Every finding on record at Northwest 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 05/6/2025,05/07/2025,and 05/08/2025 Active Census:25 At this Emergency Preparedness survey, Northwest 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.

This visit was for a Federal Recertification and State Re-licensure survey of a Home Health Provider. Survey Dates: 05/06/2025, 05/07/2025, and 05/08/2025 Unduplicated 12 month skilled admissions: 98 A partially extended survey was announced to the Administrator on 05/06/2025 at 5:00 PM. This deficiency report reflects State Findings cited in accordance with 410 IAC 17.

Written notice of patient's rights CFR(s): 484.50(a)(1)(i) (i) Written notice of the patient's rights and responsibilities under this rule, and the HHA's transfer and discharge policies as set forth in paragraph (d) of this section. Written notice must be understandable to persons who have limited English proficiency and accessible to individuals with disabilities; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the written notice of Patient Rights were provided in a language the Patient/legal representative understood in 1 of 1 clinical record reviewed with Spanish as the primary language. (Patient #3) The findings include: A clinical record review for Patient #3 evidenced a comprehensive assess for the SOC dated 04/11/2025 completed by RN 4 which indicated the Patient’s preferred language was Spanish. The written notice of Patient Rights signed by the Patient on 04/11/2025 failed to be provided in Spanish. On 05/07/2025, at 4:20 PM, RN 4 indicated the Patient and Patient’s spouse spoke Spanish and the written notice of Patient Rights were not provide in Spanish. On 05/06/2025, at 4:27 PM, the CM indicated the Patient Rights should have been provided in Spanish and would look for them. No additional documentation or information was provided prior to survey exit on 05/08/2025.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on record review, and interview, the agency failed to ensure medication interaction concerns identified during a patient’s medication review were reported to the physician in 5 of 5 active clinical records reviewed (Patient #1, 2, 3, 4, 5). Findings include: A review of the clinical record for Patient #1 evidenced a comprehensive assessment dated 04/07/2025 for the recertification period of 04/09/2025 through 06/07/2025 signed by RN 3 and indicated drug interactions were present but contained no information regarding what medications or interactions were found to have issues or how the Physician was notified and the Physician’s response. During an interview on 05/07/2025 at 2:15 PM the administrator reported drug regimen reviews were done in the office after the RN submitted the medication list to them and was not completed by the RN conducting the comprehensive assessment. 1. An undated policy, titled, “Physician Orders,” indicated when a nurse or therapist received a verbal order from a physician, the clinician would write the order to include the date, specific order and be signed by the title of the person that received the order, and all physician orders would be maintained in the clinical record. 2. An undated policy, titled, “Mediation Profile,” indicated at the time of admission the admitting professional would check all medications to identify possible adverse effects, significant side effects and report the identified problems to the physician. 3. A Comprehensive Assessment for Patient #2, dated 03/18/2025, indicated drug interactions were identified, and the physician and clinical manager were notified, and the physician was already aware of medication interactions and the risk but had determined that it was the best course of treatment for the patient and had taken appropriate precautions and was monitoring the patient for potential complications. The clinical record failed to evidence documentation the physician was notified of specific drug interactions. An Undated Medication Checker indicated 9 medication interactions were found between clonazepam (anti-anxiety medication) and midodrine (medication to treat low blood pressure), clonazepam and risperidone (antipsychotic medication), sertraline (antidepressant medication) and risperidone, sertraline and diclofenac (anti-inflammatory medication), risperidone and midodrine, diclofenac and fludrocortisone (steroid medication). The Medication Checker failed to indicate the physician was notified of the specific medication interactions. 4. A Comprehensive Assessment for Patient #4, dated 04/16/2025, indicated drug interactions were identified, and the physician and clinical manager were notified, and the physician was already aware of medication interactions and the risk but had determined that it was the best course of treatment for the patient and had taken appropriate precautions and was monitoring the patient for potential complications. An internet search of drugs.com indicated major drug interactions between buspirone (anti-anxiety medication), buspirone and tramadol (pain medication), aspirin and Eliquis (blood thinner), and buspirone and Imdur (blood vessel dilator). The clinical record failed to indicate documentation the physician was notified of specific drug interactions. 5. A Comprehensive Assessment for Patient #5, dated 03/24/2025, indicated drug interactions were identified, the physician and clinical manager were notified, and the physician was already aware of the medication interactions between Tradjenta (diabetic medication) and aspirin and the physician determined that that was the best course of treatment for the patient and had taken appropriate precautions and was monitoring the patient for potential complications. An internet search of drugs.com indicated major drug interactions between Tacrolimus (immunosuppression medication) and Venclexta (blood cancer medication). The clinical record failed to evidence documentation the physician was notified of the specific drug interactions. 6. During an interview on 05/08/2025, beginning at 12:15 PM, Registered Nurse [RN] 1 indicated the electronic medical record would populate medication interactions, she would notify the physician of the interactions by calling the physician’s office and would document if a message was left, and if a message was left, she would document the follow up response from the physician. 4 410 IAC 17-14-1(a)(1)(B) * A clinical record review for Patient #3 evidenced a comprehensive assessment for the SOC dated 04/11/2025 and a comprehensive assessment for the resumption of care dated 04/29/2024, both completed by RN 4, which indicated a medication review was completed and issues were identified. The comprehensive assessments indicated drug interactions were identified and failed to evidence which drugs interacted. The medication profile dated 04/11/2025 was signed by the CM, and the medication profile dated 04/29/2025 was signed by the Alternate CM. Neither medication profiles were signed by the RN conducting the comprehensive assessment at the time of the assessment. On 05/07/2025, at 3:19 PM, RN 4 indicated she was unaware of what the medication interactions were. On 05/07/2025, at 4:23 PM, the CM indicated either the CM or the Alternate CM reviewed the medications for interactions once the assessing RN submitted the comprehensive assessment.

Within 48 hours of the patient's return CFR(s): 484.55(d)(2) Within 48 hours of the patient's return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment was completed within 48 hours of return home from the hospital in 1 of 1 active clinical record reviewed with a hospitalization. (Patient #3) The findings include: A clinical record review for Patient #3 evidenced a Physician Order dated 04/29/2025 which indicated the agency resumed home care services after the Patient returned home from the hospital. The clinical record failed to evidence a revised comprehensive assessment following the resumption of care at time of review on 05/06/2025. On 05/06/2025, at 3:59 PM, the CM indicated the nurse had not yet completed the comprehensive assessment.

Discharge or Transfer Summary Content CFR(s): 484.58(b)(1) Standard: Discharge or transfer summary content. The HHA must send all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the discharge summary was sent to the physician within 5 business days of discharge per the agency’s policy in 1 of 1 closed record review of a patient discharged due to goals met. (Patient #6) The findings include: An undated policy titled “Discharge and Transfer” indicated the agency would send a discharge summary to the primary care practitioner within 5 business days of discharge from the agency. A clinical record review for Patient #6 evidenced a Discharge Summary which indicated the Patient discharged on 04/01/2025. The electronic health record’s (EHR) activity log indicated the discharge summary was not completed and signed by the CM until 04/08/2025. On 05/08/2025, at 1:25 PM, the CM indicated the Discharge Summary was not sent to the physician prior to the completion of the document on 04/08/2025, which was greater than 5 days from the date of discharge from the agency.

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure verbal orders were written and sent to the physician for signature in 1 of 1 active clinical records reviewed with a hospitalization. (Patient #3) The findings include: A clinical record review for Patient #3 evidenced Home Health Discharge Orders upon discharge from Entity 2 dated 04/28/2025 which indicated home health services were to include SN, PT, and OT and included the medications to continue at home. The POC for the resumption of care for certification period 04/11/2025-06/09/2025 signed and dated by RN 4 on 04/29/2025 was not yet signed by the physician. On 05/07/2025, at 4:20 PM, the CM indicated she spoke to the nurse practitioner for the physician responsible for the POC to receive the resumption order for home health. The CM indicated she did not document the verbal order received and indicated the POC upon resumption dated 04/29/2025 was not sent to the physician for signature until 05/06/2025 and was not yet returned signed. 410 IAC 17-14-1(a)(H)

