Every finding on record at Moore Home Health Care Inc

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR §484.102 Survey Dates: 04/01/205, 04/02/2025, and 04/03/2025 Active Census: 28 At this Emergency Preparedness survey, Moore Home Health Care Inc was found to be in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR §484.102. QR by Area 3 on 4-08-2025.

This visit was for a Federal Recertification and State Re-Licensure survey of a Home Health Provider. Survey Dates: 04/01/2025, 04/02/2025, and 04/03/2025 12-Month Unduplicated Skilled Admissions: 32 Moore Home Health Care Inc was found to be out of compliance with 42 CFR 484 and 410 IAC 17 of a home health survey. Abbreviations: RN Registered Nurse QR by Area 3 on 4-08-2025.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the following information: (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 comprehensive assessments accurately reflected patients' health status for 3 of 7 active clinical records reviewed. (Patients #3, #4, and #5) Findings include: 4. A review of the clinical record for Patient #4 evidenced a document titled 'OASIS Assessment' with a start of care date of 02/05/2025 for the certification period of 02/05/2025 to 04/05/2025, completed by RN 1 on 02/05/2025 indicated Integumentary Assessment there were no pressure ulcer or injury, a right shoulder surgical area with no other wounds documented. The clinical summary indicated Patient #4 had a "total reverse of right shoulder" in January, had a dressing on the right shoulder "no orders for" and "a pressure ulcer on the outer heel on the right foot" which indicated Patient #4 stated, "I had surgery on the right shoulder in January and my right heel … injury by heel protectors"; RN 1 indicated there were no orders for either, care coordination was with the ordering physician, and Patient #4, the caregiver, and the physician was in agreement with the plan of care. The OASIS assessment failed to evidence an accurate integumentary status without description or measurements of wounds; and failed to evidence a cardiovascular and gastrointestinal assessment was completed. 5. A review of the clinical record for Patient #5 evidenced a document titled OASIS Assessment' with a start of care date of 12/24/2024 for the recertification period of 02/22/2025 to 04/22/2025, completed by RN 1 on 02/17/2025 indicated the Integumentary status had fair skin turgor, condition was moist, dry/rash/itchy, temperature was marked warm, and it was noted Patient #5 had "blister". Integumentary Comments were left blank. Cardiovascular Status and Gastrointestinal Status were blank. The clinical summary indicated Patient #5 had blisters on his right foot draining a small amount of serosanguinous drainage. DME supplies cotton tips, underpads, tape, incontinent briefs, cotton tipped applicators 4 x 4's, kerlix, and saline. Further review of the clinical record for Patient #5 evidenced a document titled 'Home Health Plan of Care and Certification' signed and dated by RN 1 on 02/17/2025 indicated the following DME supplies: Underpads, incontinent briefs, 4 x4's abdominal pads, cotton tipped application, kerlix size 4, saline tape, hospital bed and walker. The OASIS assessment failed to evidence an accurate integumentary status without wound measurements and location of blister and failed to evidence a cardiovascular and gastrointestinal assessment was completed and failed to list all DME supplies required for patient care. 6. On 04/03/2024 at 11:18 AM, RN 1 indicated during initial assessments, they do complete head to toe assessments, document location and measurements of wounds. On 04/02/2025 at 3:49 PM, the Clinical Director indicated their expectations were that complete head to toe assessments were performed during assessments and during each skilled nursing visit, along with measurements and location of wounds, and would expect to have all DME supplies listed in the comprehensive assessment. 410 IAC 17-14-1(a)(1)(B) 1. A review of undated agency policy titled 'COMPREHENSIVE CLIENT ASSESSMENT C-145' stated, "… a. The Comprehensive Assessment must accurately reflect the client's status, and must include at a minimum, the following information: The client's current health … status … e. The client's medical nursing … needs…" 2. A review of the clinical record for Patient #3 evidenced a document titled 'OASIS (Outcome and Assessment Information Set, a standardized assessment tool used in home health care to collect data on patients' health status, functional abilities, and service needs) Assessment' with a start of care of 11/08/2024 and a recertification period of 03/08/2025 to 05/06/2025 contained diagnoses which included but were not limited to: cellulitis (common bacterial infection of the skin and underlying tissues characterized by redness, swelling, pain, and warmth, typically entering through a break in the skin) of the left lower leg and lymphedema (chronic condition caused by a buildup of lymph fluid in the body's soft tissues, leading to swelling, often in the arms or legs, can be managed but not cured) and was completed 03/06/2025 by RN 1. The assessment failed to evidence the patient's lung sounds had been assessed. The integumentary section indicated the patient had fair skin turgor, with a box titled, 'dry/rash/itchy' also checked. 'Skin Problems' indicated, "Other: blisters right leg", the integumentary comments section was left blank, and the document failed to evidence measurements of the site. The reassessment summary stated, "… multiple blisters noted and weeping …", indicated ordered wound care had been provided, and also stated, "… moderate amount of yellowish drainage noted from weeping blisters …" but failed to evidence the site, or measurements for the area the care had been provided to. 3. On 04/02/2025 at 3:52 PM, when queried as to missing comprehensive assessment items in patients clinical records, the Clinical Director indicated understanding the documentation should be complete and added she had instructed staff to utilize the comment sections and write findings in the summary as well, to indicate that items had been addressed.

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 include all durable medical equipment (DME) in use in 1of 5 clinical records (Patient #2) and failed to evidence complete treatment/wound orders/medication order in 2 of 3 wound care patients (Patients #3 and #5). Findings include: 5. A review of the clinical record for Patient #3 evidenced a document titled 'HOME HEALTH CERTIFICATION AND PLAN OF CARE' for the recertification period of 03/08/2025 to 05/06/2025, signed and dated by the clinical manager on 03/06/2025. Skilled nursing was ordered to provide wound care to the right lower leg 2 times weekly. The medication list included but was not limited to: "… Gentamycin Sulfate (topical) (a medication applied to the skin for treating skin infections caused by certain bacteria) external ointment 0.1 % - 3 x week to be applied to during wound change - tropically[sic] - new …" The Plan of Care failed to evidence the location the medication was to be applied to. 6. On 04/03/2025 at 3:12 PM, when queried as to the gentamycin medication listed on Patient #3's Plan of Care being written for three times per week and failing to evidence what site or location the medication was to be applied to, the Clinical Director indicated the frequency was an error and the medication was only for twice weekly, and "yes" a location should be included in the medication order, but had been included in the wound care order. 410 IAC 17-13-1(a)(1)(D)(i-xiii) 1. A review of an undated policy titled 'PLAN OF CARE C-580' stated, "SPECIAL INSTRUCTIONS … 2. The Plan of Care shall be completed in full to include: e. Need for presence of home medical equipment … m. Medications, treatments …" 2. A review of the clinical record for Patient #2 evidenced a document titled 'OASIS (Outcome and Assessment Information Set is a standardized data collection tool used by home health agencies to collect and report assessment data) Assessment' for the recertification period of 04/01/2025 to 05/30/2025, completed by RN 1 on 03/27/2025, indicated Renal/Genitourinary status, Patient #2 was incontinent with urine and bowel and DME required were under pads, briefs, and wipes. Further review of the clinical record for Patient #2 evidenced a document titled 'Home Health Plan of Care and Certification' signed and dated by RN 1 on 03/27/2025 evidenced DME supplies as hospital bed, side rails, piston syringes, wheelchair, pressure reducing mattress, heel protectors, thermometer, and non-sterile gloves. The Plan of Care failed to evidence DME: under pads, briefs, and wipes. 3. A review of the clinical record for Patient #5 evidenced an 'OASIS Assessment" for the recertification period of 02/22/2025 to 04/22/2025 dated 02/17/2025 by RN 1 which indicated Patient #5 was to have Triamcinolone (a synthetic glucocorticoid [a type of corticosteroid] used to treat various inflammatory conditions, including skin disorders, asthma, and allergic rhinitis, by reducing inflammation and suppressing the immune system) 0.1 ointment 454 gm to apply twice a day beginning 01/14/2025. Further review of the clinical record for Patient #5 evidenced a document titled 'Home Health Plan of Care and Certification' signed and dated by RN 1 on 02/17/2025 indicated wound care was to cleanse blister to right top of foot with normal saline, apply Silvadene cream, and cover with a dry dressing. The Plan of Care failed to evidence an updated order for wound care to the right lower extremity and where Triamcinolone 0.1 ointment was to be applied. 4. On 04/01/2025 at 10:20 AM, the Clinical Director indicated new medications need to be written down, MD notified, added to the medication profile, and were to update the Plan of Care. On 04/03/2025 at 11:18, RN 1 indicated they were to write a verbal order when receiving orders for patients, and add the order to the Plan of Care.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure all orders were recorded on the Plan of Care in 1 of 3 clinical records reviewed with ordered wound care. (Patient #5) Findings include: 1. A review of a policy titled 'PHYSICIAN/ALLOWED NON_PHYSICIAN PRACTITIONER (NPP) ORDERS C-635' stated, "… SPECIAL INSTRUCTIONS 1. When the nurse … receives a verbal order from the NPP, he/she shall write the order as given and then read the order back … heard it correctly and interpreted the order correctly … The order must include the date, specific order, be signed with the full name and title of the person receiving the order … 6. Documentation must be placed in the record …" 2. A review of the clinical record for Patient #5 evidenced an 'OASIS (Outcome and Assessment Information Set is a standardized data collection tool used by home health agencies to collect and report assessment data) Assessment" for the recertification period of 02/22/2025 to 04/22/2025 dated 02/17/2025 by RN 1 which indicated Patient #5 was to have Triamcinolone (a synthetic glucocorticoid [a type of corticosteroid] used to treat various inflammatory conditions, including skin disorders, asthma, and allergic rhinitis, by reducing inflammation and suppressing the immune system) 0.1 ointment 454 gm to applied twice a day beginning 01/14/2025 to the right lower extremity. Further review of the clinical record for Patient #5 evidenced a document titled 'Home Health Certification and Plan of Care' dated 02/17/2025 and signed by the Clinical Director. Patient #5 was to receive skilled nursing visits 1 hour two (2) times a week to assess and evaluate draining blister to right foot and to provided wound care and dressing changed. Procedure was to cleanse the blister to right top of foot with normal saline, apply Silvadene cream, and cover with dry dressing. The clinical record failed to evidence a verbal order was written and included on the Plan of Care to discontinue Silvadene Cream and initiate Triamcinolone 0.1 ointment 454 gm. 3. On 04/01/2025 at 10:20 AM, the Clinical Director indicated new medications need to be written down, the attending physician notified, added to the medication profile, and the Plan of Care be updated. On 04/03/2025 at 11:18 AM, RN 1 indicated they were to write a verbal order when receiving orders for patients, and add the order to the Plan of Care further indicated Patient #5 had the order for Triamcinolone for the right lower extremity since January and had forgotten to write the verbal order.

