Every finding on record at Master's Touch Home Care Inc, The

An Emergency Preparedness survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102 for a Home Health Provider and Supplier. Survey Date: 07-31-2024 and 08-01-2024 Census: 45 At this Emergency Preparedness survey, The Master’s Touch Home Care was found to be out of compliance at 42 CFR 484.102 Emergency Preparedness Requirements for Medicare/Medicaid Participating Providers and Suppliers for Home Health Agencies. QR completed by Area 3 on 8-6-2024.

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, §485.542, §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 ensure the comprehensive emergency preparedness program met all requirements to meet the health, safety, and security needs of their staff and patient population for 1 of 1 agency (E0001); failed to ensure an Emergency Preparedness Plan was in place and reviewed every 2 years, at minimum (E0004); failed to ensure a facility based and community based risk assessment utilizing an all-hazards approach (E0006); failed to ensure the agency addressed patient population, including, but not limited to, persons at-risk and continuity of operations, including delegations of authority and succession plans (E0007); failed to ensure the agency included a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials (E0009); failed to ensure a system to inform State and local emergency preparedness officials about patients in need of evacuation (E0019); failed to ensure the agency had a plan for the subsistence needs for staff and patients, whether they evacuated or sheltered in place; failed to ensure access to a plan or a system / defined procedure to track the location of on-duty staff and sheltered patients under the agency’s care during an emergency (E0021); failed to ensure a system of medical documentation that would preserve patient information, protects the confidentiality of patient information, secures and maintains the availability of records (E0023); failed to ensure the use of volunteers in an emergency or other emergency staffing strategies to address surge needs during an emergency (E0024); failed to ensure a written emergency communication plan that contains how the facility coordinates patient care within the agency, across healthcare providers, and with state and local public health departments (E0029); failed to ensure that an emergency preparedness communication plan included all staffing addresses and phone numbers, entities providing services under arrangements, and patient physicians for all districts/ territories that the agency provided services to (E0030); failed to ensure Emergency Official contact information (E0031); failed to ensure a system in place for primary or alternate means for communication with staff, Federal, State, tribal, regional, and local emergency management agencies (E0032); failed to ensure a system was in place for sharing information and medical documentation for patients under the agency’s care, as necessary, with other health providers to maintain the continuity of care (E0033); and failed to ensure the agency developed and maintained an emergency preparedness training and testing program that is based on the emergency plan and the Training and Testing was reviewed annually (E0036). The cumulative effect of these systemic problems resulted in the agency being found out of compliance with the condition, Emergency Preparedness Requirements for Medicare Participating Providers and Suppliers for Home Health Agencies. at 42 CFR 484.102. Findings include: 1. On 08-01-2024 a review of an agency’s policy titled ‘EMERGENCY MANAGEMENT PLAN Policy No. 4-001’ revealed, “… POLICY The organization will comply with all applicable, Federal, State, and local emergency preparedness requirements … PROCEDURE … Organization leadership will conduct a hazard vulnerability analysis (HVA) … 1. The HVA is evaluated annually to reflect changes in organization, risk conditions, patient information, and changes in staff. 2. Staff will work with regional or county emergency management planning agencies … A, Establishing priorities … B. Defining organization’s role in relation to the community-wide emergency management program … C. Developing an “all-hazards: command structure … 3. Specific procedures that describe mitigation, preparedness, response, and recovery strategies, actions, and responsibilities will be developed for each priority emergency. 4. Based on the hazard vulnerability analysis and community planning activities, the organization’s general emergency plan may be enhanced or revised according to identified potential emergencies and planning activities. 5. The Executive Director/Administrator … has been designated at key leadership who is responsible for all emergency activities… will determine the leadership command structure to ensure continuity of operations (See Addendum 4-001.B “Command Structure” and Addendum 4-001.C “Flow Chart of Alternate Roles and Responsibilities”). … Communication Plan The Organization will maintain an emergency preparedness communication plan that complies with Federal, State, and local laws, and is reviewed and updated annually … Training and Testing The Training and testing program is reviewed and updated at least annually. … Testing 1. The Master’s Touch Home Care will test the emergency management plan … at least annually … 2. The agency participates in a full-scale exercise that is a community-based or individual, facility-based …”. On 08-01-2024 a review of ‘ADDENDUM 4-001.A PYRAMID PHONE COMMUNICATION PLAN’ revealed “Primary Communication Method: (left blank), Alternate Communication Method: (left blank). On 08-01-2024 a review of ‘ADDENDUM 4-001.B COMMAND STRUCTURE’ was left blank. On 08-01-2024 a review of ‘ADDENDUM 4-001.C FLOW CHART OF ALTERNATE ROLES AND RESPONSIBILITIES’ was left blank. On 08-01-2024 a review of ‘ADDENDUM 4-001.D HAZARD VULNERABILITY ANAYLISIS’ was left blank. On 08-01-2024 at 8:38 AM, a review of the EP binder revealed it was a 'sample' binder to be used to develop an agency's EP Program. 2. On 08-01-2024 at 8:40 AM, this writer queried the Administrator who was in charge of the Agency’s Emergency Preparedness Program, and she indicated the Clinical Educator was in charge of the EP Program and they should be arriving at the agency soon. 3. On 08-01-2024 at 10:32 AM, the Clinical Educator indicated all patients have their EP plans in their binders in their homes and the staff are given an annual in-service on EP. When queried further if the agency had participated in a community-based exercise or conducted one annually, and if the program was developed and evaluated annually, they indicated they would have to speak with the Administrator. When queried about the EP binder that was provided to the surveyors, the Clinical Educator indicated the forms were blank, and there was missing documentation. 4. On 08-01-2024 at 3:00 PM, when the Administrator was queried about the Agency’s EP Program, she indicated the Clinical Educator was in charge of it and was putting together the EP Program, knew the EP binder provided was a sample book for a guideline, and they were part of Coalition 5 (serves as a multidisciplinary, multi-agency group that assists in the coordination with local Emergency Management agencies) but hadn't participated in any activities.

