Every finding on record at Kosciusko Home Care & Hospice Inc

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 43 CFR 494.62. Survey Dates: March 7,8,9,10,11 2022 At this Emergency Preparedness survey, Kosciusko Home Care was found to be in compliance with 42 CFR 494.62 Emergency Preparedness Requirements, including staffing and the implementation of staffing during a Pandemic for Medicare Participating Providers and Suppliers. QA: Area 2

This visit was for a federal recertification and state licensure survey. Survey Dates: March 7, 8, 9, 10, 11 (2022). The survey was announced as partially extended on 3/10/2022 at 1:09 p.m. Active Census: 17 These deficiencies reflect State Findings cited in accordance with 410 IAC 17.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the plan of care included all required elements, medications and functional limitations for 3 of 6 active records reviewed (Patients #1, 3, and 8). Findings include: Review of an agency policy titled “Plan of Care Policy and Procedure” with a revision date of 11/2018, revealed the contents of “… the individualized plan of care will … include the following … medications ….” A record review for Patient #5 was completed on 3/8/2022, which revealed a document titled “Home Health Certification and Plan of Care,” for certification period 1/21/2022 – 3/21/2022. The document revealed a medication list containing, among others, codeine sulfate to be used after dental extraction. During an interview on 3/11/2022 at 9:46 a.m., Employee F, Director of Performance Improvement and Education, confirmed codeine sulfate was not a current medication. He/ She confirmed the plan of care should identify current medications. Review of an agency policy dated 11/2018, titled “Plan of Care Policy and Procedure” indicated “… the individualized plan of care will be developed in consultation with the Agency staff and include the following … functional limitations … all medications ….” A record review for Patient #1 was completed on 03/07/2022, start of care date 04/21/2020, contained a plan of care for the certification period 02/10/2022 – 04/10/2022, with other pertinent diagnoses (but not limited to) generalized anxiety disorder (excessive, exaggerated anxiety and worry about everyday life events for no obvious reason) and gastroesophageal reflux disease (stomach acid flows back into the tube connecting the mouth and stomach). This plan of care indicated “… medications … escitalopram oxalate [used for anxiety] by mouth … 20 mg [milligram] 1tab [tablet] daily … omeprazole [used for stomach acid] by mouth … 20 mg 2 cap [capsules] bid [twice a day] PO [by mouth] ½ hr. [hour] before meals ….” The plan of care failed to evidence the discontinuation of escitalopram oxalate and failed to include the correct administration instructions for omeprazole. During an interview on 03/11/2022 at 9:30 AM, Employee F, director of performance improvement and education, indicated there was a transcription error in entering the administration instructions of omeprazole and the VA (veterans administration) had discontinued escitalopram oxalate but was not discontinued in the patient’s plan of care. A record review for Patient #3 was completed on 03/09/2022, start of care date 11/16/2018, contained a plan of care for the certification period 02/28/2022-04/28/2022. This plan of care indicated “… medications … prednisone [medication to treat conditions such as arthritis and breathing problems] by mouth table 20mg 1-3 tab daily … tapering dose as directed … orders for … treatments … dressing change … cover any draining wounds with dry gauze ….” The plan of care failed to evidence the discontinuation of prednisone and a dressing change. Review of a home health aide care plan with revised date 02/18/2022, indicated hearing as a functional limitation. The plan of care failed to evidence hearing as a functional limitation. During an interview on 03/11/2022 at 9:30 AM, Employee F, director of performance improvement and education, indicated prednisone and dressing should have been discontinued in the patient’s plan of care. Indicated the skilled nurse did not enter hearing in the plan of care. A record review for Patient #8 was completed on 03/10/2022, start of care date 05/05/2020, contained a plan of care for the certification period 02/24/2022-04/24/2022, with other pertinent diagnosis (but not limited to) controlled diabetes [condition that affects how the body uses blood sugar] with chronic kidney disease. This plan of care indicated “… nutritional req [requirement] … regular diet ….” Review of a home health aide care plan with revised date 02/18/2022, indicated diabetic as the diet for meal preparation. The plan of care failed to evidence diabetic as the diet. During an interview on 03/11/2022 at 9:30 AM, Employee F, director of performance improvement and education, indicated the nutritional requirement in the plan of care will be updated to diabetic diet.