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 infection prevention practices were adhered to while providing services to patients, in 1 of 3 home visits observed. (Registered Nurse (RN 1) Findings include: 1. A review of an agency policy titled 'HANDWASHING/HAND HYGIENE D-330' stated,"… 3. Indication for hand washing and hand antisepsis … f. after removing gloves … g. After touching objects that are potentially contaminated …" 2. On 04/02/2025 at 10:50 AM during a home visit, RN 1 was observed providing wound care to Patient #3. RN washed hands appropriately, then returned to patient area, donned gloves, then cleansed the wound with normal saline soaked 4x4 gauze then doffed their gloves. The nurse then took a pair of pre-packaged gloves out the nursing bag, set them on the barrier, unfolded the packaging and donned the new gloves. Hand hygiene was not performed after gloves had been doffed, but before new gloves had been applied. After the new dressing was applied, gloves were doffed, hand hygiene was not performed, and new gloves were donned. During the visit the nurse indicated their hand sanitizer was normally kept on top of their nursing bag, but not today. 3. On 04/02/2025 at 12:00 PM after the visit, RN 1 was queried as to what should be done after gloves are removed, but before new gloves are put on, the nurse indicated they should have used hand sanitizer. On 04/06/2025 at 4:40 PM, when queried as to the infection control breaches by RN 1 during wound care for Patient #3, the Clinical Director indicated she expected hands to be sanitized between glove changes. 410 IAC 17-12-1(m)

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 Suppliers. Survey Date: 6/6/2022, 6/7/2022, 6/8/2022, 6/9/2022, 6/10/2022, 6/13/2022, and 6/14/2022. At this Emergency Preparedness survey, Moore Home Health Care was found to be to be in compliance with Conditions of Participation 42 CFR 484.102 Emergency Preparedness requirements for Medicare Participating Providers and Suppliers, including staffing and the implementation of staffing during a pandemic.

HHA Comprehensive Assessment in Disaster CFR(s): 484.102(b)(1) §484.102(b)(1) Condition for Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (1) The plans for the HHA's patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. This STANDARD is not met as evidenced by: Based on observation, record review, and interview, the home health agency failed to ensure each patient had an individualized emergency preparedness plan for 5 of 7 clinical records reviewed. (#1, #2, #3, #4, #7) The findings include: 1. Record review of an undated agency policy retrieved on 6/14/2022, titled “Emergency Preparedness Management Policy” stated “Policy … Agency will have an identified plan in place to insure the safety and well-being of clients and employees during periods of an emergency or disaster that disrupts agency services … An emergency is a natural or human made event that significantly disrupts the environment of care and treatment, loss of utilities due to floods, civil disturbances, accidents or emergencies in the agency or its community … The agency will develop and maintain a written emergency management plan describing the process for disaster readiness and emergency management and implement it as appropriate … Purpose … To establish guidelines for client care during periods of emergency or disaster ….” 2. An observation was conducted on 6/9/2022, from 2:35 PM to 3:23 PM, for patient # 1, start of care 5/12/2022, with person D, physical therapist from entity A. At 3:06 PM, the patients home folder was reviewed for the required information provided by the agency including an individualized emergency preparedness plan. Review evidenced a page in the folder titled “Emergency Plan” which had spaces to write the contact information for their physician, emergency contact, hospital, and emergency services. The spaces provided to individualize the emergency plan remained blank. Review failed to evidence an individualized emergency preparedness plan. 3. An observation was conducted on 6/10/2022, from 9:00 AM to 9:59 AM, for patient # 2, start of care 3/5/2015, home health aide (HHA) F. At 9:50 AM, the patients home folder was reviewed for the required information provided by the agency including an individualized emergency preparedness plan. Review failed to evidence an individualized emergency preparedness plan. Clinical record review on 6/14/2022, evidenced an agency document titled “Emergency Plan” from 3/5/2015. This document stated “… Your pharmacy: [entity E] ….” Review evidenced entity E had been closed since 2019. Review failed to evidence the emergency preparedness plan on file was current and accurate. 4. An observation was conducted on 6/10/2022, from 10:31 AM to 11:23 AM, for patient # 3, start of care 4/5/2022, with Registered Nurse (RN) D. At 11:17 AM, the patients home folder was reviewed for the required information provided by the agency including an emergency preparedness plan. Review failed to evidence an individualized emergency preparedness plan. 5. Clinical record review on 6/14/2022, for patient #4, start of care 4/30/2021, evidenced an agency document titled “Patient /Client Evacuation Planning: Emergency Preparedness” which was signed by person G, as the patient’s caregiver. This document had an area subtitled “B. Emergency Contacts: [person G] … Natural Gas Provider / Number: [entity F] … Electric Provider / Number: [entity F] … During a disaster I plan to: … Stay with a relative/friend outside the area … Patient is … [willing] … to go to a shelter if evacuation is ordered ...” Another area subtitled “Medical Care and Special Needs Information: … Pharmacy Name: [entity H] … Number: [blank] … Physician Name: [person I] … Number: [blank] ….” Review of the emergency preparedness plan failed to evidence an emergency contact who lived outside the patient’s home. Review failed to evidence contact information for the gas and electric provider, pharmacy, and physician. Review failed to evidence pertinent emergency relocation information to include a name/address/phone number where the patient can go in the event they cannot stay in their home. Review failed to evidence information of the nearest shelter information in the event of an evacuation. Review failed to evidence the patients emergency preparedness plan was individualized and specific to the patient. 6. Clinical record review on 6/14/2022, for patient #7, start of care 3/1/2022, evidenced an agency document titled “Patient /Client Evacuation Planning: Emergency Preparedness” which was signed by the patient and RN D. This document had an area subtitled “B. Emergency Contacts: [person I] … Natural Gas Provider / Number: [blank] … Electric Provider / Number: [blank] … During a disaster I plan to: … Stay with a relative/friend outside the area … Patient is … [not willing] … to go to a shelter if evacuation is ordered ...” Review of the emergency preparedness plan failed to evidence an emergency contact who lived outside the patient’s home. Review failed to evidence contact information for the gas and electric provider in case of an emergency. Review failed to evidence pertinent emergency relocation information to include a name/address/phone number where the patient can go in the event they cannot stay in their home. Review failed to evidence the patients emergency preparedness plan was individualized and specific to the patient. 7. During an interview on 6/14/2022, at 11:51 AM, RN D indicated the emergency preparedness plan was reviewed at admission, recertification, and with any changes. She indicated the review would include which patients would need to be relocated and where that location is, the heat and electric company information, access to food and water, and local shelter information.

This visit was for a Federal Recertification and State Re-licensure Survey of a Home Health provider. Survey Dates: 6/6/2022, 6/7/2022, 6/8/2022, 6/9/2022, 6/10/2022, 6/13/2022, and 6/14/2022. These deficiencies reflect State Findings cited in accordance with 410 IAC 17. See State Form for additional findings.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on observation, record review and interview, the home health agency failed to ensure the plan of care was individualized to include all pertinent information including discipline services and medication instructions for every patient for 4 of 7 clinical records reviewed. (#1, #2, #3, #7) The findings include: 1. Record review of an undated agency policy retrieved on 6/14/2022, titled “Plan of Care” stated “Policy … The Plan of Care is based on a comprehensive assessment and information provided by the client/family and health team members. Planning for care is a dynamic process that addresses the care, treatment and services provided. The plan will be consistently reviewed to ensure that the client needs are met, and will be updated as necessary, but at least every sixty (60) days … Special Instructions … 1. An individualized Plan of Care signed by a physician shall be required for each client receiving home health and personal care services … 2. The Plan of care shall be completed in full to include: a. All pertinent diagnosis(es), principle and secondary, including dates of onset … c. Type, frequency, and duration of all visits/services … i. Functional limitations and precautions … j. Activities permitted or restrictions … l. Medications, treatments, and procedures … m. Medical supplies and equipment required … t. Other appropriate items … u. All of the above items must always be addressed on the Plan of Care … 12. The PRN [as needed] orders will be accompanied by a description of the client’s needs that could warrant a visit ….” 2. Clinical record review on 6/14/2022, for patient #1, start of care 5/12/2022, primary diagnosis emphysema (condition where air sacs in the lungs are damaged and enlarged, causing breathlessness), evidenced an agency document titled “Home Health Plan of Care & Certification” for certification period 5/12/2022 – 7/10/2022. This document had an area subtitled “Medications” and stated “Lasix [used to treat fluid retention and swelling] 20 MG [milligram] – Daily/PRN [as needed] – 1 Tablet … Nitroglycerin [used to treat chest pain] Sublingual [under the tongue] Tablet Sublingual 0.4 MG – every 5 minutes/prn – 1 tablet … Docusoft-S [used to treat occasional constipation] Oral Capsule 100 MG – QHS [every night]/PRN ….” Review failed to evidence indications to take the PRN medications. Review failed to evidence the plan of care had individualized medication instructions. 3. An observation was conducted on 6/10/2022, from 9:00 AM to 9:59 AM, for patient # 2, start of care 3/5/2015, home health aide (HHA) F. During the totality of the observation, the patient was cared for in a hospital bed. Clinical record review on 6/14/2022, for patient #2, primary diagnoses include but are not limited to right sided hemiplegia [paralysis], dysarthria [slurred speech], and dementia, evidenced an agency document titled “Home Health Plan of Care & Certification” for certification period 5/27/2022 – 7/25/2022. This document had an area subtitled “DME [durable medical equipment]” which failed to document a hospital bed was listed as being utilized by the patient. Record review failed to evidence all pertinent DME listed on the plan of care. Record review failed to evidence the plan of care was individualized to the patient’s needs and current condition. 4. An observation was conducted on 6/10/2022, from 10:35 AM to 11:23 AM, for patient # 3, start of care 4/5/2022, Registered Nurse (RN) D. During the totality of the observation, the patient was cared for in a hospital bed. Clinical record review on 6/14/2022, for patient #3, start of care 4/5/2022, primary diagnosis of stage 3 pressure ulcer [wound over a bony prominence that extends into the tissue beneath the skin, which forms a crater], evidenced an agency document titled “Home Health Plan of Care & Certification” for certification period 6/4/2022 – 8/2/2022. This document had an area subtitled “DME and Supplies” which failed to document a hospital bed was utilized in the patient’s home. Another area subtitled “Orders and Goals” stated “… SN [skilled nurse] using aseptic technique cleanse wound to buttock with NS [normal saline], pat dry, apply wound vac [vacuum] to buttock three times week and prn ….” Record review failed to evidence prn indications for wound care to be performed. Record review failed to evidence frequencies and duration for SN services. Record review failed to evidence all pertinent DME listed on the plan of care. Record review failed to evidence the plan of care was individualized to the patient’s needs and current condition. During an interview on 6/14/2022, at 12:31 PM, RN D indicated the SN frequency and duration should be on the plan of care. 5. Clinical record review on 6/14/2022, for patient #7, start of care 3/1/2022, evidenced an agency document titled “Home Health Plan of Care & Certification” for certification period 3/1/2022 – 4/29/2022. Review of this document failed to evidence the following including but not limited to functional limitations, activities permitted, mental status, orders, discipline frequencies and duration, goals, and medications. Review failed to evidence the plan of care contained all required information per the agency’s policy. 6. During an interview on 6/14/2022, at 11:53 AM, RN D indicated the purpose, or indications for PRN (as needed) orders, as well as and time constraints associated. 7. During an interview on 6/14/2022, at 11:59 AM, RN D indicated a skilled nurse would rely on the orders from the 485 (Plan of Care) to include but not limited to interventions, wound care, and goals. 410 IAC 17-13-1(a)(1)(D)(i-xiii)