This visit was for a Federal Recertification of a Home Health provider. Partially Extended survey on: 07-31-2024 at 3:42 PM. Fully Extended survey on: 08-01-2024 at 3:06 PM. Survey Date: 07-31 and 08-01-2024 12-Month Unduplicated Skilled Admissions: 68 Active Census: 45 This deficiency report reflects State Findings cited in accordance with 410 IAC 17. For additional state findings, refer to the State Form. During this Federal Recertification Survey, The Master’s Touch Home Care Limited Liability Company (LLC) was found to be out of compliance with Conditions of Participation 484.102 Emergency Preparedness and 484.105 Organization and Administration of Services. Based on the Condition-level deficiencies during the August 01, 2024, survey, your HHA was subject to a partial or extended survey pursuant to section 1891(c)(2)(D) of the Social Security Act on November 10, 2020. Therefore, and pursuant to section 1891(a)(3)(D)(iii) of the Act, your agency is precluded from operating or being the site of a home health aide training, skills competency, and/or competency evaluation program for a period of two years beginning August 01, 2024, and continuing through July 31, 2026. QR completed by Area 3 on 8-6-2024.

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to submit OASIS (Outcome Assessment Information Set) within 30 days of assessment completion for 2 of 5 active clinical records reviewed. (Patients #8 and 9 (3 times)) Findings Include: 1. A review of The Master’s Touch Home Care policy revised December 2018, titled “OASIS Data Transmission” indicated but was not limited to, “ … The organization will encode and will encode and transmit each completed OASIS data for each applicable patient within thirty (30) days of the M0090 date, date assessment completed … ” 2. A review of an agency document titled “OASIS Agency Final Validation.” The documents dated 07-01-2023 through 07-30-2024 were reviewed, for the reporting period of the year to date, which indicated Active Patient #9 had a section titled “RFA” listed as 01, indicating start of care OASIS assessment submitted on 07/17/2023 and the M0090 date of 06-14-2023 with message -3330 indicating record submitted late; more than 30 days after the M0090 date of the record. The validation reports indicated Patient #9 had section titled RFA listed as 04, indicating recertification OASIS assessment submitted on 09-13-2023 and the M0090 date of 08-11-2023 with message -3330 indicating record submitted late; more than 30 days after the M0090 date of the record. The validation reports indicated Patient #9 had section titled RFA listed as 04, indicating recertification OASIS assessment submitted on 06-13-2023 and the M0090 date of 08-11-2023 with message -3330 indicating record submitted late; more than 30 days after the M0090 date of the record. 3. A review of the active clinical record for Patient #9, with a start of care date of 06-14-2023, contained an initial comprehensive assessment dated 06-14-2023. The OASIS Assessment reason was for a start of care for the certification period 06-14-2023 through 08-14-2023. The record contained a comprehensive assessment dated 08-11-2023, for the recertification period 08-13-2023 through 10-11-2024. The record contained a comprehensive reassessment dated 04-05-2024, for the recertification period 04-09-2024 through 06-07-2024. 4. A review of an agency document titled “OASIS Agency Final Validation.” The documents dated 07-01-2023 through 07-30-2024 were reviewed, for the reporting period of the year to date, which indicated that Inactive Patients #8 had a section titled “RFA” listed as 01, indicating start of care OASIS assessment submitted on 06/24/2024 and the M0090 date of 04-08-2024 with message -3330 indicating record submitted late; more than 30 days after the M0090 date of the record. 5. A review of the active clinical record for Patient #8's start of care 04-08-2024, contained an initial comprehensive assessment dated 04-08-2024. The OASIS Assessment reason was for a start of care for the certification period 04-08-2024 through 06-06-2024. During a phone interview on 08/01/2024 at 3:31 PM, when queried regarding the submissions of OASIS, the Clinical Manager confirmed they submitted the agency OASIS and that they should be submitted within 30 days. The Clinical Manager further indicated they reviewed the error reports and did not have any, then indicated they may have had one. When queried regarding a review of the untimely submissions of Patients # 8, and 9, they were new then and were figuring the system out. When asked if there was a Performance Improvement Plan (PIP) for untimely submissions indicated there had not been.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure a complete psychosocial status assessment was completed on 1 of 5 active record reviews. (Patient #1) Findings include: 1. A review of an agency’s policy dated December 2018 titled ‘INITIAL AND COMPREHENSIVE ASSESSMENT Policy No. 1-016’ revealed “PURPOSE To provide guidelines for the initial assessments … D. Patient’s medical and psychosocial history …” 2. A review of the clinical record for Patient #1 revealed a document titled OASIS (the Outcome and Assessment Information Set is a group of standard data elements home health agencies integrate into their comprehensive assessment to collect and report quality data)-Start of Care (SOC) dated 01-05-2024 for the certification period of 01-05-2024 through 03-04-2024, signed by RN 1 which failed to evidence Psychosocial Problems were assessed. A review of the clinical record for Patient #1 revealed a document titled OASIS-Recertification with a SOC of 01-05-2024 for the certification period of 03-05-2024 through 05-03-2024, signed by the Alternate Clinical Director which failed to evidence Psychosocial Problems were assessed. A review of the clinical record for Patient #1 revealed a document titled OASIS-Recertification with a SOC of 01-05-2024 for the certification period of 05-04-2024 through 07-02-2024, signed by RN 1 which failed to evidence Psychosocial Problems were assessed. A review of the clinical record for Patient #1 revealed a document titled OASIS-Recertification with a SOC of 01-05-2024 for the certification period of 07-03-2024 through 08-31-2024, signed by RN 1 which failed to evidence Psychosocial Problems were assessed. 3. On 08-01-2024 at 12:17 PM, an interview with RN 1 indicated there was a system to carry over information from prior assessments, and they copied over to the current assessment because it’s too time-consuming to type all the diagnoses and codes. When RN 1 was queried how the psychosocial assessment was missed on all 4 assessments, they indicated they did not know. 4. On 08-01-2024 at 1:50 PM, an interview with the Alternate Clinical Manager, they indicated the psychosocial assessment was not completed and it should be, and clinicians can copy one assessment to another. 410 IAC 17-14-1(a)(1)(A) and (B)