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to notify the physician of a medication discrepancy in 1 of 1 active clinical record reviewed with a hospitalization. (Patient #3) The findings include: A clinical record review for Patient #3 evidenced Home Health Discharge Orders upon discharge from Entity 2 dated 04/28/2025 which indicated the medications to continue at home included cyanocobalamin (vitamin B12) 2,000 micrograms (mcg) daily and docusate sodium (stool softener) 100 milligrams (mg) twice daily for 10 days. The POC for the resumption of care for certification period 04/11/2025-06/09/2025 signed and dated by RN 4 on 04/29/2025 failed to evidence the docusate sodium to stop after 10 days and indicated 5,000 mcg of vitamin B12 was to be taken daily. The clinical record failed to evidence the agency notified the physician of the discrepancy of the medication orders with docusate sodium and vitamin B12. On 05/07/2025, at 4:20 PM, RN 4 indicated she left a message for the physician but did not hear back from the physician or physician’s representative regarding the resumption orders. On 05/08/2025, beginning at 4:23 PM, the CM indicated she spoke to the physician regarding the resumption orders but did not see the discrepancies with docusate sodium and vitamin B 12, so she did not notify the physician of the medication discrepancies. 410 IAC 17-13-1(a)(2)

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: Based on record review, and interview, the agency failed to integrate services to assure the identification of patient needs that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines in 1 of 1 active clinical records reviewed with a home health aide (Patient #2). Findings include: 1. An undated policy titled, “Coordination of Patient Services,” indicated the primary nurse would be responsible for the coordination of services to assigned patients for the ongoing evaluation of the patient’s needs, and efficient communication with all care providers would be maintained to ensure prompt transmission of significant information that could require action. 2. A Plan of Care, for certification period 03/19/2025 to 05/17/2025, for Patient #2, with a start of care date of 11/19/2024, indicated Patient received developmental disability assistance care from Entity 1, a home care provider, 5 hours per day 2 days per week. The Plan of Care indicated the agency would provide home health aide services 2 times per week. A Professional Services Order from Entity 1, dated 08/12/2022, indicated Patient #2 was to receive home health aide services 5 hours per day 5 days per week from Entity 1. The clinical record review failed to evidence further documentation of coordination of care or delineation of care with Entity 1 after 08/12/2022. During an interview on 05/08/2025, beginning at 1:00 PM, the Administrator, Administrative Staff 1, indicated the last communication with Entity 1 was in 2022, and indicated Patient was discharged and readmitted to the agency after a hospitalization on 11/19/2024. The Administrator indicated she did not know what care Entity 1 provided to Patient, Patient's family member told the agency that Entity 1 did not do bathing for Patient, and the agency was to complete Patient bathing. During a follow up interview on 05/08/2025, beginning at 2:00 PM, the Administrator indicated she had contacted Entity 1 and Patient received services 35 hours per week from Entity 1. 410 IAC 17-12-2(g)

Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA's governing body. This STANDARD is not met as evidenced by: Based on record review, and interview, the agency’s governing body failed to approve the frequency and detail of the data collection for the Quality Assessment and Performance Improvement Program in 1 of 1 agency. Findings include: 1. An undated policy, titled, “Quality Assurance Performance Improvement Program,” indicated the Quality Assurance and Performance Improvement Program activities were communicated to the governing body. 2. A Governing Body Board Members Meeting Minutes, dated 06/27/2024, failed to include documentation of the governing body’s approval of frequency and detail of the data collection for the Quality Assessment and Performance Improvement Program. During an interview on 05/08/2025, beginning at 12:30 PM, the Administrator, Administrative Staff 1 indicated there was no documentation of the governing body’s approval of the performance improvement program frequency of data collection. 410 IAC 17 17-12-2(a)

Program activities CFR(s): 484.65(c) (1) The HHA's performance improvement activities must— (i) Focus on high risk, high volume, or problem-prone areas; (ii) Consider incidence, prevalence, and severity of problems in those areas; and (iii) Lead to an immediate correction of any identified problem that directly or potentially threaten the health and safety of patients. This STANDARD is not met as evidenced by: Based on record review, and interview, the agency’s performance improvement activities failed to focus on high volume of hospital admissions to consider the severity of the problem that would lead to a correction of the identified problem in 1 of 1 agency. Findings include: An undated policy, titled, “Quality Assurance Performance Improvement Program,” indicated the agency would maintain an ongoing agency wide quality assessment and performance improvement program that would focus on high risk, high volume, and problem prone areas. The policy indicated the agency would take action aimed at performance improvement and after implementing the actions the agency would measure its success and track performance to ensure that improvements were sustained. The policy indicated the performance improvement activities would track adverse patient events, analyze their causes and trends, focus on high risk, high volume, or problem prone areas that would lead to an immediate correction of identified problems that potentially threaten the health and safety of patients, implement preventive actions and develop a plan of correction to prevent events from reoccurring. A Census Report, received on 05/06/2025, indicated the agency’s patient unduplicated census for the last 12 months of skilled patients was 98 with an active patient census of 25. A Hospital Admission Tracking Log, for 05/08/2024 to 05/06/2025, indicated 38 patient hospitalizations, 39% of patient census, hospital that included 8 hospital admissions for 01/01/2025 to 05/06/2025. A Quality Assessment and Performance Improvement Program review on 05/08/2025, failed to evidence the agency identified hospital admission high volume rate to analyze and implement improvement activities that would lead to corrective actions, and after implementing those actions would ensure the improvements were sustained. During an interview on 05/08/2025, beginning at 12:30 PM, the Administrator, Administrative Staff 1, indicated the agency did not implement an agency plan for the elevated hospitalization rate.

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 agency failed to ensure the home health aide provided services that were ordered by the physician and included in the plan of care in 1 of 1 active clinical records reviewed with a home health aide (Patient #2). Findings include: 1. An undated policy, titled, “Home Health Aide Services,” indicated a home health aide worked under the direction of a physician and registered nurse, and the assignment would be made in accordance with a plan of care established by the patient’s physician. 2. A Home Health Aide Plan of Care, for certification period 03/19/2025 to 05/17/2025, for Patient #2 indicated the home health aide should complete shaving Patient at every visit and the home health aide should report a refusal of care. Home Health Aide Visit Notes, for 03/25/2025, 03/28/2025, 04/01/2025, 04/04/2025, 04/08/2025, 04/11/2025, 04/15/2025, 04/18/2025, 04/29/2025, and 05/02/2025 indicated Patient refused to be shaved. The Home Health Aide Visit Notes failed to evidence documentation of Patient’s refusal to be shaved being reported. Home Health Aide Visit Notes, for 04/11/2025 and 04/25/2025, indicated activities completed with Patient included dangling on the side of the bed. The Home Health Aide Plan of Care, for certification period 03/19/2025 to 05/17/2025, failed to evidence activity to dangle on the side of the bed was to be completed. The Home Health Aide Plan of Care, for certification period 03/19/2025 to 05/17/2025, indicated catheter care and emptying of the drainage bag would be completed at every visit. Home Health Aide Visit Notes, for 04/04/2025 and 04/25/2025, indicated catheter care and emptying of the drainage were not completed due to not applicable and failed to evidence documentation of the reason catheter care and emptying of the drainage bag were not completed or that the task assigned was not completed was reported. The Home Health Aide Plan of Care, for certification period 03/19/2025 to 05/17/2025, indicated the home health aide would assist with transfer at every visit. A Home Health Aide Visit Note, dated 04/04/2025, indicated Patient refused assist with transfer and failed to evidence documentation the refusal was reported. A Home Health Aide Visit Note, dated 04/25/2025, indicated not applicable to assist with transfer and failed to evidence documentation of the reason transfer assistance was not provided or that the refusal was reported. During an interview on 05/08/2025, beginning at 1:00 PM, the Administrator, Administrative Staff 1, indicated if a patient refused care the home health aide should report to the nurse and the nurse should follow up with the patient. The Administrator indicated a registered nurse [RN] would instruct the home health aide on the plan of care to identify the care that would provided to the patient by the home health aide. During an interview on 05/08/2025, beginning at 12:15 PM, RN 3 indicated the home health aide should report to the nurse if a patient refused care that was ordered on the aide plan of care. RN 3 indicated a nurse would follow up with a patient if the patient refused home health aide care, and if a home health aide was performing range of motion on a patient and it was not on the plan of care the nurse should update the plan of care to include range of motion if there were no contraindications for the patient.