Review and revision of the plan of care CFR(s): 484.60(c) Standard: Review and revision of the plan of care. This STANDARD is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the plan of care was revised to include changes and to reflect the patient’s current clinical information for 1 of 1 clinical record reviewed where wound care was provided. (#3) The findings include: Record review of an undated agency policy retrieved on 6/14/2022, titled “Plan of Care” stated “Policy … The plan will be consistently reviewed to ensure that the client needs are met, and will be updated as necessary, but at least every sixty (60) days … Special Instructions … 1. An individualized Plan of Care signed by a physician shall be required for each client receiving home health and personal care services .…” Clinical Record review on 6/14/22 for Patient #3, revealed an agency document titled “Resumption of Care Orders” from 5/26/2022, and signed by RN D, indicated “Treatment: - SN [skilled nurse] using aseptic technique to Rt [right] elbow [with] NS, pat dry, dry dressing, 3x/wk [3 times per week] prn [as needed] … SN using aseptic technique … wound to buttocks … apply wound vac [at] 125 mmhg continuous suction 3x/wk/prn ….” Record review of an resumption of care assessment dated 5/26/22 indicated the patient receives enteral nutrition [a way to provide nutrition through a tube placed in the nose, the stomach, or the small intestine] and the patient is on per peg tube [feeding tube through the stomach to receive nutrition] due [to] decline of wound. The assessment also indicated the patient has a stage 3 noted to buttocks, with wound vac [device connected to a patient to gently pull fluid and pressure over a wound to assist with the healing process] in place at 125mmhg [millimeter of mercury; measurement for pressure] continuous suction and the patient has a stage 2 [a pressure sore that has broken through the top layer of the skin and part of the layer below] to right elbow. Record of an agency document titled “Home Health Plan of Care & Certification” for certification period 4/5/2022 – 6/3/2022, Failed to evidence the plan of care was updated to include the new treatment orders to the coccyx, right elbow, and failed to include the patient’s antibiotics therapy. During an interview on 6/14/2022, at 12:04 PM, administrator A indicated the plan of care should be update post-hospitalization.

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the home health agency failed to ensure each patient was provided with a current, individualized schedule for 2 of 3 clinical records reviewed where a home visit was conducted. (#2, #3) The findings include: 1. Record review of an agency document titled “Section III. Patient Rights and Responsibilities” located in the agency’s sample home folder which was indicated to be ready for patient use by alternate administrator B on 6/6/2022. This document had an area subtitled “Decision Making” which stated “… The patient has the right to choose health care providers and communicate with those providers, and to be informed about the care to be furnished and of any changes in the care to be furnished as follows: Participate in, and be informed about, and consent or refuse care in advance of and during treatment with respect to: … Completion of all assessments … The care to be furnished, based on the comprehensive assessment … Establishing and revising the plan of care … The disciplines that will furnish the care … The frequency of visits … Receive all services outlined in plan of care ….” 2. An observation was conducted on 6/10/2022, from 9:00 AM to 9:59 AM, for patient # 2, start of care 3/5/2015, with home health aide (HHA) F. At 9:50 AM, the patient’s home folder was reviewed for the required information provided including a schedule for each discipline who serviced the patient. Review of the home folder evidenced a calendar schedule from February 2021. Review of the home folder failed to evidence a current patient schedule for HHA services. Review of the home folder failed to evidence a current schedule for Skilled Nurse services. 3. An observation was conducted on 6/10/2022, from 10:31 AM to 11:23 AM, for patient # 3, start of care 4/5/2022, with Registered Nurse (RN) D. At 11:17 AM, the patients home folder was reviewed for the required information provided by the agency including a schedule for each discipline who serviced the patient. Review of the home folder failed to evidence a current patient schedule for HHA services. Review of the home folder failed to evidence a current schedule for Skilled Nurse serviced provided by the agency. 4. During an interview on 6/14/2022, at 12:04 PM, RN D indicated a tentative schedule is created upon admission based on patients’ preference and agency availability. She indicated the tentative schedule should be kept in the patients home.

Treatments and therapy services CFR(s): 484.60(e)(3) Any treatments to be administered by HHA personnel and personnel acting on behalf of the HHA, including therapy services. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the home health agency failed to ensure each patient was provided with a current individualized plan of treatment for 3 of 3 clinical records reviewed where a home visit was conducted. (#1, #2, #3) The findings include: 1. Record review on 6/6/2022, of an agency document titled “Section III. Patient Rights and Responsibilities” and located in the agency’s sample home folder, which was indicated to be ready for patient use by alternate administrator B. This document had an area subtitled “Decision Making” which stated “… The patient has the right to choose health care providers and communicate with those providers, and to be informed about the care to be furnished and of any changes in the care to be furnished as follows: Participate in, and be informed about, and consent or refuse care in advance of and during treatment with respect to: … The care to be furnished, based on the comprehensive assessment … The disciplines that will furnish the care … The frequency of visits … Expected outcomes of care, including patient identified goals, and anticipated risks and benefits ….” Review failed to evidence the agency adhered to the items listed within this document. 2. An observation was conducted on 6/9/2022, from 2:35 PM to 3:23 PM, for patient # 1, start of care 5/12/2022, with person D, physical therapist (PT) from entity A. At 3:06 PM, the patients home folder was reviewed for the required information provided by the agency, including a current plan of treatment. Review of the patient’s home folder failed to evidence a current, individualized plan of treatment. Review failed to evidence the patient was provided with a plan of treatment to include, but not limited to, disciplines, frequency of visits, goals, expected outcomes and care to be furnished. 3. An observation was conducted on 6/10/2022, from 9:00 AM to 9:59 AM, for patient # 2, start of care 3/5/2015, home health aide (HHA) F. At 9:50 AM, the patients home folder was reviewed for the required information provided by the agency including a current plan of treatment. Review of the patient’s home folder failed to evidence a current, individualized plan of treatment. Review failed to evidence the patient was provided with a plan of treatment to include, but not limited to, disciplines, frequency of visits, goals, expected outcomes and care to be furnished. 4. An observation was conducted on 6/10/2022, from 10:31 AM to 11:23 AM, for patient # 3, start of care 4/5/2022, with Registered Nurse (RN) D. At 11:17 AM, the patients home folder was reviewed for the required information provided by the agency including a current plan of treatment. Review of the patient’s home folder failed to evidence a current, individualized plan of treatment. Review failed to evidence the patient was provided with a plan of treatment to include but not limited to disciplines, frequency of visits, goals, expected outcomes and care to be furnished. 5. During an interview on 6/14/2022, at 12:04 PM, RN D indicated a plan of care or treatment plan should have been kept in the patients home and updated at least with every recertification.

Other pertinent instructions CFR(s): 484.60(e)(4) Any other pertinent instruction related to the patient's care and treatments that the HHA will provide, specific to the patient's care needs. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the home health agency failed to ensure all pertinent information was provided to each patient including a home health aide care plan, for 1 of 2 clinical records reviewed with home health aide services. (#2) The findings include: Record review of an undated agency policy, retrieved on 6/14/2022, titled “Home Health Aide Care Plan” stated “Policy … All home health aide staff will follow the identified plan. The Care Plan will be available to all persons involved in client care, including contracted providers … Special Instructions … 2. The Care Plan shall be developed in plain, non-technical lay terms and identify the duties to be performed such as, but not limited to: … 9. The original Care Plan shall be filed in the clinical record. A copy of the Care Plan shall be placed in the client’s home….” An observation was conducted on 6/10/2022, from 9:00 AM to 9:59 AM, for patient # 2, start of care 3/5/2015, with home health aide (HHA) F. At 9:50 AM, the patient's home folder was reviewed for the required information provided by the agency including but not limited to the home health aide care plan. Review failed to evidence a care plan in the home folder for the home health aide. During an interview on 6/14/2022, at 11:55 AM, administrator A indicated a HHA should utilize the care plan to know which tasks to complete for the patient, which should be kept in the patient’s home.