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure the individualized plan of care included patient-specific interventions, specific education, and training provided by the Registered Nurse (RN), measurable outcomes, and goals identified by the home health agency in 1 of 2 active clinical records of patients with seizures. (Patient: #3) (Employees: Alternate Clinical Manager, Admin 3) Findings Include: 1. A review of The Master’s Touch Home Care policy revision date December 2018 “Care Planning Process” indicated but was not limited to, “ … To provide direction to the clinicians providing direct patient care … the plan of care will include … Patient-specific interventions and education Reasonable, measurable, and individualized goals and outcomes identified … ” 2. A review of the clinical record for Patient #3, start of care 08-17-2016, contained a plan of care for the recertification period 07-21-2024 through 09-19-2024, co-signed by the Alternate Clinical Manager, Admin 3, dated 07-16-2024. The plan of care evidenced Patient #3’s principal diagnosis, Autistic Disorder (a condition related to brain development that impacts how a person interacts with others, communicates, learns, and behaves), and other diagnoses of Seizures and Developmental Disorders of Speech and Language. The plan of care failed to evidence interventions, measurable, and patient-specific goals for Patient #3’s diagnosis of seizures. During a home visit at Patient #3's residence on 08-01-2024 at 10:05 AM, when asked where the patient was, HHA 2, Patient #3’s caregiver, indicated Patient #3 had a seizure two days ago and was sleeping. When queried regarding a seizure plan or education provided by the agency’s RN, the HHA indicated they did not have a seizure plan or education from the agency; they just turned the patient on their side as instructed by Patient “3’s neurologist. 3. During an interview with the Administrator and Alternate Clinical Manager, Admin 3, on 07-31-2024 at 3:42 PM, they indicated upon review of the clinical record for Patient #3, there was no seizure plan in the plan of care. They confirmed it was the agency’s responsibility to have educated and documented a seizure plan in the plan of care. 410 IAC 17-12-1(a)