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 the home health aide supervision by a registered nurse [RN] included that the home health aide was following the patient’s plan of care for completion of tasks in 1 of 1 active clinical records reviewed with a home health aide (Patient #2). Findings include: 1. An undated policy, titled, “Home Health Aide Supervision,” indicated supervisory visits were made to patients by the RN to assure that the home health aide services are being provided in accordance with the plan of care. The policy indicated the RN would assess the home health aide’s provision of services as outlined in the assignment sheet to determine if changes are required. 2. A Home Health Aide Plan of Care, for certification period 03/19/2025 to 05/17/2025, for Patient #2 indicated the home health aide should completed shaving Patient at every visit and the home health aide should report a refusal of care. Home Health Aide Visit Notes, for 03/25/2025, 03/28/2025, 04/01/2025, 04/04/2025, 04/08/2025, 04/11/2025, 04/15/2025, 04/18/2025, 04/29/2025, and 05/02/2025 indicated Patient refused to be shaved. The Home Health Aide Visit Notes failed to evidence documentation of Patient’s refusal to be shaved being reported. Home Health Aide Visit Notes, for 04/11/2025 and 04/25/2025, indicated activities completed with Patient included dangling on the side of the bed. The Home Health Aide Plan of Care, for certification period 03/19/2025 to 05/17/2025, failed to evidence activity to dangle on the side of the bed was to be completed. The Home Health Aide Plan of Care, for certification period 03/19/2025 to 05/17/2025, indicated catheter care and emptying of the drainage bag would be completed at every visit. Home Health Aide Visit Notes, for 04/04/2025 and 04/25/2025, indicated catheter care and emptying of the drainage were not completed due to not applicable and failed to evidence documentation of the reason catheter care and emptying of the drainage bag were not completed or that the task assigned was not completed was reported. The Home Health Aide Plan of Care, for certification period 03/19/2025 to 05/17/2025, indicated the home health aide would assist with transfer at every visit. A Home Health Aide Visit Note, dated 04/04/2025, indicated Patient refused assist with transfer and failed to evidence documentation the refusal was reported. A Home Health Aide Visit Note, dated 04/25/2025, indicated not applicable to assist with transfer and failed to evidence documentation of the reason transfer assistance was not provided or that the refusal was reported. Home Health Aide Supervisory Visits Notes, dated 03/25/2025, 04/01/2025, 04/08/2025, 04/15/2025, 04/29/2025 and 05/06/2025 indicated the home health aide followed the patient’s plan of care for the completion of tasks assigned. The Supervisory Visits failed to evidence documentation of Patient’s refusal to be shaved, catheter care and drainage bag being emptied were not completed, and patient dangling on the side of the bed was completed when the plan of care did not include the assignment. During an interview on 05/08/2025, beginning at 12:15 PM, RN 3 indicated completion of the home health aide supervisory visits were completed by communication with the patient and family to see if they were satisfied with the aide’s care, ensure the aide’s plan of care was being followed, and the RN would follow up with the patient and the aide if care was not being completed as assigned in the aide plan of care. 410 IAC 17-14-1(n)

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the timely documentation of clinical notes in 1 of 3 active clinical records reviewed with PT services. (Patient #3) The findings include: A clinical record review for Patient #3 evidenced Home Health Discharge Orders upon discharge from Entity 2 dated 04/28/2025 which indicated home health services were to include PT. The clinical record review on 05/06/2025 failed to evidence any PT visit notes. On 05/06/2025, at 4:54 PM, the CM indicated PT completed an assessment on 05/01/2025 which was not yet documented. 410 IAC 17-15-1(b)

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102. Survey Dates: 6/27/2022, 6/28/2022, 6/29/2022, 6/30/2022, 7/1/2022, 7/5/2022 Facility ID: 006647

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to develop an emergency preparedness plan that was based on and included a documented facility-based and community-based risk assessment utilizing an all-hazards approach. The findings include: Record review on 6/29/2022, evidenced an emergency preparedness binder which failed to include a documented all-hazards, facility-based and community-based risk assessment. During an interview on 6/29/2022, at 12:15 PM, when queried where the documentation was for the community and facility-based all-hazards risk assessment, administrator/clinical manager A indicated they would have to look to see if they had one. Upon survey exit, no further documentation was provided.

Emergency Officials Contact Information CFR(s): 484.102(c)(2) §403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at §483.73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at §483.475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the emergency preparedness communication plan included contact information for federal and state local emergency preparedness staff. The findings include: Record review on 6/29/2022, evidenced an emergency preparedness binder which failed to include contact information for state or federal emergency preparedness staff. During an interview on 6/29/2022, at 12:45 PM, when queried if the communication plan included contact information for state or federal emergency preparedness staff, administrator/clinical manager A indicated it did not, but she would add state and federal emergency preparedness contact information.

This was a Federal Re-certification, and State re-licensure survey for a home health agency, conducted by the Indiana Department of Health. Survey Dates: 6/27/2022, 6/28/2022, 6/29/2022, 6/30/2022, 7/1/2022, and 7/5/2022. Facility ID: 006647 This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Northwest Home Health Care, Inc. is precluded from providing its own home health aide training and competency evaluation for a period of two years from 7/5/2022 - 7/5/2024, due to being found out of compliance with Conditions of Participation 42CFR 484.60 Care planning, coordination of services, and quality of care. Quality Review Completed 07/14/2022

Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient's status at the time of assessment. This STANDARD is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure OASIS data accurately reflected patient’s status at time of assessment in 3 of 5 active clinical records reviewed. (#1, 4, 5) The findings include: 1. Record review evidenced an undated agency policy obtained 7/5/2022, titled “Encoding and Reporting OASIS Data” which stated, “… Data will reflect patient status at time of assessment ….” 2. Observation of a home visit for patient #1 was conducted on 6/28/2022, at 11:00 AM, to observe a routine home health aide visit. During the visit, the patient ambulated with a walker and standby assist to the bathroom for a shower. The patient was able to stand and change positions with minimal assistance and denied pain. Clinical record review for patient #1 was completed on 7/1/2022, for certification period 5/11/2022 – 7/9/2022. Record review evidenced an OASIS (outcome and assessment information set) Resumption of Care assessment dated 6/3/2022, which stated, “… Height/Weight … [M1060] … Item could not be assessed … For example, patient cannot be weighed because of extreme pain, immobility, or risk of pathological fractures ….” 3. Clinical record review for patient #4 was completed on 7/1/2022, for certification period 6/6/2022 – 8/4/2022. Record review evidenced an OASIS Resumption of Care assessment dated 6/20/2022, which stated, “… Height/Weight … [M1060] … Item could not be assessed … For example, patient cannot be weighed because of extreme pain, immobility, or risk of pathological fractures ….” This document also indicated the patient was ambulatory with a walker, able to sit to stand independently, walked with supervision, and did not have extreme pain. 4. Clinical record review for patient #5 was completed on 7/1/2022, for certification period 6/7/2022 – 8/5/2022. Record review evidenced an OASIS start of care assessment dated 6/7/2022, which stated, “… Height/Weight … [M1060] … Item could not be assessed … For example, patient cannot be weighed because of extreme pain, immobility, or risk of pathological fractures ….” This document indicated the patient was a partial/moderate assist to a sit to stand and did not have extreme pain. During an interview on 7/1/2022 at 10:26 AM, when queried why the OASIS resumption of care assessments indicated the patients could not be weighed, administrator/clinical manager A stated, “… the problem with this is … the computer system will not let us put them in ….” Administrator/clinical manager A indicated the height and weight should be included in the OASIS assessments.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure an initial assessment visit was conducted within 48 hours of referral or on the physician ordered start of care date in 1 of 5 active records reviewed. (#1) The findings include: Record review evidenced an agency policy revised 7/16/2009, titled “… Standards of Practice” which stated, “… Upon acceptance and admission of a patient, the admitting Registered Nurse/Therapist will assign the individual to the appropriately skilled professional … Service will be initiated within 48 hours after the assessment, unless documentation supports alternate plan based on patient needs and wishes and caregiver availability ….” Clinical record review for patient #1 was completed on 7/1/2022, for certification period 1/11/2022 – 3/12/2022. Record review evidenced a referral document dated 1/3/2022, which indicated the agency accepted patient #1 for home health services. Record review evidenced the initial assessment visit was conducted on 1/11/2022, 8 days after referral. Record review failed to evidence the physician had ordered an initial assessment visit on 1/11/2022. During an interview on 7/1/2022 at 10:22 AM, when queried what the time frame was to complete initial assessment visits, administrator/clinical manager A stated, “… Within 24 – 48 hours … if we can’t see the patient … if they cancel … we have a paper document if it was a missed admission order … and we have a physician order that we can’t see the patient ….” When queried why patient #1’s initial assessment was delayed, administrator/clinical manager A stated, “… the patient/family cancelled … I don’t know why ….” 410 IAC 17-14-1(a)(1)(A)