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 home health agency failed to ensure every employee practiced standard precautions and hand hygiene during patient care to prevent the spread of infectious or communicable diseases for 1 of 1 clinical record where a home visit was conducted with a home health aide. (Employee F) The findings include: Record review of an undated agency policy, retrieved on 6/14/2022, titled “Infection Prevention Control” stated “Policy … Agency will observe the recommended precautions for home care as identified by the Centers for Disease and Control and Prevention (CDC) … Purpose … To ensure employee and client safety … To reduce the risk of transmission of microbes from both recognized and unrecognized sources of infections … Standard Precautions – Tier One … 1. Standard precautions apply to blood, all body fluids, secretions, excretions, non-intact skin, and mucous membranes. All are to be treated as a potential source of infection regardless of whether the client has a communicable disease … 2. Hands are washed if contaminated with blood or body fluid, immediately after gloves are removed, between client contacts, and when indicated to prevent transfer of microorganisms between other clients or the environment … 3. Gloves are worn when touching blood, body fluids, secretions, excretions, non-intact skin, mucous membranes, or contaminated items ….” Record review of an undated agency policy, retrieved on 6/14/2022, titled “Hand Washing/ Hand Hygiene” stated “Policy … In an effort to reduce the risk for infection in clients and staff members, through hand washing/ hand antisepsis is required of all employees. The agency will establish guidelines for all staff and will provide education and direction on accepted practices … Purpose … to improve hand hygiene practices of agency staff and to reduce transmission of pathogenic microorganisms to clients and personnel in the home care setting … Special Instructions … 3. Indications for hand washing and hand antisepsis: … d. Between tasks on the same client … f. After removing gloves … k. After assisting client to use the bathroom … p. Decontaminate hands after contact with client intact skin, after contact with body fluids, excretions, non-intact skin and wound dressings … q. Decontaminate hands after contact with inanimate objects including equipment in the immediate vicinity of the client … r. Decontaminate hands after removing gloves ….” An observation was conducted on 6/10/2022, from 9:00 AM to 9:59 AM, for patient # 2, start of care 3/5/2015, with home health aide (HHA) F. During the home visit, HHA F performed an occupied bed bath for the patient. At 9:06 AM, HHA F turned the water on in the kitchen sink, then came to the patient’s bedside and checked their oral temperature, without performing hand hygiene in between tasks. HHA F filled 2 basins (pink and gray) with water, brought them to the patient’s bedside table, and donned new gloves without performing hand hygiene prior. At 9:31 AM, HHA F changed the bath water which included dumping the pink basin into the toilet, rinsing the basin, filling with fresh bathroom sink water, and brought the pink basin back to the bedside table. HHA F dumped the gray basin into the toilet, flushed the toilet, rinsed the basin, filled with fresh bathroom sink water, and brought the gray basin back to the bedside table. HHA F removed their gloves and donned a new pair without performing hand hygiene in between. At 9:33 AM, HHA F washed and dried the patient perineal area (pertaining to the area of the genitals and buttocks), and placed a clean pad under the patient. At 9:40 AM, HHA F completed the perineal care, removed gloves, and donned a new pair without performing hand hygiene in between. Observation failed to evidence the HHA performed hand hygiene between tasks performed on the patient. Observation failed to evidence the HHA performed hand hygiene in between glove changes. Observation failed to evidence the HHA failed to practiced hand hygiene per the agency’s policy. Observation failed to evidence the HHA followed standard precautions to prevent the transmission of possible infectious microbes per the agency’s policy. During an interview on 6/14/2022, at 12:05 PM, RN D indicated in-services on hand hygiene with a return demonstration was performed with every clinician, which included, but was not limited to washing, drying, when to change gloves, and when appropriate times to use hand sanitizer. 410 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 home health agency failed to ensure each patient had a care plan created specific to duties and tasks assigned to the home health aide (HHA) for 1 of 1 closed clinical records reviewed where home health aide services were provided. (#7) The findings include: Record review of an undated agency policy retrieved on 6/14/2022, titled “Home Health Aide Care Plan” stated “Policy … A complete and appropriate Care Plan, identifying duties to be performed by Home Health Aide, shall be developed by a Registered Nurse or Therapist. All home health aide staff will follow the identified plan. The Care Plan will be available to all persons involved in client care, including contracted providers … Purpose … To provide a means of assigning duties to the home health aide that are clear to the Nurse, Home Health Aide, and to the client/caregiver being served … Special Instructions … 2. The Care Plan shall be developed in plain, non-technical lay terms and identify the duties to be performed such as, but not limited to: … a. Personal Care … b. Ambulation and exercise … 9. The original Care Plan shall be filed in the clinical record. A copy of the Care Plan shall be placed in the client’s home….” Clinical record review on 6/14/2022, for patient #7, start of care 3/1/2022, evidenced an agency document titled “Start of Care Orders” signed by Registered Nurse (RN) D, on 3/1/2022. This document stated “HHA Frequency: 4hrs [hours]/day 2 times/week x [for] 9 wks [weeks] ….” This document remained unsigned by the physician. Record review evidenced home health aide services were received on 3/3/2022, 3/8/2022, and 3/10/2022. Clinical record review failed to evidence a home health aide care plan was established by the registered nurse, as indicated in the agency's policy. HHA should utilize the care plan to know which tasks to complete for the patient. 410 IAC 17-13-2(a).

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure all tasks were completed as assigned to the home heath aide on the aide care plan for 2 of 5 active clinical records reviewed where home health aide services were provided. (#2, #5) The findings include: 1. Record review of an undated agency policy retrieved on 6/14/2022, titled “Home Health Aide Documentation” stated “Policy … Home Health Aides will document care/services provided on the home health aide charting form. Care/services provided should be in accordance with direction provided in the Home Health Aide Care Plan … Purpose … To provide documentation of the care performed by the Home Health Aide on each visit ….” 2. Record review of an undated agency policy retrieved on 6/14/2022, titled “Home Health Aide Care Plan” stated “Policy … A complete and appropriate Care Plan, identifying duties to be performed by Home Health Aide, shall be developed by a Registered Nurse or Therapist. All home health aide staff will follow the identified plan. The Care Plan will be available to all persons involved in client care, including contracted providers … Purpose … To provide a means of assigning duties to the home health aide that are clear to the Nurse, Home Health Aide, and to the client/caregiver being served … Special Instructions … 2. The Care Plan shall be developed in plain, non-technical lay terms and identify the duties to be performed such as, but not limited to: … a. Personal Care … b. Ambulation and exercise ….” 3. Clinical record review on 6/14/2022, for patient #2, primary diagnoses include, but are not limited to, right sided hemiplegia [paralysis], dysarthria [slurred speech], and dementia, evidenced an agency document titled “Aide Plan of Care” effective 5/27/2022. This document had an area subtitled “Assignment” which was followed by columns subtitled “Each Visit … Weekly … Special Note” for the registered nurse to indicate the frequency of the assigned tasks. The tasks assigned to be completed each visit included nail care, fall precautions, and assistance with wheelchair and/or Hoyer lift [an assistive device used to transfer a patient to and from the bed, chair, or other resting place using a hydraulic lift system]. Record review evidenced agency documents titled “Aide Visit Note” signed by HHA F, which failed to evidence nail care was provided on the following dates: 4/4/2022 through 4/8/2022, 4/18/2022 through 4/22/2022, 4/25/2022 through 4/29/2022, 5/2/2022 through 5/6/2022, 5/9/2022 – 5/13/2022, 5/15/2022 through 5/20/2022, and 5/23/2022 through 5/27/2022. Record review evidenced agency documents titled “Aide Visit Note” signed by HHA F, which failed to evidence fall precautions were followed on the following dates: 4/4/2022, 4/5/2022, 4/6/2022, 4/7/2022, and 4/8/2022. Record review evidenced agency documents titled “Aide Visit Note” signed by HHA F, which failed to evidence transfer assistance was provided on the following dates: 4/4/2022 through 4/8/2022, 4/18/2022 through 4/22/2022, 4/25/2022 through 4/29/2022, 5/2/2022 through 5/6/2022, 5/9/2022 – 5/11/2022, 5/14/2022, 5/17/2022 through 5/20/2022, and 5/23/2022 through 5/27/2022. Record review failed to evidence the HHA completed all tasks as assigned on the plan of care. 4. Clinical record review on 6/14/2022, for patient #5, start of care 6/23/2021, diagnoses included, but was not limited to, visual loss, morbid obesity, and gait/mobility abnormalities. Clinical record review evidenced an agency document titled “Aide Plan of Care” effective 4/19/2022. This document had an area subtitled “Assignment” which was followed by columns subtitled “Each Visit … Weekly … Special Note” for the registered nurse to indicate the frequency of the assigned tasks. The tasks assigned to be completed each visit included hair care, skin care, and personal care. Record review evidenced agency documents titled “Aide Visit Note” signed by HHA H, which failed to evidence hair care was provided on the following dates: 4/20/2022, 4/22/2022, 4/25/2022, 4/27/2022, and 4/29/2022. Record review evidenced agency documents titled “Aide Visit Note” signed by HHA H, which failed to evidence foot care was provided on the following dates: 4/20/2022, 4/25/2022, 4/27/2022, and 4/29/2022 Record review evidenced agency documents titled “Aide Visit Note” signed by HHA H, which failed to evidence personal care was provided on the following dates: 4/18/2022, 4/20/2022, 4/22/2022, 4/25/2022, 4/27/2022, and 4/29/2022. 5. During an interview on 6/14/2022, at 11:56 AM, RN D indicated if there was an assigned task the HHA did not complete, the HHA could document why the task had not been completed.