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the Home Health Aide (HHA) coordinated care with the Registered Nurse (RN) in 1 of 1 active clinical record (Patient #3) reviewed with a change in the patient’s condition. (Employees: HHA 2) Findings Include: 1. A review of The Master’s Touch Home Care policy revision date December 2018 “Care/Service Coordination” indicated but was not limited to, “ … Care Coordination will include, but not be limited to: C. Regularly occurring telephone or email communication among team members … E. Timely documentation of coordination of care activities … I. Integration of services … to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines … 8. Written evidence of care coordination may be found in the plan of care/service, case conference summary forms, clinical notes in the patient’s chart clinical record … ” 2. During a home visit at Patient #3's residence on 08-01-2024 at 10:05 AM, when asked where the patient was, HHA 2, Patient #3’s caregiver, indicated Patient #3 had a seizure two days ago and was sleeping. The HHA further indicated they did not have a seizure plan from the RN and did not let the RN know about Patient #3’s seizures. 3. A review of the clinical record for Patient #3, start of care 08-17-2016, contained a plan of care for the recertification period 07-21-2024 through 09-19-2024, co-signed by the Alternate Clinical Manager, Admin 3, dated 07-16-2024. The plan of care evidenced Patient #3’s principal diagnosis, Autistic Disorder (a condition related to brain development that impacts how a person interacts with others, communicates, learns, and behaves), and other diagnoses of Seizures and Developmental Disorders of Speech and Language. A review of the agency documents titled “Team Conference/Coordination of Care Notes,” dated 07-16-2024 through 07-31-2024, failed to evidence coordination of care between HHA 2 and Alternate Clinical Manager, Admin 3, who managed Patient #3’s case. During an interview on 08-01-2024 at 12:00 PM, when queried regarding Patient #3’s seizures, last reported seizure, and protocols of reporting by HHAs, the Alternate Case Manager, Admin 3, reviewed Patient #3’s clinical record and indicated Patient #3’s last seizure was in March 2023. Admin 3 further stated, “No, the HHA did not report Patient #3’s seizure.” 410 IAC 17-12-2(g)

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 they coordinated care delivery to meet the patient’s needs who received outside services from personal care agencies in 3 of 3 (Patients: #1, 4, and 5) active records reviewed, and 1 of 1 active record reviewed receiving dialysis treatments at an in-center facility. (Patient: #4) Findings Include: A review of the clinical record for Patient #1 revealed a Home Health Certification and Plan of Care document with a start of care date of 01-05-2024 for the certification period of 07-03/2024 through 08-31-2024 which evidenced Coordination of Care: Patient #6 was to receive services through Entity 4. The record failed to evidence care coordination of the type of services and frequency, with Entity 4. On 07-31-2024 at 12:14 Person 5, the office manager from Entity 4 indicated Patient #1 was receiving attendant care services through their agency 3-6 PM daily, and further indicated that the Agency had never reached out to them regarding services being provided. On 07-31-2024 at 3:52 PM, during an interview with RN 1 indicated they don’t call other Agencies to find out days/hours of services are being provided, further indicated they didn’t know if the Agency had a form for them to complete coordination of care and thought Patient #1 was to receive 3 hours a day of attendant care services. 1. A review of The Master’s Touch Home Care policy revision date December 2018 “Care/Service Coordination” indicated but was not limited to, “ … Care Coordination will include, but not be limited to: E. Timely documentation of coordination of care activities … J. Coordination of care delivery to meet the patient’s needs, and involve the patient representative, and caregivers, as appropriate, in coordination of care activities 8. Written evidence of care coordination may be found in the plan of care/service, case conference summary forms, clinical notes in the patient’s chart clinical record … ” 2. A review of the clinical record for Patient #4, start of care 06-30-2022, contained a plan of care for the recertification period 0-19-2024 through 08-17-2024 signed by the Clinical Manager, dated 06-18-2024. The plan of care indicated in the “Coordination of Care” section evidenced that Patient #3 received in-center dialysis from Entity 1 and Attendant care services from Entity 3. A review of the agency documents titled “Team Conference/Coordination of Care Notes,” dated 09-01-2023 through 07-31-2024, failed to evidence coordination of care with Entity 1 or Entity 3. During an interview on 07-31-2024 at 12:44 PM, Person 2, the Director of Operations for Entity 1, confirmed Patient #4 received dialysis treatments every Monday, Wednesday, and Friday at Entity 1. Person 2 further indicated their review of Patient#4’s clinical record evidenced no communication or coordination of care with The Master’s Touch Home Care. Person 2 indicated that the last interdisciplinary team meeting was on 07-22-2024, and there was no coordination of care with knowledge of Patient #4’s services with The Master’s Touch Home Care. 3. During an interview on 07-31-2024 at 3:00 PM, when queried regarding the coordination of care documentation with Entity 1 or Entity 3, reviewed the coordination care notes and record and stated, “We are not documenting communication.” 4. During a home visit at Patient#5’s residence on 08-01-2024 at 9:00 AM, noted a schedule on Patient #5’s refrigerator that stated, “The Master’s Touch Home Health Services … Client Monthly Schedule … For the Month August 2024.” The schedule listed Home Health Aide (HHA) times and Attendant times noted daily. When queried about the Attendant hours on the schedule, Patient #5 indicated they received Attendant hours for their caregiver during the evening and night from 6:00 PM to 11:00 PM due to falls. A review of the clinical record for Patient #5, start of care 03-13-2024, revealed a plan of care for the recertification period 07-11-2024 through 09-08-2024, co-signed by the Alternate Clinical Manager, dated 07-08-2024. The plan of care indicated in the section titled “Coordination of Care” evidenced “None.” A review of the agency documents titled “Team Conference/Coordination of Care Notes,” dated 03-13-2024 through 07-31-2024, failed to evidence coordination of care with Entity 3. During an interview on 08-01-2024 at 3:00 PM, the Alternate Clinical Manager, Admin 3, confirmed Patient #5 received a waiver for Attendant care services. Admin 3 indicated they did not coordinate care with Entity 3, the sister agency of The Master’s Touch Home Care, a personal care attendant agency.