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment accurately reflected the patients’ current health status in 2 of 5 active clinical records reviewed. (#1, 2) The findings include: 1. Record review on 7/5/2022, evidenced an undated agency policy obtained 7/5/2022, titled “Comprehensive Patient Assessment” which stated, “… In addition to general health status/system assessment, Northwest Home Health Care Inc. comprehensive assessment tool will include: … Nutritional status is assessed … High risk indicators may include: … Weight loss of ten pounds in thirty days … Significant underweight or overweight status ….” 2. Clinical record review for patient #1 was completed on 7/1/2022, for certification period 5/11/2022 – 7/9/2022. Record review evidenced a resumption of care/comprehensive re-assessment dated 6/3/2022, which failed to include a height and weight. Record review evidenced a recertification/comprehensive re-assessment dated 5/10/2022, which failed to include a height and weight. During an interview on 7/1/2022, at 10:50 AM, when queried why patient #1’s height and weight was not included in the comprehensive assessment, administrator/clinical manager A indicated there should have been a note indicating why the nurses could not obtain a weight. 3. Clinical record review for patient #2 was completed on 7/1/2022, for certification period 5/20/2022 – 7/18/2022. Record review evidenced a recertification/comprehensive re-assessment dated 5/17/2022, which failed to include a height and weight. During an interview on 7/1/2022, at 10:50 AM, administrator/clinical manager A indicated a height and weight should have been included in comprehensive assessments. 410 IAC 17-14-1(a)(1)(B)

Primary caregiver(s), if any CFR(s): 484.55(c)(6)(i,ii) The patient's primary caregiver(s), if any, and other available supports, including their: (i) Willingness and ability to provide care, and (ii) Availability and schedules; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to include the patient’s available support including their willingness and ability to provide care and availability and schedules in 1 of 5 active clinical records reviewed. (#5) The findings include: Record review evidenced an undated agency policy obtained 7/5/2022, titled “Comprehensive Patient Assessment” which stated, “… In addition to general health status/system assessment … comprehensive assessment tool … will include: … Supportive assistance ….” Clinical record review for patient #5 was completed on 7/1/2022, for certification period 6/7/2022 – 8/5/2022. Record review evidenced a start of care assessment/comprehensive assessment dated 6/7/2022, which stated, “… Caregiver availability/Type of assistance … Family can help if needed ….” This document failed to indicate names of family or their willingness, availability or schedule. During an interview on 7/1/2022, at 12:42 PM, when queried what information was expected to be included in the comprehensive assessment regarding supportive assistance, administrator/clinical manager A indicated the agency always asked the patient who would be available to help with specific tasks, and when they were available to assist. Administrator/clinical manager A indicated they would include it on all comprehensive assessments in the future.

Update of the comprehensive assessment CFR(s): 484.55(d) Standard: Update of the comprehensive assessment. The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient's condition warrants due to a major decline or improvement in the patient's health status, but not less frequently than- This STANDARD is not met as evidenced by: Based on observation, record review, and interview, the agency failed to update the comprehensive assessment due to a major decline in patient’s health status in 1 of 5 active clinical records reviewed. (#3) The findings include: Record review evidenced an undated agency policy obtained 7/5/2022, titled “Patient Reassessment/Update of Comprehensive Assessment” which stated, “… The comprehensive assessment will be updated and revised as often as the patient’s condition warrants due to major decline or improvement in health status ….” Observation of a home visit for patient #3 was conducted on 6/29/2022, at 5:00 PM, to observe a routine skilled nurse visit. The patient was observed to be bedbound, severely obese, alert, oriented, wearing 3 liters of oxygen per nasal cannula, and in a hospital bed. The patient had a nebulizer machine in her lap. Registered nurse B removed dressings to abdomen and left arm, which were dated 6/27/2022. The abdominal wound dressing was 100% soaked in drainage. Registered nurse B indicated the patient received skilled nursing for dressing changes once per week, and the dressings were to be changed daily, which were completed by person B. Patient was observed to have an abdominal wound, which had a copious amount of foul smelling, brown drainage, with macerated skin surrounding; and a large, bright red, very painful wound in the inner forearm extending to the inner, upper arm. During wound care, patient #3 was observed grimacing and yelling out in pain. After prompting from surveyor, registered nurse B laid the patient flat in bed and turned her on her side to assess the skin on her buttocks, which was pink, purple, and scarred. After laying flat and rolling, the patient was repositioned in bed sitting up. At this time, the patient appeared to be short of breath, breathing rapidly, anxious, and was unable to complete a sentence without taking breaths. Patient #3 requested her albuterol (a medicine that opens the airways) nebulizer treatment. Registered nurse B looked, but the patient did not have any more albuterol. Person B (family member) indicated the albuterol had not been delivered by the pharmacy, and they had run out of albuterol the previous day. Patient #3 used a rescue albuterol inhaler instead, and after about 15 minutes, appeared to be in no respiratory distress, and was resting comfortably. Registered nurse B called the pharmacy, which was closed, and indicated they would call again the next day. Clinical record review for patient #3 was completed on 7/5/2022, for certification period 6/21/2022 – 8/19/2022. Record review failed to evidence the agency had performed a comprehensive assessment in response to decline in patient status, including foul smelling wound with copious drainage, respiratory distress, or severe pain. Clinical record review evidenced a communication note dated 6/29/2022, which stated, “… Patient is short of breath every time head of bed is not elevated and when constantly talking. Patient’s wounds has a little bit of foul odor. This is a chronic problem. Coordinated with [physician C] and stated we cannot just keep on giving antibiotics all the time. [Physician C] will see the patient today. SN [skilled nurse] to monitor and check patient’s wounds again next week and [physician C] will decide if she needs to be in hospital ….” During an interview on 7/1/2022, at 11:39 AM, when queried when the agency would complete an updated comprehensive assessment, administrator/clinical manager A stated, “… if there’s a sudden change in patient’s condition or if patient went to the hospital, and every certification ….” When queried why another comprehensive assessment was not completed, administrator/clinical manager A indicated the doctor had been made aware and indicated the nurse should recheck the patient the next week. When queried if the doctor saw the patient, administrator/clinical manager A indicated the doctor did not see the patient but was planning on visiting the next week. 410 IAC 17-14-1(a)(1)(B)

Discharge or Transfer Summary Content CFR(s): 484.58(b)(1) Standard: Discharge or transfer summary content. The HHA must send all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to send all necessary medical information pertaining to the patient’s current course of illness and treatment to the health care practitioner in 1 of 2 discharge records reviewed. (#7) The findings include: Record review evidenced an undated agency policy obtained 7/5/2022, titled “Discharge Summary” which stated, “… The discharge summary will include … diagnosis ….” Clinical record review for patient #7 was completed on 7/5/2022, for certification period 4/8/2022 – 6/6/2022. Record review evidenced a discharge summary dated 6/2/2022, which failed to include the following diagnoses which were included, and addressed with interventions, on the plan of care: hypertension (high blood pressure), rheumatoid arthritis (a type of auto-immune arthritis), irritable bowel syndrome, hyperlipidemia (high cholesterol), and hypothyroidism (low thyroid levels). During an interview on 7/5/2022, at 10:48 AM, when queried what information should be included on the discharge summary, administrator/clinical manager A indicated the discharge summary have included the diagnoses from the plan of care.