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 registered nurse failed to inform the physician of changes in the patients’ wound that suggested the plan of care should have been altered for 1 of 6 active records reviewed (Patient #3). Findings include: Review of an agency policy titled “Plan of Care Policy and Procedure” with a revision date of 11/2018, indicated “… agency must promptly alert the relevant physician(s) to any changes in the patient’s condition … that suggest … the plan of care should be altered ….” A record review for Patient #3 was completed on 03/09/2022, which revealed a document titled “Home Health Certification and Plan of Care” for certification period of 12/30/2021-02/27/2022, indicated “… orders … assess wound L [left] upper chest wound … dressing change … cover any draining wounds with dry gauze ….” The plan of care failed to evidence the current status of patients’ skin. Review of an agency document dated 12/27/2021 and titled “Visit Record” indicated “… skin … wound L [left] upper chest has healed with pink scarring ….” During an interview on 03/11/2022 at 9:30 AM, Employee F, Director of Performance Improvement and Education, indicated the wound healed on 09/07/2021 but does reopen. 410 IAC 17-13-1 (a)(2)

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 record review and interview, the agency failed to ensure staff self-screened for COVID symptoms, potentially affecting all agency staff and patients. Findings include: 1. Review of an agency policy, “COVID – 19 Vaccination of Agency Staff Policy and Procedure,” revision date 2/2022, revealed “all staff … expected to self-screen, prior to their work day ….” 2. Review of an agency policy, “Exposure to Coronavirus (COVID – 19): Disease Response and Management,” updated 2/1/2022, revealed, “Employees are required to self-screen for any symptoms of COVID – 19 daily ….” 3. During an interview on 3/9/2022 at 11:39 a.m., Employee E, Certified Nurse Aide (CNA), confirmed he/she does not self- screen for COVID – 19 at this time. Employee E, CNA, confirmed he/she self-screens for COVID only if exposed or has had COVID. 4. During an interview on 3/11/2022 at 1:15 p.m., Employee A, Administrator, confirmed staff are expected to self-screen for COVID daily. IAC 17-12-1(m)

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on record review and interview, the registered nurse (RN) failed to ensure the home health aide care plan was authenticated and specific to the needs of the patients for 2 of 3 clinical records reviewed with aide services (Patient #6 and 8). Findings include: Review of an agency policy titled “Home Health Aide Services Policy and Procedure” with a revision date of 11/2018, revealed the home health aide completes care “… with written patient care instructions … prepared by … registered nurse ….” A record review for Patient #6 was completed on 3/10/2022, which revealed a document titled "Home Health Certification and Plan of Care" for certification period 10/5/2021 - 12/3/2021. The document revealed home health aide services 1 – 2 times per week. Review of a document titled “Aide Plan of Care,” revealed the document was not signed or dated by a registered nurse. Review of documents titled “Aide Flowsheet,” dated 10/12, 10/19, 10/22, 10/26, 10/28, and 11/3/2021, revealed personal care services provided to Patient #6. During an interview on 3/11/2022 at 11:55 a.m., Employee F, Director of Performance Improvement and Education, confirmed there was no Aide Plan of Care. A record review for Patient #8 was completed on 3/10/2022, which revealed a document titled "Home Health Certification and Plan of Care" for certification period 02/24/2022 – 04/24/2022 indicated “… nutritional reg [requirement] … regular diet … mental status … forgetful ….” The plan of care failed to evidence the correct diet and mental status. Review of an agency document dated as revised on 02/18/2022 and titled “Veterans Administration Aide Plan of Care” indicated “… Diet: diabetic … mental status … oriented ….” During an interview on 03/11/2022 at 9:40 AM, Employee F, Director of Performance Improvement and Education, indicated the nurse entered the incorrect information into the plan of care.