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 the Home Health Aide (HHA) performed hand hygiene and glove changes while providing patient care in 1 of 2 HHA home visit observations. (Employees: HHA 2) Findings Include: 1. A review of The Master’s Touch Home Care policy titled “Handwashing” indicated but was not limited to, “ … To prevent the spread of infection … After Caring for client … Before touching organic material … After handling contaminated equipment … ” 2. During a home visit at Patient #5’s residence on 08-01-2024 at 9:05 AM, observed HHA 2 providing range of motion exercises and ambulatory assistance to Patient #5. HHA 2 performed hand hygiene, donned gloves, and swept the kitchen floor. The HHA discarded their gloves in the trash receptacle and donned new gloves without performing hand hygiene. HHA 2, with gloved hands, assisted Patient #5 from a sitting position to stand from the couch using Patient #5’s assistive device. Patient #5 ambulated in the apartment hallway with their walker with stand by assistance twice. HHA 2 assisted Patient #5, to the couch and held Patient #5’s walker for Patient #5. The HHA moved the walker and asked Patient #5 if they wanted a drink, obtained a bottle of water from the refrigerator, and handed the bottle of water. HHA 2 failed to remove their gloves and perform hand hygiene after they touched Patient #5’s walker before obtaining the bottle of water. During an interview on 08-01-2024 at 9:25 AM, HHA 2 indicated they had received infection control training from the agency. When queried regarding hand hygiene and glove changes while providing patient care, HHA 2 indicated gloves and hand hygiene were to be done after each procedure. HHA 2 stated, “ I did not change my gloves after I touched the walker prior to going to the refrigerator to obtain a bottle of water.” 410 IAC 17-12-1(m)

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: G940 Based on observation and interview, the agency failed to evidence the Governing Body ensured lines of authority were established and managed the roles and responsibilities of administrator and alternate administrators/supervisors (G 942); failed to ensure a qualified alternate administrator was appointed and put in place in the event the administrator was not available (G 954); failed to ensure the Administrator completed and executed their responsibilities for the day-to-day activities of running the home care agency, including compliance with Emergency Preparedness, timely submissions of Outcome Assessment Information Set (OASIS), plan of care content, assessment content, coordination of care with other service providers, employees health files are completed and updated per policy, failed to ensure agency personnel received job descriptions and job orientation and infection control (G948). These deficiencies had a potential cumulative effect on all 45 patients and 78 staff. The cumulative effect of these systemic problems resulted in the home health agency's inability to ensure the provision of quality health care in a safe environment for the Condition of Participation of 42 CFR 484.105, Organization and Administration of Services. Findings Include: *

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on record review and interview, the Governing Body failed to ensure full responsibility and legal authority for the agency’s overall management and operation, compliance with state and federal regulations, and provision of all home health services; failed to periodically review the written bylaws; failed to review define the corporate structure, and clearly indicate lines of authority, and failed to review the policies and procedures to ensure they reflected current state and federal regulations for 1 of 1 agency. Findings Include: 1. A review of the undated The Master’s Touch Home Care policy titled, “Governing Body” indicated but was limited to, “The Governing Body shall assume full legal authority and responsibility for the operation of The Master’s Touch Home Care … To ensure lines of authority are established … Appoint a Qualified Administrator … Adopt and periodically review and approve administrative and personnel policies, client care policies and procedures, bylaws as required by state licensure regulations … ” 2. On 07-21-2024 at 11:02 AM, the Administrator provided an agency document titled “ Organization Chart.” The organization chart failed to evidence the Governing Body, and the Administrator and their lines of authority and delegation. 3. On 08-01-2024 at 2:34 PM, the Administrator provided an agency document titled, “ Governing Body Meeting Agenda Minutes. The meeting minutes, dated April 5, 2021, indicated the Director of Nursing (DON) and Assistant Director of Nursing (ADON) were terminated, and a new DON was hired. The document failed to state the name of the DON or governing body approval. The minutes indicated they reviewed and agreed to the operating and capital budget., and the meeting will be held yearly and quarterly. The governing body failed to meet yearly or quarterly, failed to review the agency’s policies and procedures, and failed to review the bylaws. During an interview on 08-01-2024 at 2:51 PM, when queried about the Governing Body meetings and other meeting minutes to review, the Administrator indicated the Governing Body was to meet yearly and they needed to obtain new members for the Governing Body. The Administrator further confirmed April 2021, was the only meeting completed by the Governing Body. 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 and interview, the Governing Body failed to ensure the Administrator completed and executed their responsibilities for the day-to-day activities of running the home care agency, including compliance with Emergency Preparedness, timely submissions of Outcome Assessment Information Set (OASIS), plan of care content, assessment content, coordination of care with other service providers, transfer summaries, employees health files were completed and updated per policy, failed to ensure agency personnel received job descriptions and job orientation and infection control for 1 of 1 agency. Findings Include: 1. A review of agency documents including: Emergency Preparedness (See E 000), timely submission of OASIS (See G 372), comprehensive assessments (See G 528), plan of care being patient-specific interventions with measurable goals (See G 572), coordination of care delivery (See G 608), Infection Control (See G 682), and failed to ensure personnel files were updated with current medical requirements, and staff had been provided job descriptions and job orientation. During an interview on 08-01-2024 at 3:00 PM, when reviewing the concerns with the Administrator and Alternate Clinical Manager, Admin 3 confirmed they are not documenting communication or meetings regarding patient care. The Administrator indicated they were not aware of the documentation not being completed. 410 IAC 17-12-1(c)(1)

