missed HHA visits during the certification period. During an interview with Employee C on 10/18/21 at 2:00 p.m. Employee C stated that Patient 1 previously only received care from HHA's, until the prior year when a pressure ulcer developed. 7. The complete clinical record for Patient 3, SOC 03/14/2019, was reviewed on 10/18/2021. The record indicated, but was not limited to, the following: A document titled Plan of Care for the certification period from 03/03/2021-05/01/2021, signed on 03/02/2021, included orders for a HHA up to 5 hours per day, 5 days per week. The clinical record evidenced that there were 40 missed HHA visits during the certification period. A document titled Client Discharge, dated 08/26/2021, indicated that Patient 3 was discharged from the agency per patient choice. When asked if Employee C knew why the patient chose to discharge from the agency, Employee C stated , "I don't know, probably because we didn't have the staff." During an interview with Employee C on 10/18/2021 at 3:40 p.m., when asked at why there were so few visits during the certification period, Employee C stated that Patient 3 only liked certain staff members. 8. The complete clinical record for Patient 4, SOC 06/11/2020, was reviewed on 10/18/2021. The record indicated, but was not limited to, the following: A document titled Plan of Care for the certification period from 08/25/2021-10/23/2021, included orders for a SN for 2 encounters every day, for 9 weeks and orders for a HHA 4 hours per day, 7 days per week for 9 weeks. The clinical record evidenced that there were 9 days with only one SN visit for the day, and 14 days with no SN visits, and 22 missed HHA visits during the certification period. 9. The complete clinical record for Patient 5, SOC 08/13/2018, was reviewed on 10/18/2021. The record indicated, but was not limited to, the following: A document titled Plan of Care for the certification period from 07/28/2021-09/25/2021, included orders for a HHA 4 hours per day, 7 days per week. The clinical record evidenced that there were 14 missed visits during the certification period. 10. During an interview with Employee C on 10/18/2021 at 3:40 p.m., when asked at what point the agency would consider discharging a patient, or referring to another agency, if the agency wasn't able to fulfill the visits ordered in then plan of care, Employee C stated "I don't know. Some patients are ok with sporadic visits, or only want certain staff members, so it's hard to say." 17-14-1(a)(1)(C)