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 home health agency failed to ensure there was a qualified alternate appointed in writing by the governing body to act in the administrator’s absence. The findings include: Record review of an undated agency policy retrieved on 6/14/2022, titled “Governing Body” stated “Policy … The Governing Body (or designated persons so functioning) shall assume full legal authority and responsibility for the overall management and operation of the Agency … Purpose … To provide direction and supervision of the agency’s operation and services … To ensure lines of authority are established … Special Instructions … The duties and responsibilities of the Governing Body shall include: … 2. The Administrator or a pre-designated person is available during all operating hours. The back up person assumes the administrators responsibilities and obligations when acting in that role. This position must be approved by the Governing Body ….” Record review on 6/9/2022, of the agency's governing body information failed to evidence a designated alternate administrator in writing. During an interview on 6/14/2022, at 10:33 AM, administrator A indicated if the governing body appointed alternate administrator B in writing, the information would be in the meeting minutes from over 10 years ago. 410 IAC 17-12-1(d)(8).

Clinical manager CFR(s): 484.105(c) Standard: Clinical manager. One or more qualified individuals must provide oversight of all patient care services and personnel. Oversight must include the following-- This STANDARD is not met as evidenced by: Based on record review and interview, the home health agency failed to appoint a qualified alternate clinical manager to act in the absence of the clinical manager. (Employee A) The findings include: Record review of an undated agency policy retrieved on 6/14/2022, titled “Clinical Manager” stated “Policy … This position provides clinical oversight over all client care services and staff … Purpose … To coordinate referrals and client care between disciplines and physicians … To assure the development, implementation, and updates of the individualized plan of care … Special instructions … 1. This position may be held by one or more individuals, but it is specific position with specific responsibilities. The appointments will be made by the Governing Body or their designee(s) … 4. The oversight provided by the clinical manager(s) includes: a. Making client and personnel assignments … b. Coordinating client care … c. Coordinating referrals … d. Assuring the client needs are continually assessed … e. Assuring the development, implementation, and updates to the individualized plans of care … 7. It is NOT recommended that the Administrator also assume the role as the clinical manager....” Record review of an undated agency policy retrieved on 6/14/2022, titled “Director of Clinical Services Backup” stated “Policy ... In compliance with established policy, in the event that the Director of Clinical Services is not available, a designated, qualified alternative will assume his or her duties and responsibilities and be available to respond to emergencies. In the event that the Director of Clinical Services leaves employment, the designated alternate will assume the Director’s responsibilities until a replacement is hired and oriented. The Director of Clinical Services or alternate will be available during hours of operation … Purpose … To assure that qualified individual is designated to fulfill the responsibilities of the Director of Clinical Services in the Director's absence ….” Personnel record review on 6/14/2022, for alternate clinical manager C, evidenced a document titled “Contract” and stated “This Agreement is entered into on between Moore Home Health Care and [entity B] on 6-30-14 … It is agreed as follows: Service to be provided … 1. As requested [entity B] Director of Nursing, [alternate clinical manager C], will serve as Moore Home Health Care Alternate Director of Nursing … 5. In the absence of Moore Home Health Care Director of Nursing, the Alternate Director of Nursing will be available at all times during operating hours and participate in all activities relevant to the professional services furnished … 6. [Entity B] understands the necessity to conform to all applicable Agency policies including personnel qualifications and will furnish Moore Home Health Care with applicable documents … 7. The Alternate Director of Nursing will comply with all Federal and State regulations, laws, practice acts including universal precautions and the blood borne pathogen standard. Services will be in accordance with the rules and regulations of Moore Home Health Care. ….” This document was signed by administrator A (who is also the clinical manager for Moore Home Health Care) and alternate clinical manager C on 6/30/2014. Record review failed to evidence Moore Home Health Care demonstrated agency policy recommendation against holding both roles as clinical manager and administrator. Review failed to evidence the administrator/clinical manager A selected a qualified person who would be available during business hours to assist in furnishing services. Review failed to evidence alternate clinical manager B was oriented to Moore Home Health Care’s policies and procedures. During an interview on 6/9/2022, at 3:23 PM, person D from entity A (contracted agency for therapy services), indicated if there was something to report to the nurse regarding a patient’s status, they would call the office and leave a message. Person D indicated they did not know who to contact specifically regarding any patient changes. During an interview on 6/10/2022, at 9:50 AM, when queried to whom they report to clinically, Home Health Aide (HHA) F indicated Registered Nurse (RN) D is the main nurse or director of nursing. During an interview on 6/14/2022, at 10:34 AM, administrator/clinical manager A indicated that Moore Home Health Care and entity B had an agreement to ensure both agencies always had an alternate clinical manager in place due to a high turnover rate for that role. Administrator A indicated she was the alternate clinical manager for entity B and alternate clinical manager C held the role at Moore Home Health Care. Administrator A indicated alternate clinical manager C would stop in the office 2 or 3 times a year and has never seen a patient at the agency. She indicated alternate clinical manager C would not know anything about the patients at Moore Home Health Care. 410 IAC 17-12-1(d)

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the clinical record contained all required information including interventions and patient response for 2 of 4 active clinical records reviewed where home health aide provided services. (#3, #5) The findings include: 1. Record review of an undated agency policy titled “Clinical Documentation” stated “Policy … Agency will document each direct contact with the client. This documentation will be completed by the direct caregivers and monitored by the skilled professional responsible for managing the client’s care … Purpose … to ensure that there is an accurate record of the services provided, client response and ongoing need for care ... To document conformance with plan of care, modifications to the plan, and interdisciplinary involvement ….” 2. Clinical record review for patient #3, start of care 4/5/2022, primary diagnosis of stage 3 pressure ulcer [wound over a bony prominence that extends into the tissue beneath the skin, which forms a crater] of the right buttocks, evidenced an agency document titled “Home Health Plan of Care & Certification” for certification period 4/5/2022 – 6/3/2022. This document had an area subtitled “Orders and Goals” which stated “Skilled Nursing Orders … Order: Observation and Assessment Nutrition/Hydration Status … Order: Observation and Assessment Wound Healing Status … Order: Parameter to notify Physician … Temperature … Respirations … Blood Pressure … Pulse Rate … Pulse Ox [oximeter; used to measure oxygen saturation] … Pain Levels > [greater than] 0 ….” Review evidenced the SN was to assess vital signs and pain levels. Record review of an agency document titled “Skilled Nursing Visit Note (according to POC [plan of care])” from 4/18/2022, and digitally signed by Registered Nurse (RN) D. This document had an area subtitled “Vital Signs” which had space provided to document the following: pulse rate, respirations, blood pressure, and pain, which remained blank. An area subtitled “Wound Care” stated “No signs and symptoms of infection noted by nurse at this time … Wounds Information … Type of Wound: pressure … Location: right buttocks ...” Another area subtitled “General Notes” stated “… SN using aseptic technique cleansed and performed wound care to buttocks per MD [Doctor of Medicine] orders. Wound to buttocks responding well to treatment ….” Review failed to evidence the SN assessed patient’s vital signs and pain levels as indicated on the plan of care. Review failed to evidence further information about wound care and interventions to include but not limited to drainage, odor, color of wound, and condition of skin on the surrounding area. Review failed to evidence the SN documented all interventions. Review failed to evidence the patient’s response to the wound care intervention. During an interview on 6/14/2022, at 12:40 PM, RN D indicated the vital signs and pain assessment, and wound care response was not on the skilled nurse visit note. 3. Clinical record review for patient #5, start of care 6/23/2021, diagnoses include but not limited to visual loss, osteoarthritis, and morbid obesity, evidenced an agency document titled “Home Health Plan of Care & Certification” for certification period 4/19/2022 – 6/17/2022. This document had an area subtitled “Orders and Goals” which stated, “Skilled Nursing Orders … Order: Observation and assessment effectiveness of pain management ….” Record review evidenced an agency document titled “OASIS [Outcomes and Assessment Information Set] Assessment Details … Recertification (follow-up) reassessment” which was digitally signed by RN D, on 4/14/2022. This document had an area subtitled “(M1242) Frequency of Pain interfering with patients activity or movement: … Daily, but not constant …” Another area subtitled “Pain Assessment” stated “Pain Location … generalized … Pain at its best: … 0 … Average Pain Level: … 4 …” An area subtitled “Cause and Relief of Pain” stated “What causes pain to increase? Activity … What causes pain to decrease? medication/ position change ….” Review evidenced medication and position change helped to decrease pain. Record review of an agency document titled “Skilled Nursing Visit Note” from 4/27/2022, and digitally signed by RN E. This document had an area subtitled “Vital Signs” which stated “Pain Location: Right leg … Pain intensity: 6 …” This area had sections to document an acceptable pain level, medication last taken, and pain management intervention but remained blank. Another area stated “General Notes … Pt [patient] able to make needs known with c/o [complaints of] pain to [his/her] right leg. Teaching on pain management provided with positive feedback ….” Review of this document evidenced the pain level assessed at this visit was higher than the average pain level on the most recent comprehensive assessment. Review failed to evidence a complete pain assessment to include interventions provided. Review failed to evidence medication administration or position change interventions to decrease pain. Review failed to evidence a response to a specific pain management technique. During an interview on 6/14/2022, at 12:47 PM, RN D indicated teaching pain management was not a complete pain assessment or intervention.