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 there was a qualified, pre-designated person authorized in writing by the Administrator and Governing Body to assume the same responsibilities and obligations as the Administrator for 1 of 1 agency. Findings Include: 1. A review of an undated The Master’s Touch Home Care policy, titled, “Governing Body” was provided by the Alternate Clinical Manager, Admin 3, on 08-01-2024, at 2:00 PM. The document indicated but was not limited to “ … To ensure lines of authority are established … Appoint a qualified Administrator. Delegate to that individual the authority and responsibility for the provision of home care services in accordance with state and federal regulations … ” 2. A review of the Indiana Department of Health agencies report completed by the Administrator on 03-03-2023 indicated the Clinical Manager was the Alternate Administrator. 3. During the entrance conference on 07-31-2024 at 9:20 AM, the Administrator, when asked who the Alternate Administrator was, indicated the Clinical Manager, who was out with COVID, was the Alternate Administrator. 4. A review of agency documents titled “Professional Advisory Committee Meeting Minutes,” dated April 5, 2021, indicated the Governing body meeting would be held as needed, yearly and quarterly. The document further evidenced the termination of the Director of Nursing (DON), and a new DON was hired. The document failed to prove the governing body had approved and appointed the Clinical Manager and Alternate Administrator. During an interview on 08-01-2024 at 2:37 PM, the Administrator, when queried regarding the governing body appointing/approving the Clinical Manager/Alternate Administrator, stated, “ No, not going to say I have it. No, the governing body did not appoint her.” The Administrator further indicated the governing body had not met since 2021. 5. A review of the Clinical Manager/Alternate Administrator’s personnel record failed to evidence the employee was appointed to their position by the Governing Body.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure a transfer summary was completed on 1 of 2 transfer patient reviews. (Patient #2) Findings include: 1. A review of an agency's policy dated December 2018 titled 'TRANSFER SUMMARY Policy No. 1-023' revealed "PURPOSE To define the requirements for the documentation of a patient transfer ... POLICY All patients transferred from the organization will have a transfer summary completed and filed in the clinical record PROCEDURE 1. Within 48 hours of transfer ... will complete a transfer summary that includes ... A. the reason for transfer B. The Physical and psychosocial status at the time of transfer ... C. Continuing symptom management needs D. Medication profile E. Summary of the care ... G. The existence of any Advance Directives ... H. Date of face-to-face encounter I. The date of transfer ..." 2. A review of the clinical record for Patient #2 evidenced an order sent to Person 6, the attending physician for Patient #2, indicating the patient was taken to Entity 7 and services for skilled nursing were on hold. The record for Patient #2 failed to evidence a transfer summary had been created and sent to Entity 7. 3. On 08-01-2024 at 2 PM, the Alternate Clinical Director indicated no transfer summary had been sent to Entity 7, but there should have been. They further indicated they were the one who usually creates the discharge and transfer summaries, and they must have missed it. 410 IAC 17-15-1(a)(6)

This visit was for a Federal Recertification and State Licensure Survey of a Medicaid Home Health Provider. A partially extended survey was announced on 11/19/2021 at 3:15 PM. Survey dates: 11/16/2021 to 11/22/2021 Facility ID: 013677 Provider #: 15K139 Medicaid #: 701323570A Census: 44 These deficiencies reflect State Findings cited in accordance with 410 IAC 17. Quality Review Completed on 12/06/2021 by Area 3

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 record review, the agency failed to ensure clinicians follow accepted standards of practice, including the use of standard precautions, to prevent transmission of infections and communicable diseases. Agency failed to follow infection prevention measures in 1 of 3 home visits conducted. (Patient #5) Findings include: In an undated policy titled 'Hand Hygiene Policy No. 7-009' states, "Personnel providing care in the home setting will regularly wash their hands, per the most recently published CDC (Centers for Disease Control) regulations and guidelines for hand hygiene in healthcare settings. When hands are visibly dirty, contaminated with proteinaceous material, or are visibly soiled with blood or other body fluids, they should be washed with either a non-antimicrobial or antimicrobial soap and water. When hands are not visibly soiled, they should be washed using an alcohol-based hand rub for routinely decontaminating hands. An alternative to use of an alcohol-based hand rub is to wash hands with an antimicrobial soap and water." The policy further specifies that "3. Hand decontamination... should be performed: A. Before direct contact with patients... F. After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient." On 11/17/21 at 12:00 pm, a home visit with patient #5 and home health aide D evidenced a breach in infection control. During bathing, patient #5 who was seated in a shower chair in a shower stall, requested employee D to, "fix" the bathmat. Employee D obliged and picked up the edge of a suctioned bathmat which was on the floor of the shower stall to readjust and straighten out mat, as at it had become bunched up under the feet of the seated patient. Employee D then proceeded to apply gloves and continued washing and rinsing patient, failing to perform hand hygiene after touching mat, nor before continuing to provide hands-on care to patient. The findings of concern were reviewed with the Administrator and Clinical Manager on 11/17/21 at 3:15 pm. No further information or explanation was provided. 410 IAC 17-12-1(m)