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on observation, record review and interview, the home health agency failed to: ensure patients were accepted for care based on the expectation the home health agency was able to meet their needs (see tag G0570); ensure each patient received home health services written in their plan of care and the plan of care was individualized (see tag G0572); ensure the plan of care contained all medications and treatments, diagnoses, medical equipment and nutritional requirements (see tag G0574); ensure all orders were recorded in the plan of care (see tag G0576); ensure services and treatments were administered only as ordered by a physician (see tag G0580); ensure the home health agency staff promptly alerted the primary care physician to changes in the patient’s condition (see tag G0590); and coordinate care delivery to meet the patient’s needs and/or involve the patient in the coordination of care activities (see tag G0608). The cumulative effect of these systemic problems has resulted in the home health agency inability to ensure provision of quality health care in a safe environment for the condition of participation 42 CFR 484.60 Care Planning, Coordination of Services, and Quality of Care. A standard citation was also evidenced at this level as follows: Based on observation, record review, and interview, the agency failed to accept patients based on the expectation that the agency could meet the patient’s medical, nursing, and rehabilitative needs in the patient’s place of residence in 3 of 7 clinical records reviewed. (#1, 3, 6) The findings include: 1. Record review evidenced an agency policy revised 7/16/2009, titled “Standards of Practice” which stated, “… If Northwest Home Health Care, Inc. cannot fulfill the required health care need, a referral will be made to other appropriate community resources and referral source will be notified ….” 2. Clinical record review for patient #1 was completed on 7/1/2022, for certification period 5/11/2022 – 7/9/2022. Record review evidenced a hospital referral dated 6/1/2022, which stated, “… Based on the clinical findings of this encounter, the following services are medically necessary: … skilled nursing … speech language pathology … Based on clinical findings of this encounter, this patient has a need for these skilled services because: … has a functional swallowing disorder ….” Clinical record review evidenced a plan of care for certification period 5/11/2022 – 7/9/2022, dated 6/3/2022, which indicated the patient was to receive skilled nursing once a week for six weeks and home health aide twice a week for 5 weeks. Review failed to evidence speech language pathology orders. During an interview on 6/28/2022, at 11:00 AM, when queried if patient #1 received speech therapy services, person A (patient #1’s family member) indicated the patient had not received speech therapy services. Person A indicated patient #1 had been on thickened liquids after discharge from the hospital, and when they ran out of thickener, the home health nurse observed the patient drink a cup of thin liquids. Person A indicated the home health nurse said patient #1 was fine and did not have any issues swallowing. During an interview on 7/1/2022, at 10:37 AM, when queried why patient #1 did not receive speech language pathology services as ordered on the referral, administrator/clinical manager A stated, “… the hospital is aware that we don’t have a speech therapist … we tell them we can’t take the patient if they need speech ….” 3. Observation of a home visit for patient #3 was conducted on 6/29/2022, at 5:00 PM, to observe a routine skilled nurse visit. The patient was observed to be bedbound, severely obese, alert, oriented, wearing 3 liters of oxygen per nasal cannula, and in a hospital bed. The patient had a nebulizer machine in her lap. Registered nurse B removed dressings to abdomen and left arm, which were dated 6/27/2022. The abdominal wound dressing was 100% soaked in drainage. Registered nurse B indicated the patient received skilled nursing for dressing changes once per week, and the dressings were to be changed daily, which were completed by person B. Patient was observed to have an abdominal wound, which had a copious amount of foul smelling, brown drainage, with macerated skin surrounding; and a large, bright red, very painful wound in the inner forearm extending to the inner, upper arm. Registered nurse B asked patient #3 if patient had a wound clinic appointment yet, and patient #3 indicated she had not. During dressing change to left arm, patient #3 was observed grimacing and yelling in pain. Registered nurse B asked patient when she last took pain medication, and patient indicated the previous day, no further pain assessment was observed. After prompting from surveyor, registered nurse B laid the patient flat in bed and turned her on her side to assess the skin on her buttocks, which was pink, purple, and scarred. After laying flat and rolling, the patient was repositioned in bed sitting up. At this time, the patient appeared to be short of breath, breathing rapidly, anxious, and was unable to complete a sentence without taking breaths. Patient #3 requested her albuterol (a medicine that opens the airways) nebulizer treatment. Registered nurse B looked, but the patient did not have any more albuterol. Person B (family member) indicated the albuterol had not been delivered by the pharmacy, and they had run out of albuterol the previous day. Patient #3 used a rescue albuterol inhaler instead, and after about 15 minutes, appeared to be in no respiratory distress, and was resting comfortably. Registered nurse B called the pharmacy, which was closed, and indicated they would call again the next day. Registered nurse B failed to assess the patient’s vital signs during or after the respiratory distress. The surveyor requested the nurse check the patient’s vitals before exiting the home visit, and the oxygen saturation was 96%. Clinical record review for patient #3 was completed on 7/1/2022, for certification period 4/22/2022 – 6/20/2022 and 6/21/2022 – 8/19/2022. Record review evidenced a referral/discharge summary dated 4/20/2022, which stated, “… Recommendations for placement given skilled need for dressing changes but spoke with both her nephew and her daughter which did not want placement and will have 24-hour care including nurse 3 times a week for dressing changes as well as a home health care doctor ….” This document indicated the wound dressing to abdomen was to be changed every 12 hours and as needed for 50% drainage, and the left arm dressing was to be changed daily and as needed. Record review evidenced a comprehensive assessment/start of care document dated 4/22/2022, for certification period 4/22/2022 – 6/20/2022, which indicated patient received skilled nursing visits 1 time per week for 1 week, 2 times per week for 2 weeks, and 1 time per week for 6 weeks. This document indicated the abdominal wound measured 1.2 cm (centimeters) x 1.0 cm x 0.4 cm. Record review evidenced a comprehensive re-assessment/recertification dated 6/16/2022, for certification period 6/21/2022 – 8/19/2022, which indicated the abdominal wound measured 1.3 cm x 1.2 cm x 0.5 cm. Record review evidenced a plan of care for certification period 6/21/2022 – 8/19/2022, which indicated the patient was to receive skilled nursing visits 1 time per week for 9 weeks. This document indicated the abdominal and left arm dressings were to be changed every 2 days and as needed. Record review failed to evidence the home health agency provided 3 skilled nurse visits per week as ordered on discharge from the hospital. Clinical record review evidenced a communication note dated 1/21/2021, which indicated the home health agency had arranged transportation to wound clinic. Record review failed to evidence any current communication notes regarding transportation to wound clinic. During an interview on 7/1/2022, at 11:28 AM, when queried why patient #3 did not receive 3 skilled nurse visits per week as indicated on the referral order, administrator/clinical manager A indicated it was because the nurses taught the patient’s family member to do the dressing changes instead. When queried why the abdominal wound was larger on the recertification than on the start of care assessment, administrator/clinical manager A stated, “… every visit if there was any change in condition, we always coordinate with the physician … we coordinated with the physician regarding wound status … and it’s documented ….” Administrator/clinical manager A indicated the abdominal wound size always fluctuated, and because patient #3 was not a surgical candidate due to co-morbidities, the wound would never heal. At 11:41 AM, when queried if patient #3 ever went to the wound clinic, administrator/clinical manager A stated, “… she previously went to wound clinic … I called all the ambulance services, and there’s no medical necessity for an ambulance unless she’s going to the hospital … her primary doctor goes to her house and looks at her wounds too … because her wounds won’t ever heal the wound clinic said it’s not necessary ….” At 11:51 AM, when queried what interventions were completed regarding the patient not having albuterol nebulizer, administrator/clinical manager A stated, “… after [registered nurse B] left, we coordinated with the doctor … We called in the morning and at night … I called [person B] to make sure the patient was fine … When she talks she gets shortness of breath … I spoke with the doctor, and he said no he didn’t make a visit, but will visit next week ….” Administrator/clinical manager A indicated the pharmacy delivered patient #3’s albuterol nebulizer on 6/30/2022. When queried how the agency was meeting patient needs if the patient did not receive wound care as initially ordered, wound was not healing, patient could not get transport to wound clinic, patient did not have nebulizer medication available, the nurse did not adequately assess the patient, and the patient experienced respiratory distress, administrator/clinical manager A stated, “… our goal for her is no more further deterioration … no hospitalization … and prevention of further pressure ulcer development ….” Administrator/clinical manager A indicated the nurse should always recheck vitals if a change in patient status was observed. 4. Clinical record review for patient #6 was completed on 7/5/2022, for certification period 11/23/2021 – 1/21/2022. Record review evidenced a start of care assessment dated 11/23/2021, which stated, “… patient agreeable to home healthcare services to include SN [skilled nurse], PT [physical therapy], HHA [home health aide] ….” Record review evidenced a plan of care dated 11/23/2021, for certification period 11/23/2021 – 1/21/2022, which failed to evidence any orders for home health aide services. Record review evidenced a physician order dated 12/20/2021, which stated, “… Request for home health aide to start … frequency 2x5 [twice per week for 5 weeks] ….” Review indicated the agency failed to order home health aide services for 28 days after identifying patient’s need. During an interview on 7/5/2022, at 10:11 AM, when queried why the patient did not receive home health aide services when the need was identified, administrator/clinical manager A indicated the agency should have made an order for whatever discipline was ordered on start of care. 410 IAC 17-13-1(a)