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 home health agency failed to ensure a discharge summary was completed to include, but not be limited to, discharge instructions, services provided, and laboratory data for 2 of 2 closed clinical records reviewed. (#6, #7) The findings include: 1. Record review of an undated agency policy retrieved on 6/14/2022, titled “Discharge Summary” stated “Policy … A Discharge Summary will be completed for clients discharged from Agency … Purpose … To record a summary of care received by the client from the start of care through discharge … To document client status at the time of discharge, identified unmet needs, and referrals initiated … To document instructions given to the client/family regarding medications, treatment, referrals, and necessary follow-up … Special Instructions … 2. The Discharge Summary will incorporate findings from the discharge OASIS [Outcomes and Assessment Information Set] assessment and shall include, but not be limited to: … b. Services provided … c. Diagnosis(es) … e. Status at time of discharge … f. Notifications of discharge … g. Reason for discharge … h. Transfer information, as applicable … i. Unmet needs, referrals made … j. Instructions provided for the family ….” 2. Clinical record review on 6/14/2022, for patient #6, start of care 3/28/2022, evidenced an agency document titled “Discharge Summary” from 5/16/2022. This document stated “Caregiver: [Registered Nurse (RN) D] …” and indicated the patient received physical therapy (PT) services only. This document had area left blank which included, but was not limited to, clinical summary/lab data, and patient and/or family post discharge instructions. Record review failed to evidence the discharge summary was completed. During an interview on 6/14/2022, at 12:55 PM, RN D indicated the physical therapist should have completed the discharge summary. 3. Clinical record review on 6/14/2022, for patient #7, start of care 3/1/2022, evidenced an agency document titled “Discharge Summary” from 5/16/2022. This document stated “Caregiver: [administrator/clinical manager A] …” and indicated the patient received home health aide (HHA) services only. This document had area left blank which included, but was not limited to, clinical summary/lab data, emergency contact information, patient’s status at time of discharge, and patient and/or family post discharge instructions. Record review failed to evidence the discharge summary was completed. During an interview on 6/14/2022, at 1:02 PM, RN D indicated the discharge summary was not complete. 4. During an interview on 6/14/2022, at 12:06 PM, RN D indicated the discharge summary should include, but was not limited to, follow up information (who/where/when), medications, and general discharge instructions. 410 IAC 17-15-1(a)(6)

This was a federal complaint investigation of a home health agency. Complaint # IN00355118 - substantiated with findings Survey Dates: 7/27/2021, 7/28/2021, 7/29/2021 Facility ID: 157498 These deficiencies reflect State Findings cited in accordance with 410 IAC 17. Refer to state form for additional state findings. Quality Review Completed 08/19/2021

Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure patient rights were upheld to ensure all services were received as outlined in the plan of care for 1 of 3 active clinical records reviewed. (#3) The findings include: Review of an undated agency policy titled "Plan of Care " policy number C-580 which "Policy ... The Plan of Care is based on a comprehensive assessment and information provided by client/ family and health team members. Planning for care is dynamic process that addresses the care, treatment and services to be provided. The plan will be consistently reviewed to ensure that the client's needs are met, and will be updated as necessary, but at least every 60 days ... Purpose To provide guidelines for agency staff to develop a plan of care individualized to meet specific identified needs ... To reflect client's ability to make choices and actively participate in establishing and following the plan designated to attain personal health goals ... To assure that the plan meets state/ federal guidelines, and all applicable laws and regulations ... Special instructions ... 2. The plan of care shall be completed in full to include: ... c. Type, frequency, and duration of all visits/ services ... 5. The plan of care/ 485 will be developed following the initial assessment and the original will be mailed or faxed to the physician for signature ... 8. The total plan of care shall be reviewed by the attending physician and agency personnel as often as the severity of the client's condition requires, but at least one time every 60 days ... 10. Professional staff shall promptly alert the physician to any changes that suggest a need to alter the plan of care...." Clinical record review on 7/29/2021, for patient #3, start of care 4/2/2021, diagnoses included, but are not limited to, diabetes, stage 3 pressure ulcer, and generalized weakness, evidenced an agency document titled "Patient's Bill of Rights" signed by the person B, caregiver and former employee A, on 4/2/2021. This document stated "... The patient has the right to participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to ... (viii) Any changes in the care to be furnished. Receive all services outlined in the plan of care...." Review failed to evidence all services were provided as outlined in the plan of care. Record review evidenced an agency document titled "Home health Certification and Plan of Care" for certification period 6/1/2021 - 7/30/2021, and was signed by the alternate administrator C on 6/1/2021. This document had an area subtitled "Home Health Aide Orders" which stated "Order: Frequency and Duration: 3W9 [3 times a week, for 9 weeks] ... To Provide/Assist with Personal Care and ADL's [activities of daily living] ... Order: Respite Home Health Aide - 40 hrs. [hours] a month ... Patient will have assistance with personal care and IADL's [instrumental activities of daily living] .... " This document was signed by the physician on 6/25/2021. Review failed to evidence a home health aide (HHA) visit had been completed during this certification period as ordered on the plan of care. During an interview on 7/29/2021 at 2:41 PM, administrator A agreed the current plan of care indicated HHA services were to be provided 3 times a week, for 9 weeks. The administrator indicated person B requested all staff show proof of negative covid test before entering the patient's home. The administrator reported the HHAs were not willing to show person B proof of a recent negative test.

HHA can no longer meet the patient's needs CFR(s): 484.50(d)(1) The transfer or discharge is necessary for the patient's welfare because the HHA and the physician or allowed practitioner, who is responsible for the home health plan of care agree that the HHA can no longer meet the patient's needs, based on the patient's acuity. The HHA must arrange a safe and appropriate transfer to other care entities when the needs of the patient exceed the HHA's capabilities; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to arrange a safe discharge/transfer to another home health agency to ensure patient needs were being met in 1 of 3 active clinical records reviewed. (#3) The findings include: Review of an undated agency policy titled "Plan of Care " policy number C-580 which "Policy ... The Plan of Care is based on a comprehensive assessment and information provided by client/ family and health team members. Planning for care is dynamic process that addresses the care, treatment and services to be provided. The plan will be consistently reviewed to ensure that the client's needs are met, and will be updated as necessary, but at least every 60 days ... Purpose To provide guidelines for agency staff to develop a plan of care individualized to meet specific identified needs ... To reflect client's ability to make choices and actively participate in establishing and following the plan designated to attain personal health goals ... To assure that the plan meets state/ federal guidelines, and all applicable laws and regulations ... Special instructions ... 2. The plan of care shall be completed in full to include: ... c. Type, frequency, and duration of all visits/ services ... 8. The total plan of care shall be reviewed by the attending physician and agency personnel as often as the severity of the client's condition requires, but at least one time every 60 days ... 10. Professional staff shall promptly alert the physician to any changes that suggest a need to alter the plan of care...." Clinical record review on 7/29/2021 for patient #3, start of care 4/2/2021, diagnoses included, but were not limited to, diabetes, stage 3 pressure ulcer, and generalized weakness, evidenced an agency document titled "Patient's Bill of Rights" signed by person B, caregiver and former employee A, on 4/2/2021. This document stated "... The patient has the right to participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to ... (viii) Any changes in the care to be furnished. Receive all services outlined in the plan of care ... The agency may only transfer or discharge the patient from the agency if: 1. The transfer or discharge is necessary for the patient's welfare because of the home health agency and the physician who is responsible for the home health plan agree that the home health agency can no longer meet the patient's needs ... 4. The patient refuses services, or elects to be transferred or discharged...." Record review evidenced an agency document titled "Home Health Certification and Plan of Care" for certification period 6/1/2021 - 7/30/2021, signed by alternate administrator C on 6/1/2021. This document had an area subtitled "Home Health Aide Orders" which stated "Order: Frequency and Duration: 3W9 [3 times a week, for 9 weeks] ... To Provide/Assist with Personal Care and ADL's [activities of daily living] ... Order: Respite Home Health Aide - 40 hrs. [hours] a month ... Patient will have assistance with personal care and IADL's [instrumental activities of daily living] .... " This document was signed by the physician on 6/25/2021. Review failed to evidence a home health aide (HHA) visit had been completed during this certification period as ordered on the plan of care. Clinical record review failed to evidence the home health agency provided the patient with a home health aide as ordered on the plan of care in order to meet the patient's healthcare needs. The home health agency failed to meet the home health aide needs and failed to assist the patient with a transfer / discharge to another home health agency that could meet the patient's home health aide needs. During an interview on 7/28/2021 at 1:10 PM, person B indicated the home health aides "abandoned" patient #3. Person B indicated the home health aides that were coming prior to 06/01/2021 failed to ensure patient #3 had a "proper" bath, as evidenced by the patient always having "dirty ears". Person B indicated they requested a recent negative covid test from clinicians prior to entering their home and since this request have not heard from the administrator or anyone from Moore Home Health about providing the patient with a home health aide services since 06/01/2021. During an interview on 7/29/2021 at 2:32 PM, administrator A indicated they had a conversation with person B and explained there are other home health options. The administrator also indicated there was communication with the patient's case worker, but could not provide documentation of what other agencies had been suggested to person B and patient #3.

Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient's updated comprehensive assessment, and contain information concerning the patient's progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure every plan of care was revised to reflect the most current patient information for 1 of 3 active clinical records reviewed. (#3) The findings include: 1. Review of an undated agency policy titled "Plan of Care " policy number C-580 which "Policy ... The Plan of Care is based on a comprehensive assessment and information provided by client/ family and health team members. Planning for care is dynamic process that addresses the care, treatment and services to be provided. The plan will be consistently reviewed to ensure that the client's needs are met, and will be updated as necessary, but at least every 60 days ... Purpose To provide guidelines for agency staff to develop a plan of care individualized to meet specific identified needs ... To reflect client's ability to make choices and actively participate in establishing and following the plan designated to attain personal health goals ... To assure that the plan meets state/ federal guidelines, and all applicable laws and regulations ... Special instructions ... 2. The plan of care shall be completed in full to include: ... c. Type, frequency, and duration of all visits/ services ... 5. The plan of care/ 485 will be developed following the initial assessment and the original will be mailed or faxed to the physician for signature ... 8. The total plan of care shall be reviewed by the attending physician and agency personnel as often as the severity of the client's condition requires, but at least one time every 60 days ... 10. Professional staff shall promptly alert the physician to any changes that suggest a need to alter the plan of care ...." 2. Clinical record review on 7/29/2021, for patient #3, start of care 4/2/2021, diagnoses include but are not limited to diabetes, stage 3 pressure ulcer, and generalized weakness, evidenced an agency document titled "Home health Certification and Plan of Care" for certification period 6/1/2021 - 7/30/2021 and was signed by the alternate administrator C on 6/1/2021. This document had an area subtitled "Home Health Aide Orders" which stated "Order: Frequency and Duration: 3W9 [3 times a week, for 9 weeks] ... To Provide/Assist with Personal Care and ADL's [activities of daily living] ... Order: Respite Home Health Aide - 40 hrs. [hours] a month ... Patient will have assistance with personal care and IADL's .... " This document was signed by the physician on 6/25/2021. Review failed to evidence a home health aide (HHA) visit had been completed during this certification period. Record review evidenced an agency document titled "Verbal Order" from 5/24/2021, which stated "Home Health Aide services on hold per Primary Caregiver ...." This document was signed by the physician on 6/3/2021. Review failed to evidence the plan of care was revised to reflect the most current patient information. During an interview on 7/29/2021, at 2:41 PM, the administrator A agreed the current plan of care indicated HHA services were to be provided 3 times a week, for 9 weeks. The administrator indicated person B requested all staff show proof of negative covid test before entering the patient's home. The administrator reported the HHAs were not willing to show person B proof of a recent negative covid test.