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the RN case managers assessed patients when a change in condition was identified in regards to a patient with a new onset of wheezing/ new medication order and a patient who had fallen and obtained a fracture for 2 of 5 active records reviewed. (Patients #3 and 5) Findings include: 1. A review of an undated agency policy Ongoing Assessments undated Policy No. 1-017 revealed "Purpose, to provide guidelines for assessments of the patient during ongoing care. Under subtitle Procedure 3. Re-assessments should focus on: ... B. Changes in patient condition C. Changes in patient diagnoses..." 2. During a home visit on 11/17/21 at 12:00 PM with patient #5, it was discovered that on 11/16/21, the patient had been prescribed a new medication called ipratropium bromide/albuterol sulfate by her Primary Care Physician for new-onset symptom of wheezing. Patient #5 indicated employee D, the home health aide, was aware and had assisted the patient in setting up the nebulizer for the patient to self-administer. The clinical record for patient #5 was reviewed on 11/17/21. The clinical record contained a plan of care for the certification period of 11/5/21 through 1/4/22, with patient diagnoses, included but are not limited to, Chronic Obstructive Pulmonary Disease (a type of progressive lung disease characterized by long-term respiratory symptoms and airflow limitation), Congestive Heart Failure (a chronic condition in which the heart cannot pump {systolic} or fill {diastolic} adequately). The plan of care revealed Patient #5 is receiving home health aide services 2-4 hours per day, 3-5 days per week. The clinical record failed to evidence that a nurse provided any visits to assess the patient when it was discovered that the patient had a new onset of wheezing and new medication. During an interview on 11/18/21 at 9:00 AM, Employee G, RN was queried as to whether she had been made aware by the home health aide of a new medication in the home related to a new patient complaint of wheezing on 11/16/21, which Employee G stated the aide did not make her aware of this until approximately 3 PM on 11/17/21, after this surveyor's visit to the home. Employee G indicated she does not normally make a visit to the patient's home after changes in medication. When queried if a nurse would be making a visit in relation to reported change in condition, new wheezing, the nurse indicated she saw the patient on 11/2/21 for the Recertification visit and the patient's lungs were clear, "no respiratory distress", and "O2 [oxygen] sats were good". Employee G indicated she would visit the patient if he/she felt the patient was having difficulty breathing or had low O2 saturation readings. When reminded that the recertification visit was several days ago and wheezing is new for the patient, Employee G stated she had no upcoming plans for visiting or assessing the patient, stating the patient did not have orders for nursing services. 3. The clinical record of patient #3 was reviewed on 11/17/2021. The clinical record contained a recertification assessment on 09/13/2021 that indicated the patient had fallen in the home, with Employee E, the Hha, present, and had sustained a fractured left wrist on 08/19/2021. During a phone interview with patient #3 and Employee E on 11/17/2021 at 12:48 PM, patient #3 did confirm they had fallen on 08/19/2021 at approximately 10:30 AM, stating the reason they know this is because the Hha and patient #3 had returned from a veterinarian appointment at 10 AM and was back home by 10:30 AM. The patient stated they had walked into the kitchen unassisted by Hha to fix a glass of chocolate milk when they fell, stating "I hit my head, and I hurt all over." Employee E stated they heard the fall, asked if the patient was OK, the patient said"no, I am hurt." Employee E said they were getting ready to vacuum in the living room when the fall occurred, then entered the kitchen and patient #3 stated they needed Employee E to push the alarm (medical alert button). Employee E was instructed by the emergency personnel on how to care for patient #3 until the EMTs (emergency medical technicians) arrived. The patient was taken to the hospital by ambulance. Patient #3 stated the hospital did an x-ray of the left wrist and did a CT scan of the head, they didn't give the patient a splint or brace for the wrist, stating they would have to return the following day to the medical professional building to be given the brace, discharged to home, with written instructions. The clinical record failed to evidence that a Registered Nurse provided had gone to the patient's home after the patient fell and after the hospital emergency visit, to reassess the patient's needs for home health. During an interview on 11/19/2021 at 11:30 Employee B stated since the patient had been seen in the hospital emergency room, the nursing staff does not follow up with the patient. 410 IAC 17-12-2(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 observation, record review, and interview, the home health aide failed to notify their case manager or clinical manager of a new onset of symptoms and new medication for 1 of 3 home visits conducted. (Patient #5) Findings include: Review of a document titled 'Job Description': Home Health Aide', page 2 details aide duties, "notifying nursing supervisor of changing or unusual conditions." Additional duties include, "Monitor patients... and report on their condition." During a home visit on 11/17/21 at 12:00 PM, Patient #5 indicated they were prescribed a new medication called ipratropium bromide/albuterol by their Primary Care Physician for a complaint of new onset wheezing on 11/16/21. Patient #5 indicated Employee D, home health aide, was also aware and had assisted in setting up a nebulizer for the patient to self-administer the new medication. The clinical record for Patient #5 was reviewed on 11/17/21. The clinical record contained a plan of care for the certification period of 11/5/21 through 1/4/22 with orders for home health aide services 2-4 hours per day, 3-5 days per week. A review of the clinical record and the aide visit note on 11/16/21 failed to evidence that the aide reported the change in condition and the new medication to the case manager and/or clinical manager. During an interview on 11/18/21 at 9:10 AM, when queried as to whether she had been made aware by the home health aide of a new medication in the home related to a new patient complaint of wheezing on 11/16/21 Employee G, RN, stated the aide did not make her aware of this until approximately 3:00 PM on 11/17/21 after this surveyor visited the home.