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure the patients received the services written in an individualized plan of care in 3 of 5 active clinical records reviewed. (#1, 2, 3) The findings include: 1. Record review evidenced an undated agency policy obtained 7/5/2022, titled “Coordination of Patient Services” which stated, “… The following are essential components of professional coordination and supervision of services to assigned patients for the ongoing evaluation of the patient’s needs … Appropriate and timely completion of physician orders ….” 2. Record review evidenced an undated agency policy obtained 7/5/2022, titled “Patient Rights” which stated, “… The Patient Rights includes but is not limited to, the patient’s right to: … Receive all services outlined in the plan of care ….” 3. Clinical record review for patient #1 was completed on 7/1/2022. Record review evidenced a plan of care for certification period 5/11/2022 – 7/9/2022, dated 6/3/2022. This document stated, “… Therapy services required for increased functional disability programs … Patient requires skilled intervention of physical therapy for exercises to increase strength and endurance, implementation of safety measures and evaluation for assistive devices due to impaired function or declining functional ability as demonstrated by increased weakness ….” Record review failed to evidence patient received physical therapy services as ordered on the plan of care. During an interview on 7/1/2022, at 10:43 AM, when queried what services the patients should receive, administrator/clinical manager A indicated the patients should receive all the services ordered on the plan of care, as ordered by a physician. When queried why patient #1 did not receive therapy services as ordered on the plan of care, administrator/clinical manager A indicated they had previously provided therapy to patient #1. 4. Clinical record review for patient #2 was completed on 7/1/2022. Record review evidenced a plan of care for certification period 5/20/2022 – 7/18/2022, dated 6/3/2022. This document indicated the patient was to receive skilled nursing care once per week for 9 weeks. Record review evidence the patient failed to receive a skilled nurse visit on 5/21/2022 and 6/7/2022, as ordered on the plan of care. Record review evidenced a missed visit note dated 5/21/2022, which stated, “… Reason: Patient/family cancelled … will reschedule visit: next week ….” Review evidenced a missed visit note dated 6/7/2022, which stated, “… Reason: Patient/family cancelled … will reschedule visit: next week ….” Record review failed to evidence the physician ordered visits to be rescheduled for the following week. During an interview on 7/1/2022, at 11:02 AM, when queried how the agency handled missed visits, administrator/clinical manager A stated, “… for rescheduling a missed visit … when the nurse calls the patient and patient wants to reschedule, we make a schedule … If the patient doesn’t want to reschedule we create a missed visit ….” Administrator/clinical manager A indicated the physician would be notified of a missed visit, but an order was not required to reschedule for the next week. When queried why patient #2 cancelled his nursing visits, administrator/clinical manager A stated, “… I will start giving reasons why … sometimes they don’t give me reasons … but I will add documentation now … I don’t know why he cancelled ….” 5. Observation of a home visit for patient #3 was conducted on 6/29/2022, at 5:00 PM, to observe a routine skilled nurse visit. During the visit, the patient was observed to be alert, oriented, severely obese, wearing 3 liters of oxygen per nasal cannula, and bedbound. Registered nurse B asked patient #3 how her pain is, but failed to ask patient for any descriptors, location, or rating, and failed to instruct patient in measures to mitigate her pain. Registered nurse B asked patient #3 when she last took pain medication, and the patient indicated the previous day. The patient was observed to have a small abdominal wound with a copious amount of brown, foul smelling drainage, and macerated surrounding skin. Patient had a large wound to left interior forearm and left interior upper arm, in the crease of the elbow, with a bright red wound bed, and clear/bloody drainage. When registered nurse B attempted to remove the old dressing from the left arm wounds, patient #3 was observed grimacing, and yelling/crying out in pain at the slightest touch to the wound. During the visit, registered nurse B failed to perform a complete physical assessment to include assessment of pedal pulses, peripheral edema, and a pain assessment. Registered nurse B failed to complete a full skin assessment, including skin on buttocks, sacrum, and ischium, failed to apply Vitamin A and D ointment to buttocks, sacrum, and ischium, and failed to assess skin on back or heels. At 5:50 PM, registered nurse B began cleaning up the wound care supplies and packing to leave the home visit. At this time, surveyor requested registered nurse B to assess the patient’s skin on bottom. Registered nurse B rolled patient on her side, and surveyor observed the skin to buttocks, which was scarred, pink, and purple. Clinical record review for patient #3 was completed on 7/1/2022. Record review evidenced a plan of care dated 6/27/2022, for certification period 6/21/2022 – 8/19/2022. This document included but was not limited to the following orders for skilled nursing: notify physician of pain level greater than 5, monitor and mitigate pain, perform complete physical assessment each visit, notify physician of any potential problems that impede completion of patient recovery and desired goals, assess integumentary status, cleanse wound on sacrum (bone at base of spine) to ischium (bottom pelvic bones) with normal saline, pat dry, apply Vitamin A and D ointment daily, and cleanse wound on left and right buttocks with normal saline, pat dry, apply Vitamin A and D ointment daily. Record review failed to evidence physician was notified of extreme level of pain to left arm during dressing changes. During an interview on 7/1/2022, at 11:37 AM, when queried what nurse should do to mitigate pain as ordered on the plan of care, administrator/clinical manager A indicated the nurse should call the patient before going to the visit for wound care and instruct patient to take pain medication to mitigate pain. Administrator/clinical manager A indicated the physician should be notified if the pain is greater than a 5. At 11:55 AM, when queried what a complete assessment should include, administrator/clinical manager A stated, “… we do a head-to-toe assessment, I always ask so I can get the supplies … Full body assessment, check for pressure ulcers, open wounds, and check with the doctor … If there are wounds, we use the wound worksheet, the type of wound, size, type of wound, dressing type ….” Administrator/clinical manager A indicated a complete assessment should have included checking pulses, heart rate, blood pressure, and edema. Administrator/clinical manager A stated, “… Usually we always do a full assessment and a full skin assessment. 410 IAC 17-13-1(a)

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 agency failed to ensure the plan of care included nutritional requirements, type of supplies or equipment required, all medications and treatments, and/or all pertinent diagnoses in 4 of 5 active clinical records reviewed. (#1, 2, 3, 4) The findings include: 1. Record review evidenced an undated agency policy obtained 7/5/2022, titled “Plan of Care” which stated, “… The plan of care shall be completed in full to include: … All pertinent diagnosis … Type of services, supplies, equipment required … The frequency, and duration of all visits to be made … Specific dietary or nutritional requirements or restrictions … All medications, treatments, and procedures … All patient care orders, including verbal orders, must be recorded in the plan of care ….” 2. Clinical record review for patient #1 was completed on 7/1/2022, for certification period 5/11/2022 – 7/9/2022. Record review evidenced a hospital referral order dated 6/1/2022, which indicated the patient had a swallowing disorder, required home health speech therapy services, and was on a thickened liquid diet. Review of a plan of care for certification period 5/11/2022 – 7/9/2022, dated 6/3/2022, failed to include nutritional requirements of thickened liquids. During an interview on 6/28/2022, at 11:00 AM, person A (patient #1’s family member) indicated patient #1 was on thickened liquids following hospital discharge on 6/1/2022. During an interview on 7/1/2022, at 10:40 AM, when queried what nutritional requirements patient #1 should have included on their plan of care, administrator/clinical manager A indicated the plan of care should include the thickened liquid requirements. 3. Observation of a home visit for patient #2 was conducted on 6/29/2022, at 2:30 PM to observe a routine physical therapy visit. During the visit, the patient was observed to have a commode in use. Clinical record review for patient #2 was completed on 7/1/2022. Record review evidenced a plan of care for certification period 5/20/2022 – 7/18/2022 which failed to include a commode under durable medical equipment and supplies. During an interview on 7/1/2022, at 11:10 AM, when queried what equipment should be included on the plan of care, administrator/clinical manager A stated, “… whatever the patient is using … I even include what patient is not using … It’s included on the plan of care ….” 4. Observation of a home visit for patient #3 was conducted on 6/29/2022, at 5:00 PM, to observe a routine skilled nurse visit. The patient stated during the visit that she got dizzy when repositioning. Clinical record review for patient #3 was completed on 7/1/2022, for certification periods 4/22/2022 – 6/20/2022 and 6/21/2022 – 8/19/2022. Record review evidenced a referral order dated 4/20/2022, which evidenced the following diagnoses, which were not included on the patient’s plan of care: deep vein thrombosis (blood clot in vein), GI bleed (bleeding in stomach), and hypotension (low blood pressure). During an interview on 7/1/2022, at 11:26 AM, when queried which diagnoses should be included on the plan of care, administrator/clinical manager A stated, “… whatever has the biggest impact on the patient … her biggest/most severe problems ….” 5. Clinical record review for patient #4 was completed on 7/1/2022, for certification period 6/6/2022 – 8/14/2022. Record review evidenced a discharge summary/referral order dated 6/17/2022, which indicated the patient was discharged on the following medications not included in the plan of care: ciprofloxacin (antibiotic) and hydrocodone-acetaminophen (pain medication). Clinical record review evidenced a comprehensive re-assessment/resumption of care assessment completed on 6/20/2022, which stated, “… Also noted the day after he was released he had ER visit due to gout [disease causing joint pain] flare up and has also started prednisone [medication for inflammation] ….” Record review failed to evidence diagnosis of gout on plan of care. During an interview on 7/1/2022, at 12:21 PM, when queried why patient #4’s plan of care did not include all medications, administrator/clinical manager A indicated every recertification or resumption of care the agency updates the patient’s medication list, typically by reviewing the discharge medication list, and updating as necessary. At 12:30 PM, when queried if the diagnosis of gout should be on this patient’s plan of care, administrator/clinical manager A stated, “… we expect the pertinent diagnoses to be listed if it doesn’t affect the patient then sometimes won’t be on there ….” 410 IAC 17-13-1(a)(1)(B) 410 IAC 17-13-1(a)(1)(C) 410 IAC 17-13-1(a)(1)(D)(ii, viii, ix)