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 home health agency failed to ensure all staff practiced standard precautions to prevent the transmission of possible diseases/infections for 2 of 3 patients who received a home visit. (#1, #2) The findings include: 1. Record review of an undated agency policy titled "Infection Prevention/Control" policy number B-403, stated "Policy Agency will observe the recommended precautions for home care as identified by the Centers for Disease Control and Prevention (CDC) ... Purpose To ensure employee and client safety ... To reduce the risk of transmission of microbes from both recognized and unrecognized sources of infection ... Standard Precautions - Tier One ... 1. Standard precautions apply to blood, all body fluids, secretions, excretions, non-intact skin, and mucous membranes. All are to be treated as a potential source of infection regardless of whether the client has a communicable disease ... 2. Hands are washed if contaminated with blood or body fluid, immediately after gloves are removed between client contacts, and when indicated to prevent transfer of microorganisms between other clients or the environment ... 3. Gloves are worn when touching blood, body fluids, secretions, excretions, non-intact skin, mucous membranes, or contaminated items...." 2. Record review of an undated agency policy titled "Handwashing/ Hand Hygiene" policy number D-330, stated "Policy In an effort to reduce the risk for infection in clients and staff members, thorough hand washing/hand antisepsis is required of all employees. The agency will establish guidelines for all staff and will provide education and direction on accepted practices ... Purpose To improve hand-hygiene practices of agency staff and to reduce transmission of pathogenic microorganisms to clients and personnel in the home care setting ... Special Instructions ... 3. Indications for hand washing and hand antisepsis: ... c. When there is prolonged or intense contact with the client (bathing the client). d. Between tasks on the same client ... f. After removing gloves. g. After touching objects that are potentially contaminated ... k. After assisting client to use the bathroom. l. Before eating, drinking, handling food or serving food. m. When hands are visibly dirty or contaminated with proteinaceous material or are visibly soiled with blood or other body fluids, wash hands with either a non-antimicrobial soap and water or an antimicrobial soap with water ... p. Decontaminate hands after contact with client's intact skin, after contact with body fluids, excretions, non-intact skin and wound dressings. q. Decontaminate hands after contact with inanimate objects including equipment in the immediate vicinity of the client. r. Decontaminate hands after removing gloves...." 3. During an observation, on 7/28/2021, for patient #1, start of care 1/15/2021, home health aide (HHA) D was observed assisting the patient with a sponge bath. At 9:12 AM, HHA D washed hands with soap and water in the patient's kitchen sink, dried with paper towels and discarded soiled materials in the garbage. HHA D prepared water for partial bath, collected supplies needed and donned new gloves. The patient ambulated to the bathroom with the assistance of a rolling walker, then sat on the toilet next to the bathroom sink and removed clothing. HHA D rinsed a washcloth under warm water, handed it to the patient, and indicated it was the washcloth for their face. The HHA prepared another washcloth, which was indicated to be specifically for the patient's body. The patient washed the upper portion of their body, including but not limited to bilateral arms and underarms, chest, under breasts, stomach and under stomach folds. HHA D rinsed the washcloth intended for the patient's body and handed it back to the patient and they washed the same body areas again, this process was repeated 2 more times. The HHA rinsed the body washcloth, handed it back to the patient for patient to wash their thighs. At 9:24 AM, HHA D removed their gloves, donned a new pair and washed the bottom of the patient's legs. The HHA rinsed body washcloth in the sink, re-washed the patient's bilateral lower extremities, and dried with a clean towel. At 9:28 AM, HHA D removed gloves and donned a new pair. Patient #1 stood up, turned around, and bent over to use the sink and toilet to lean against while HHA D cleaned their backside. Using the towel identified to be used on the patient's body, HHA D cleaned the patient's perineal area from behind, using the front to back (clean to dirty) method. Using the same washcloth, the HHA rinsed and then washed the patient's buttocks. At 9:31 AM, HHA D dried the patients perineal and buttocks with a dry towel. At 9:33 AM, the HHA assisted the patient in applying deodorant, lotion, powder, assisted dressing the patient, then removed gloves and washed hands in the kitchen sink with soap and water. Observation evidenced HHA D had cross contaminated the identified body towel by washing clean to dirty, then dirty to clean body areas. Observation failed to evidence HHA D sanitized hands in between patient contact, after removing gloves, and when touching known possible contaminated areas to prevent the transmission of potentially infectious microorganisms. 4. During an observation, on 7/28/2021 for patient #2, start of care 11/16/2013, HHA E was observed assisting the patient with feeding and personal care. At 11:34 AM, patient #2 indicated they would like to be fed. HHA E warmed the meal in the microwave, donned new gloves, and began feeding the patient at the bedside. After the patient stated, "I'm full" HHA E cleaned up the area and removed their gloves. At 12:13 PM, the patient indicated they had a bowel movement and needed to be cleaned up. HHA E donned a new pair of gloves, and turned the bathroom sink on to warm up the water. HHA E returned to the patient's bedside with a basin of water and washcloths. HHA E washed patient #2's face and set that washcloth aside. At 12:17 PM, the HHA rinsed a new washcloth, applied body wash to the washcloth and rang excess water from towel into the basin. HHA E wiped the patient's back and buttocks and placed the washcloth in the basin. At 12:24 PM, HHA E obtained a new washcloth and submerged it in the dirty basin water, then laid the patient on their back to clean the perineal area. HHA E wiped the patient's genitals with the washcloth from the contaminated basin, then dried with a clean washcloth. At 12:29 PM, HHA E changed the bath water, returned to the patient's bedside and began to undress the patient's upper body. HHA E obtained a clean washcloth, submerged in the basin and applied body wash to it. HHA E washed the patient's chest, stomach, neck, fingers, and underarms. The HHA rinsed the washcloth in the basin water and then wiped down the patient's upper body again. HHA E applied lotion to the patient's legs and feet, applied deodorant to the patient's underarms, assisted the patient to put their shirt on, then placed heel protectors on the patient's feet. This observation evidenced cross contamination from placing washcloths in dirty bath water and then wiped the patient with them. The observation failed to evidence hand hygiene was performed prior to feeding the patient, in between glove changes, and between tasks during the bath to prevent the transmission of potentially infectious microorganisms. 5. During an interview on 7/28/2021 at 4:36 PM, administrator A indicated hand hygiene should be performed after wearing gloves and after patient contact. The administrator indicated a clinician should change their gloves after patient contact. 6. During an interview on 7/28/2021 at 4:44 PM, the administrator and alternate administrator were notified of the infection control concerns observed during the patient's home visits. The administrator stated, "We need to do a bathing in-service." 410 IAC 17-12-1(m)