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 observation, record review, and interviews, the agency failed to assure the patients needs are continually assessed of 2 out of 5 patients. (Patients #3 and #5) Findings include: 3. During a home visit on 11/17/21 at 12:00 PM with patient #5, it was discovered that on 11/16/21, the patient had been prescribed a new medication called ipratropium bromide/albuterol sulfate by her Primary Care Physician for new-onset symptom of wheezing. Patient #5 indicated employee D, the home health aide, was aware and had assisted the patient in setting up the nebulizer for the patient to self-administer. The clinical record for patient #5 was reviewed on 11/17/21. The clinical record contained a plan of care for the certification period of 11/5/21 through 1/4/22, with patient diagnoses, included but are not limited to, Chronic Obstructive Pulmonary Disease (a type of progressive lung disease characterized by long-term respiratory symptoms and airflow limitation), Congestive Heart Failure (a chronic condition in which the heart cannot pump {systolic} or fill {diastolic} adequately). The plan of care revealed Patient #5 is receiving home health aide services 2-4 hours per day, 3-5 days per week. The clinical record failed to evidence that a nurse provided any visits to assess the patient when it was discovered that the patient had a new onset of wheezing and new medication. During an interview on 11/18/21 at 9:00 AM, Employee G, RN was queried as to whether she had been made aware by the home health aide of a new medication in the home related to a new patient complaint of wheezing on 11/16/21, which Employee G stated the aide did not make her aware of this until approximately 3 PM on 11/17/21 after this surveyor visited the home. Employee G indicated she does not normally visit the patient's home after changes in medication. When queried if a nurse would be visiting concerning the reported change in condition, new wheezing, the nurse indicated she saw the patient on 11/2/21 for the Recertification visit and the patient's lungs were clear, "no respiratory distress", and "O2 [oxygen] sats were good". Employee G indicated she would visit the patient if he/she felt the patient was having difficulty breathing or had low O2 saturation readings. When reminded that the recertification visit was several days ago and wheezing is new for the patient, Employee G stated she had no upcoming plans for visiting or assessing the patient, stating the patient did not have orders for nursing services. 1. A review of an undated agency policy Ongoing Assessments Policy No. 1-017 revealed "Purpose, to provide guidelines for assessments of patients during ongoing care. Under subtitle Procedure 3. Re-assessments should focus on: ... B. Changes in patient condition C. Changes inpatient diagnoses..." 2. The clinical record of patient #3 was reviewed on 11/17/2021. The clinical record contained a recertification assessment on 09/13/2021 that indicated the patient had fallen in the home, with Employee E, the Hha, present, and had sustained a fractured L wrist on 08/19/2021. During a phone interview with patient #3 and Employee E on 11/17/2021 at 12:48 PM, patient #3 did confirm they had fallen on 08/19/2021 at approximately 10:30 AM, stating the reason they know this is because the Hha and patient #3 had returned from a veterinarian appointment at 10 AM and was back home by 10:30 AM. The patient stated they had walked into the kitchen unassisted by Hha to fix a glass of chocolate milk when they fell, stating "I hit my head, and I hurt all over." Employee E stated they heard the fall, asked if the patient was OK, the patient said"no, I am hurt." Employee E said they were getting ready to vacuum in the living room when the fall occurred, then entered the kitchen and patient #3 stated they needed Employee E to push the alarm (medical alert button). Employee E was instructed by the emergency personnel on how to care for patient #3 until the EMTs (emergency medical technicians) arrived. The patient was taken to the hospital by ambulance. Patient #3 stated the hospital did an x-ray of the left wrist and did a CT scan of the head, they didn't give the patient a splint or brace for the wrist, stating they would have to return the following day to the medical professional building to be given the brace, discharged to home, with written instructions. The clinical record failed to evidence that a Registered Nurse provided had gone to the patient's home after the patient fell and after the hospital emergency visit, to reassess the patient's needs for home health. During an interview on 11/19/2021 at 11:30 Employee B stated since the patient had been seen in the hospital emergency room, the nursing staff does not follow up with the patient