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 patient care orders were recorded on the plan of care in 1 of 3 home visits conducted. (#3) The findings include: Record review evidenced an undated agency policy obtained 7/5/2022, titled “Plan of Care” which stated, “… All patient care orders, including verbal orders, must be recorded in the plan of care ….” Clinical record review for patient #3 was completed on 7/5/2022, for certification periods 4/22/2022 – 6/20/2022 and 6/21/2022 – 8/19/2022. Record review evidenced a referral order dated 4/20/2022, which included the following wound care treatment orders, which were not included on the plan of care: Cavilon (barrier ointment for skin protection) to skin surrounding abdominal wound and to buttocks, sacrum (bone at base of spine), and ischium (bones forming the base of the pelvis), Venelex (skin cream for wound treatment) to heels, feet, elbows, and posterior ears, and Micotin (antifungal powder) powder and Kaltostat (absorbent wound dressing) to breast and groin skin folds. During an interview on 7/1/2022, at 11:26 AM, when queried why Cavilon, Micotin, Venelex and Kaltostat were not included on the plan of care, administrator/clinical manager A stated, “… let me check … the particular day we admitted her there was no open areas or redness, but we always coordinate with the doctor if it needs to be ordered ….”

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure services and treatments were administered only as ordered by a physician in 2 of 5 active clinical records reviewed. (#1, 4) The findings include: 1. Record review evidenced an undated agency policy obtained 7/5/2022, titled “Plan of Care” which stated, “… Home care services are furnished under the supervision and direction of the patient’s physician ….” 2. Clinical record review for patient #1 was completed on 7/1/2022, for certification period 5/11/2022 – 7/9/2022. Record review evidenced a hospital referral order dated 6/1/2022, which indicated the patient had a swallowing disorder, required home health speech therapy services, and was on a thickened liquid diet. Review of a plan of care for certification period 5/11/2022 – 7/9/2022, dated 6/3/2022, failed to evidence any orders for a swallow evaluation by the home health nurse. During an interview on 6/28/2022, at 11:00 AM, person A (patient #1’s family member) indicated patient #1 was on thickened liquids following hospital discharge on 6/1/2022. Person A indicated when patient #1 ran out of thickener for fluids, a nurse from the home health agency observed the patient drink thin liquids and the nurse said the patient was fine and didn’t have any problems swallowing. Person A indicated patient drank thin liquids and a regular diet after nurse evaluation. During an interview on 7/1/2022, at 10:40 AM, when queried what treatments the nurses should be providing to patients, administrator/clinical manager A indicated they should be performing the orders ordered by the physician and included on the plan of care. 3. Clinical record review for patient #4 was completed on 7/1/2022, for certification period 6/6/2022 – 8/4/2022. Record review evidenced a resumption of care assessment dated 6/20/2022, which stated, “… pt [patient] is due to have foley [catheter inserted into the urethra to drain urine] removed today and was done so with no complications ….” Record review evidenced a plan of care for certification period 6/6/2022 – 8/4/2022, which failed to include an order for the skilled nurse to remove the foley catheter. During an interview on 7/1/2022, at 12:34 PM, when queried why the nurse removed the foley if there was no order, administrator/clinical manager A stated, “… the plan of care has not been sent yet, but we will send it and always make orders for interventions ….” 410 IAC 17-13-1(a)

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the agency failed to promptly alert the physician to any changes in patients’ condition or needs which suggested outcomes were not being achieved, or the plan of care needed to be altered in 2 of 3 home visits conducted. (#1, 3) The findings include: 1. Record review evidenced an undated agency policy obtained 7/5/2022, titled “Plan of Care” which stated, “… Professional staff shall promptly alert the physician to any changes that suggest a need to alter the Plan of Care ….” 2. Observation of a home visit for patient #1 was conducted on 6/28/2022, at 11:00 AM, to observe a routine home health aide visit. During the visit, the patient was observed to have 3+ pitting edema (swelling that when pressed, leaves an indentation of 5–6 mm that takes up to 30 seconds to rebound) to bilateral feet and ankles. During the visit, the patient was observed to have a purple/brown, scabbed area to top of third toe. Clinical record review for patient #1 was completed on 7/1/2022. Record review evidenced two comprehensive re-assessments dated 5/10/2022, and 6/3/2022, for certification period 5/11/2022 – 7/9/2022. These documents indicated patient did not have any edema (swelling) to lower legs or feet and indicated patient’s skin was intact at time of assessment. Review evidenced a skilled nurse visit note dated 5/17/2022, which indicated the patient had non-pitting edema to bilateral lower extremities. Review failed to evidence the physician was notified of new edema on 5/17/2022, or 6/28/2022, visit. Record review failed to evidence the physician was notified of scabbed area to top of right third toe during 6/28/2022, home visit. During an interview on 7/1/2022, at 10:54 AM, when queried if the physician was notified of new edema, administrator/clinical manager A stated, “… They always coordinate with the doctor … maybe it’s on and off again for his edema … and we would document that the edema is on and off ….” At 10:55 AM, when queried what the agency considers a wound, administrator/clinical manager A stated, “… Any disruption in the skin is considered a wound ….” When queried about scabbed area to third toe observed during home visit and if the physician was notified, administrator/clinical manager A stated, “… we always coordinate with the physician … maybe it’s new … but I’ll check … any new change in the skin we document and coordinate with the physician ….” 3. Observation of a home visit for patient #3 was conducted on 6/29/2022, at 5:00 PM, to observe a routine skilled nurse visit. During the visit, the nurse performed wound care to a left arm wound. Patient was observed grimacing and yelling out in pain with any slight touch to wound. Registered nurse B asked patient when she last took pain medication, and patient indicated the day before. Clinical record review for patient #3 was completed on 7/5/2022. Record review evidenced a plan of care for certification period 6/21/2022 – 8/19/2022, which stated, “… Patient’s activity level will improve due to effective pain control by/within 8/19/2022 … Patient will attain optimal effectiveness of pain management regimen … Patient/Caregiver will demonstrate ability to manage pain medication regimen ….” Record review evidenced a communication note dated 6/29/2022, which failed to evidence the physician was notified of patient’s severe pain and need for plan of care to be altered to meet patient’s needs. During an interview on 7/1/2022, at 11:37 AM, when queried if the physician was notified of patient’s high level of pain, and need for plan of care to be altered, administrator/clinical manager A stated, “… the doctor was aware, and we always instruct the family members to give pain medications to the patient before the visits … I will ask the nurse if she needs stronger medication for pain and to get an order from the doctor ….” 410 IAC 17-13-1(a)(2)

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to coordinate care delivery to meet the patient’s needs and/or involve the patient in the coordination of care activities in 1 of 5 active clinical records reviewed. (#5) The findings include: Record review evidenced an undated agency policy obtained 7/5/2022, titled “Coordination of Patient Services” which stated, “… The following are essential components of professional coordination and supervision of services to assigned patients for the ongoing evaluation of the patient’s needs: … Maintaining efficient communications with patient, family, physician and all care providers to ensure prompt transmission of significant information that may require immediate action or decision-making … Coordinating with patient, family and caregivers and all involved services to unify and maximize their contributions to ensure patient safety, comfort and benefits of services ….” Clinical record review for patient #5 was completed on 7/1/2022. Record review evidenced a plan of care for certification period 6/7/2022 – 8/5/2022, which indicated the patient was to receive skilled nursing services 2 times per week for 1 week and 1 time per week for 8 weeks for wound care to right 4th toe and left heel, and home health aide services 1 time per week for 9 weeks. This document indicated the patient went to dialysis and also a wound clinic for wound care treatment to his left heel. The plan of care failed to indicate which days patient went to wound clinic or dialysis, and failed to indicate location or specific contact information for dialysis clinic or wound clinic. Record review evidenced a physical therapy plan of care for certification period 6/7/2022 – 8/5/2022, which indicated the patient was to receive physical therapy services 2 times per week for 3 weeks, and 1 time per week for 3 weeks. Record review indicated the patient only received 1 physical therapy visit the week of 6/12/2022, and failed to receive any home health aide, skilled nurse, or physical therapy visits for week of 6/19/2022 and 6/26/2022. Record review evidenced missed visit notes for dates 6/16/2022, 6/21/2022, 6/23/2022 and 6/28/2022, which all stated, “… Patient/family cancelled ….” These notes failed to include any additional information regarding reason patient cancelled. Record review failed to evidence any coordination or documentation from the wound clinic or dialysis clinic. During an interview on 7/1/2022, at 12:30 PM, administrator/clinical manager A indicated patient #5 went to wound clinic on Thursdays or Fridays. When queried which days patient went to dialysis, administrator/clinical manager A stated, “… I think, if I’m not mistaken Monday, Wednesday, and Friday … I’ll double check with the nurse ….” At 12:40 PM, when queried how the agency coordinated care for patients who have multiple disciplines and other services, administrator/clinical manager A stated, “… for him it is very difficult … I speak with him … say this is the day the nurse will go … tell the other disciplines to not go that day, to spread out … in case he always cancels, we coordinate with the doctor for the meantime to d/c [discontinue] the therapy … He cooperates when therapy is there ….” At 12:47 PM, when queried how the agency coordinated care with the wound clinic, administrator/clinical manager A stated, “… we coordinate as needed and at least every 30 days … We always give them our information if they want to coordinate with us … we always get papers from the wound clinic, and I’m going to ask now … I think we don’t have them yet … but the nurse called wound clinic ….” When queried which wound clinic patient went to, administrator/clinical manager A indicated she didn’t know which one exactly. 410 IAC 17-14-1(a)(1)(F) 410 IAC 17-14-1(c )(6)