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on record review an interview, the agency failed to ensure all home health aides (HHA) followed the individualized care plan for each patient for 3 of 3 active clinical records reviewed. (#1, #2, #3) The findings include: 1. Review of an undated agency policy, titled "Home Health Aide Services" policy C-220, stated "Policy Home Health Aide services will be provided to appropriate clients ... under the direct supervision of an agency Registered Nurse/Therapist in accordance with a medically approved Plan of Care. The duties of a home health aide include the provision of hands-on personal care, performance of simple procedures as an extension of therapy or nursing services ... Purpose To abide by state/federal guidelines and offer guidelines to the agency staff, physicians, and community for the appropriate utilization of Home Health Aide services ... Special Instructions 1. Home Health Aide services may include: a. Providing personal care services including bathing, dressing, feeding, weighing, back rubs, skin care, and shampoos as directed by the care plan and licensed professional ... d. Obtaining client temperature, pulse, respiration, and blood pressure ... 3. The Aide will follow the care plan and will not initiate new services or discontinue services without contacting the supervising Nurse ... 8. All services provided by the Home Health Aide shall be documented in the clinical record...." 2. Review of an undated agency policy, titled "Home Health Aide: Documentation" policy C-800, stated "Policy Home Health Aides will document care/services provided on the home health aide charting form. Care/services provided should be in accordance with direction provided in the Home Health Aide Care Plan ... Purpose To provide documentation of the care performed by the Home Health Aide on each visit ... Special Instructions 1. The Home Health Aide shall utilize the appropriate Home Health Aide flow sheet or charting form to document services rendered to the client ... 3. The designated Registered Nurse/Therapist or designated person is responsible for reviewing the Home Health Aide's charting before it is placed in the chart...." 3. Clinical record review on 7/29/2021 for patient #1, start of care 1/15/2021, diagnoses included, but were not limited to diabetes, mental illness, and generalized weakness, evidenced an agency document titled "Aide Care Plan" which was effective 7/14/2021. This document had an area subtitled "Assignment" which indicated the tasks to be completed each visit which included, but were not limited to, skin care, mouth/denture care, foot care, nail care, make bed and assist with dressing. Review failed to evidence all tasks assigned on the individualized care plan were completed each visit as ordered. Review of an agency document titled "Aide Visit Note" failed to evidence the patient received skin care or dressing assistance on 7/20/2021. Review of agency documents titled "Aide Visit Note" failed to evidence mouth/denture care was performed on 7/15/2021 and 7/20/2021. Review of agency documents titled "Aide Visit Note" failed to evidence foot care was provided on the following dates: 7/19/2021, 7/20/2021, and 7/21/2021. Review of agency documents titled "Aide Visit Note" failed to evidence nail care was performed on the following dates: 7/14/2021, 7/15/2021, 7/16/2021, 7/17/2021, 7/19/2021, 7/20/2021, and 7/21/2021. Review of agency documents titled "Aide Visit Note" failed to evidence the patient's bed was made for the following dates: 7/14/2021, 7/15/2021, 7/16/2021, 7/17/2021, 7/19/2021, 7/20/2021, 7/21/2021 7/22/2021, and 7/23/2021. 4. Clinical record review on 7/29/2021 for patient #2, start of care 11/16/2013, diagnoses included, but are not limited to, paralysis and generalized weakness, evidenced an agency document titled "Aide Care Plan" which was effective 6/7/2021. This document had an area subtitled "Assignment" which indicated the tasks to be completed each visit included, but were not limited to, mouth/denture care and foot care. Review failed to evidence all tasks assigned on the individualized care plan were completed each visit as ordered. Review of agency documents titled "Aide Visit Note" failed to evidence mouth/denture care was performed on the following dates: 5/28/2021, 6/18/2021, 6/25/2021, 7/2/2021, 7/9/2021, and 7/16/2021. Review of an agency document titled "Aide Visit Note" failed to evidence the patient received foot care on 7/14/2021. 5. Clinical record review on 7/29/2021 for patient #3, start of care 4/2/2021, diagnoses included, but were not limited to, diabetes, stage 3 pressure ulcer, and generalized weakness, evidenced an agency document titled "Aide Care Plan" which was effective 4/2/2021. This document had an area subtitled "Assignment" which indicated the tasks to be completed each visit that included, but were not limited to, skin care, mouth/denture care, foot care, hair care, take out trash and take patient's temperature. Review failed to evidence all tasks assigned on the individualized care plan were completed each visit as ordered. Review of agency documents titled "Aide Visit Note" failed to evidence hair care was performed on the following dates: 4/13/2021, 4/14/2021, 4/15/2021, 4/20/2021, 4/21/2021,4/22/2021, 4/27/2021, 4/28/2021, and 4/29/2021. Review of agency documents titled "Aide Visit Note" failed to evidence mouth/denture care was performed on the following dates: 4/13/2021, 4/14/2021, 4/15/2021, 4/20/2021, 4/21/2021,4/22/2021 5/4/2021, 5/5/2021, 5/6/2021, 5/18/2021, 5/19/2021 and 5/20/2021. Review of agency documents titled "Aide Visit Note" failed to evidence foot care was performed on the following dates: 4/6/2021, 4/7/2021, 4/8/2021, 4/13/2021, 4/14/2021, 4/15/2021, 4/20/2021, 4/21/2021,4/22/2021 5/4/2021, 5/5/2021, 5/6/2021, 5/13/2021, 5/18/2021, 5/19/2021 and 5/20/2021. Review of agency documents titled "Aide Visit Note" failed to evidence skin care was performed on the following dates: 4/6/2021, 4/7/2021, and 4/8/2021. Review of agency documents titled "Aide Visit Note" failed to evidence the patient received assistance with dressing on the following dates: 4/6/2021, 4/7/2021, 4/8/2021 and 5/13/2021. Review of agency documents titled "Aide Visit Note" failed to evidence the patient's temperature was taken on the following dates: 4/13/2021, 4/28/2021, 5/5/2021 and 5/12/2021. Review of agency documents titled "Aide Visit Note" failed to evidence foot care was performed on the following dates: 4/13/2021, 4/14/2021, 4/15/2021, 4/20/2021, 4/21/2021, 4/22/2021 4/27/2021, 4/28/2021, and 4/29/2021. 6. During an interview on 7/29/2021 at 2:57 PM, the administrator/clinical supervisor A and alternate clinical supervisor C were notified of items on the HHA care plan that were not performed as directed for all patients. The administrator/clinical supervisor stated they understood if the items were not documented on the visit note, "It didn't happen."

HH aide supervision elements CFR(s): 484.80(h)(4)(i-vi) Home health aide supervision must ensure that aides furnish care in a safe and effective manner, including, but not limited to, the following elements: (i) Following the patient's plan of care for completion of tasks assigned to a home health aide by the registered nurse or other appropriate skilled professional; (ii) Maintaining an open communication process with the patient, representative (if any), caregivers, and family; (iii) Demonstrating competency with assigned tasks; (iv) Complying with infection prevention and control policies and procedures; (v) Reporting changes in the patient's condition; and (vi) Honoring patient rights. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure all home health aides (HHA) followed the individualized care plan for each patient during supervisory visits for 3 of 3 active clinical records reviewed. (#1, #2, #3) The findings include: 1. Review of an undated agency policy, titled "Home Health Aide Supervision" policy C-340, stated "Policy Agency shell provide home health Aide services under the direction and supervision of a registered professional nurse/ therapist when personal care services are indicated and ordered by the physician ... Purpose To observe the aid while providing care to clients, and to assess competency in basic skills as well as delegated nursing tasks ... To provide the aid with the opportunity for direct interaction with nurse and client as it relates to the current plan of care... Special instructions ... 8. The aide visit record is reviewed by the supervising nurse/ therapist to assure services are being provided according to the care plan...." 2. Review of an undated agency policy, titled "Home Health Aide Supervision" policy C-340, stated "Policy A complete and appropriate care plan, identifying duties to be performed by the Home Health Aide, shall be developed by a registered nurse or therapist. A home health aide staff will follow the identified plan... Purpose To provide a means of assigning duties to the home health aide that are clear to the nurse, home health aide, and to the client/ caregiver being served ... To provide documentation that the clients care is individualized to his/ her specific needs ... Special Instructions 1. Following the initial nursing assessment and consultation with the client/ caregiver, a written plan identifying personal care and supportive care services are prepared by a registered nurse ... 2. The care plan shall be developed in plain, non-technical lay terms and identify the duties to be performed such as, but not limited to: a. Personal care ... c. Household services essential to health care at home...." 3. Clinical record review on 7/29/2021 for patient #1, start of care 1/15/2021, diagnoses included, but were not limited to, diabetes, mental illness, and generalized weakness, evidenced an agency document titled "Aide Care Plan" which was effective 7/14/2021. This document had an area subtitled "Assignment" which indicated the tasks to be completed each visit included, but were not limited to skin care, mouth/denture care, foot care, nail care, make bed and assist with dressing. Clinical record review evidenced an agency document titled "Supervisory Visit Note" which was signed by RN F on 7/13/2021. This document stated " ... 2. Follows client's Care Plan ..." which indicated yes. Review failed to evidence all tasks assigned on the individualized aide care plan were completed each visit as indicated on the supervisory visits. Review of an agency document titled "Aide Visit Note" failed to evidence the patient received all ordered tasks listed on the Aide Care Plan on the following dates: 7/14/2021, 7/15/2021, 7/16/2021, 7/17/2021, 7/19/2021, 7/20/2021, 7/21/2021 7/22/2021, and 7/23/2021. 4. Clinical record review on 7/29/2021 for patient #2, start of care 11/16/2013, diagnoses included, but were not limited to, paralysis and generalized weakness, evidenced an agency document titled "Aide Care Plan" which was effective 6/7/2021. This document had an area subtitled "Assignment" which indicated the tasks to be completed each visit included, but were not limited to, mouth/denture care and foot care. Clinical record review evidenced an agency document titled "Supervisory Visit Note" which was signed by alternate clinical supervisor C on 7/2/2021. This document stated " ... 2. Follows client's Care Plan for completion of tasks assigned ..." which indicated yes. Review failed to evidence all tasks assigned on the individualized aide care plan were completed each visit as indicated on the supervisory visits. Review of an agency document titled "Aide Visit Note" failed to evidence the patient received all ordered tasks listed on the Aide Care Plan on the following dates: 5/28/2021, 6/18/2021, 6/25/2021, 7/2/2021, 7/9/2021, 7/14/2021 and 7/16/2021. 5. Clinical record review on 7/29/2021 for patient #3, start of care 4/2/2021, diagnoses included, but were not limited to, diabetes, stage 3 pressure ulcer, and generalized weakness, evidenced an agency document titled "Aide Care Plan" which was effective 4/2/2021. This document had an area subtitled "Assignment" which indicated the tasks to be completed each visit included, but were not limited to, skin care, mouth/denture care, foot care, hair care, take out trash and take patient's temperature. Clinical record review evidenced an agency document titled "Supervisory Visit Note" which was signed by former employee A on 5/5/2021. This document stated " ... 2. Follows client's Care Plan ... 11. Patient/Family satisfied with Care Plan ..." which indicated yes. Clinical record review evidenced an agency document titled "Supervisory Visit Note" which was signed by former employee A on 5/19/2021. This document stated " ... 2. Follows client's Care Plan ... 11. Patient/Family satisfied with Care Plan ..." which indicated yes. Review failed to evidence all tasks assigned on the individualized aide care plan were completed each visit as indicated on the supervisory visits. Review of an agency document titled "Aide Visit Note" failed to evidence the patient received all services listed on the Aide Care Plan on the following dates: 4/6/2021, 4/7/2021, 4/8/2021, 4/13/2021, 4/14/2021, 4/15/2021, 4/20/2021, 4/21/2021,4/22/2021, 4/27/2021, 4/28/2021, 4/29/2021, 5/4/2021, 5/5/2021, 5/6/2021, 5/12/2021, 5/13/2021, 5/18/2021, 5/19/2021 and 5/20/2021. 6. During an interview on 7/29/2021 at 2:57 PM, the administrator/clinical supervisor A and alternate clinical supervisor C were notified of items on the HHA care plan that were not performed as directed for all patients. The administrator stated they understood if the items were not documented on the visit note, "It didn't happen." The administrator indicated the agency would look into changing the frequencies of tasks for respite patient's to be more accurate in documentation. 410 IAC 17-14-1(n)