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure patients received written medication schedule/instructions which included all of the medication names, dosages, and frequency in 3 of 3 home visits conducted. (#1, 2, 3) The findings include: 1. Record review evidenced an undated agency policy obtained 7/5/2022, titled “Plan of Care” which stated, “… Northwest Home Health Inc. Shall provide the patient and caregiver with a copy of written instructions outlining: … Patient medication schedule/instructions, including medication name, dosage and frequency and which medications will be administered by the NHHC, INC. Personnel and personnel acting on behalf of the agency ….” 2. Observation of a home visit for patient #1 was conducted on 6/28/2022, at 11:00 AM, to observe a routine home health aide visit. During the visit, a home health binder was reviewed which contained a medication list. This medication list failed to include the following medications which were ordered on the plan of care: ferrous sulfate (iron), Triflora Arthritis Gel (gel for arthritis pain), probiotic (for digestive health), Imodium (for diarrhea), and acetaminophen (for pain). During an interview on 7/1/2022, at 10:53 AM, when queried why the written medication schedule in patient’s home did not include all medications ordered, administrator/clinical manager A stated, “… I will enforce with my nurses ….” At 10:20 AM, when queried how the agency provides written instructions for medications to patients, administrator/clinical manager A stated, “… The nurse fills out a medication list in the patient’s chart … they look at all the bottles … if there are new medications, we update their medication profile ….” 3. Observation of a home visit for patient #2 was conducted on 6/29/2022, at 2:30 PM, to observe a routine physical therapy visit. During the visit, a home health binder was reviewed, which contained a medication list. The medication list failed to include Flonase (for stuffy nose), which was included on the patient’s plan of care. 4. Observation of a home visit for patient #3 was conducted on 6/29/2022, at 5:00 PM, to observe a routine skilled nurse visit. During the visit, a home health binder was reviewed, which contained a medication list. The medication list failed to include Protonix (medication for stomach acid), which was on the patient’s plan of care medication list. During an interview on 7/1/2022, at 11:20 AM, when queried which medications were included on patients’ written medication instructions, administrator/clinical manager A indicated all medications should have been included.

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 agency failed to provide a copy of a written plan of care in 1 of 3 home visits conducted. (#1) The findings include: Record review evidenced an undated agency policy obtained 7/5/2022, titled “Plan of Care” which stated, “… Northwest Home Health Care Inc. shall provide the patient and caregiver with a copy of written instructions outlining: … Any treatments to be administered by NHHC, INC. personnel acting on behalf of NHHC, INC. including therapy services ….” Observation of a home visit for patient #1 was conducted on 6/28/2022, at 11:00 AM, to observe a routine home health aide visit. During the visit, a home health binder was reviewed. This binder failed to evidence a current plan of care or written instructions regarding treatments to be administered by home health personnel. During an interview on 7/1/2022 at 10:17 AM, when queried what written information the agency provided to patients regarding treatments to be administered, administrator/clinical manager A indicated the agency provided patients with a written plan of care document. When queried why patient #1 did not have a written plan of care document, administrator/clinical manager A indicated they did not know, all patients should receive one.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to accurately prepare clinical notes in 1 of 5 active clinical records reviewed. (#1) The findings include: Record review evidenced an undated agency policy obtained 7/5/2022, titled “Skilled Nursing Services” which stated, “… The registered nurse … prepare clinical notes ….” Record review evidenced an agency policy revised 7/16/2009, titled “Clinical Records” which stated, “… All entries recorded in the record must be legible and accurate ….” Clinical record review for patient #1 was completed on 7/1/2022. Record review evidenced a plan of care for certification period 5/11/2022 – 7/9/2022, which indicated the patient received skilled nursing and home health aide services. Record review evidenced a transfer summary dated 5/24/2022, which indicated the patient received skilled nursing, home health aide, and physical therapy services. Clinical record review on 7/1/2022, evidenced a skilled nurse visit dated 5/17/2022, which stated, “… Patient requires skilled intervention of physical therapy to teach and train patient/caregiver on exercises to increase strength and endurance, implementation of safety measures and use of assistive devices due to impaired function or declining functional ability to perform ADL’s/IADL’s [activities of daily living/instrumental activities of daily living] safely ….” During an interview on 7/1/2022, at 10:24 AM, when queried why patient #1’s transfer summary indicated they received physical therapy services when they were not, administrator/clinical manager A indicated they had included physical therapy services on the transfer summary because the patient had previously received therapy services. Administrator/clinical manager A indicated the patient was not receiving physical therapy during the certification period pertinent to the transfer summary. At 10:43 AM, when queried why the skilled nurse visit note indicated patient needed therapy services, which were not provided, administrator/clinical manager A stated, “… I think it was just carried over from the previous notes … I will check ….” 410 IAC 17-14-1(a)(1)(E)

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure communication with all physicians involved in the plan of care as related to the current plan of care in 1 of 5 active clinical records reviewed. (#4) The findings include: Record review evidenced an undated agency policy obtained 7/5/2022, titled “Medical Supervision” which stated, “… Northwest Home Health Care, Inc. Responsibilities include: … Periodic updates on patient condition/progress … Confidential and accurate communication about patients … Prompt reporting of a change in patient condition ….” Clinical record review for patient #4 was completed on 7/1/2022, for certification period 6/6/2022 – 8/4/2022. Record review evidenced a referral/discharge summary dated 6/17/2022, which included the following medications not included on the patient’s plan of care or medication list: ciprofloxacin (antibiotic) and hydrocodone-acetaminophen (pain medication). This document indicated patient was to stop taking Bactrim (antibiotic), which was included in plan of care. Record review failed to evidence any communication with physician regarding medication list discrepancy on discharge orders and plan of care. During an interview on 7/1/2022, at 12:29 PM, when queried if the physician was notified, administrator/clinical manager A stated, “… yes they should be, but I’ll see if it’s documented ….” 410 IAC 17-14-1(a)(1)(G)

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure a registered nurse made supervisory visits at least every 14 days in 1 of 5 active clinical records reviewed. (#2) The findings include: Record review evidenced an agency policy revised 7/16/2009, titled “Supervision of Staff” which stated, “… When patients are receiving skilled nursing services in addition to personal care, the registered nurse will make an onsite supervisory visit to the patient’s residence at least every two weeks either when the aide is present to observe and assist, or when the aide is absent, to assess the relationship and determine whether the goals are being met ….” Clinical record review for patient #2 was completed on 7/1/2022, for certification period 5/20/2022 – 7/18/2022. Record review evidenced a plan of care dated 6/2/2022, for certification period 5/20/2022 – 7/18/2022 which indicated the patient was receiving home health aide services twice per week, skilled nursing services once per week, and physical therapy services once per week. Record review failed to evidence any supervisory visits were conducted during the certification period. During an interview on 7/1/2022, at 11:00 AM, when queried how often supervisory visits were completed, administrator/clinical manager A stated, “… every week … the rule is 2 weeks … but we do every week for best practice ….” When queried why patient #2 had no supervisory visits completed, administrator/clinical manager A stated, ”… we always have them … it’s really weird why they aren’t in there ….”