Every finding on record at Nurses and More, Inc

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102 Survey Dates: 11/12/2024, 11/13/2024, 11/14/2024 Active Census: 15 At this Emergency Preparedness survey, Nurses and More, Inc was not found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 484.102 QR completed by Area 3 on 11-25-2024.

Establishment of the Emergency Program (EP) CFR(s): 484.102 §403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.542, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must establish and maintain a [comprehensive] emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements: * (Unless otherwise indicated, the general use of the terms "facility" or "facilities" in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This CONDITION is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive emergency preparedness program met all requirements to ensure the health, safety, and security needs of their staff and patient population for 1 of 1 agency (E0001); failed to ensure an emergency preparedness plan was in place and reviewed every 2 years at minimum (E0004); failed to ensure a facility based and community based risk assessment utilizing an all-hazards approach (E0006); failed to ensure the agency had a plan for subsistence needs for staff or patients, whether they evacuated or sheltered in place: failed to ensure access to a plan or a system / defined procedure to track the location of on-duty staff and sheltered patients under the agency’s care during an emergency (E0021); failed to provide a primary and alternate means for communicating with Federal, State, tribal, regional, and local emergency management agencies (E0032); failed to provide emergency preparedness training at least every 2 years and maintain documentation of all emergency preparedness training (E0032), and failed to conduct exercises to test the emergency plan annually by participating in a full scale exercise that is community based every 2 years, and conducting an additional exercise /mock drill or tabletop exercise, opposite the year of the full scale exercise (E0039). The cumulative effect of these systematic problems resulted in the agency being out of compliance with the condition, Emergency Preparedness Requirements for Medicare Participating Providers and Suppliers for Home Health Agencies, at 42 CFR 484.102. Findings include: 1.A 2021 agency policy titled “Comprehensive Emergency Management Plan (CEMP)” dated 04/04/2021, indicated but was not limited to, “ … purpose is to effectively plan for, manage, and respond to natural or man-made emergencies and restore Agency operations to pre-emergency status as effectively as possible . . . The plan is reviewed and updated every 2 years … leadership of the Agency performs a Hazard Vulnerability Analysis at least annually to identify potential emergencies that could impact patient services . . . other community home care agencies will be contacted to determine their availability to provide care to the Agency’s patients . . . The Agency maintains a current, up-to-date list of phone numbers and contact information for staff, entities providing services under arrangement . . . plan includes a process for cooperation and collaboration with local, tribal, regional, state, and federal emergency preparedness officials . . . Staff receives training about the company’s Emergency Management Plan . . . during orientation and at least annually . . . The company shall conduct an annual emergency practice drill, either in cooperation with or independent of community agencies . . . When a community-based exercise is not accessible organization will conduct an individual, facility-based exercise no less than every 2 years . . .”. 2. A review of the agency’s emergency preparedness (EP) binder dated 2021 failed to ensure an EP plan was reviewed and updated every 2 years at a minimum, failed to ensure a community based risk assessment utilizing an all hazards approach, failed to ensure the agency had a plan for subsistence needs for staff and patients, whether they evacuated or sheltered in place, failed to evidence a system to track the location of on-duty staff and sheltered in place patients, failed to provide a primary and alternate means for communicating with Federal, State, tribal, regional, and local emergency management agencies, and failed to evidence documentation of training provided. 3. During an interview on 11/12/2024 at 3:40 PM, Administrative staff # 2 indicated the EP program was last updated in 2021. The agency had no contact information for Federal, state, tribal, regional, and local emergency management agencies, no updated staff contact information, had not designated another agency to assist during an emergency, no documentation of annual training, and no community-based or facility-based risk assessments have been completed since 2021. The agency had not conducted emergency drills or tabletop exercises.

This visit was for a Federal Recertification and State Re-Licensure survey of a Home Health Provider. Survey Dates: 11/12, 11/13, and 11/14/2024 12-Month Unduplicated Skilled Admissions: 13 Survey was fully extended on 11/14/2024 During this Federal Recertification Survey, Nurses and More, Incorporated was found to be out of compliance with Conditions of Participation §484.45 Reporting OASIS Information, 484.55 Comprehensive Assessment of Patients, 484.60 Care Planning, Coordination, and Quality of Care, 484.65 Quality Assessment Performance Improvement, 484.105 Organization and Administration, and 484.102 Emergency Preparedness. Based on the Condition-level deficiencies during the 11/14/2024 survey, your HHA was subject to a partial or extended survey pursuant to section 1891(c)(2)(D) of the Social Security Act on 11/14/2024. Therefore, and pursuant to section 1891(a)(3)(D)(iii) of the Act, your agency is precluded from operating a home health aide training, skills competency, and/or competency evaluation program for a period of two years beginning November 14, 2024, and continuing through November 13, 2026. This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Abbreviations: RN Registered Nurse POC Plan of Care LPN Licensed Practical Nurse SOC Start of Care HHA Home Health Aide ROC Resumption of Care DON Director of Nursing CM Clinical Manager LPN Licensed Practical Nurse EMR Electronic Medical Record ADLs Activities of Daily Living EP Emergency Preparedness OASIS Outcome and Assessment Information Set QR completed by Area 3 on 11-25-2024.

Reporting OASIS information CFR(s): 484.45 Condition of participation: HHAs must electronically report all OASIS data collected in accordance with §484.55. This CONDITION is not met as evidenced by: Based on record review and interview, the agency failed to transmit any skilled Medicare or Medicaid patients utilizing federally funded health plans, not meeting the exceptions to the transmittal requirement in 1 of 1 agency. The cumulative effect of this systemic problem resulted in the home health agency's inability to ensure the provision of quality health care in a safe environment for the Condition of Participation of 42 CFR 484.45, Reporting of OASIS information. Findings Include: 1. Review of an agency policy dated 2020, titled “OASIS Collection/Transmission,” indicated but was not limited to, “The agency shall encode and be capable of accurately transmitting OASIS data for each applicable patient within seven days of completing the OASIS data set electronically … OASIS are collected, encoded, and transmitted on all Medicare and Medicaid patients receiving skilled services ….” 2. Review of Nurses and More IQIES report titled, “OASIS Agency Final Validation” report period, 11/08/2023 through 11/08/2024, evidenced the agency’s last submission date and time of 03/04/2024 at 15:16:45. 3. Review of an agency document titled “View Validation Reports” generated from the agency's electronic medical record system indicated no OASIS files were uploaded from 04/01/2024 to 11/14/2024. During an interview on 11/13/2024 at 1:45 PM, the DON confirmed they were responsible for submitting OASIS data. The DON further indicated they had not been submitting OASIS due to a lack of training, and the last OASIS submissions were completed at the end of March before the previous Clinical Manager left.

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to submit OASIS within 30 days of assessment completion for 14 of 14 qualified active skilled records reviewed (Patients: #1, 2, 4, 5, 9, 10, 12, 13, 14, 15, 16, 17, 18, and 19), and 3 of 3 qualified inactive records reviewed (Patients: # 6, 7, and 8) where OASIS information was collected and transmitted. Findings include: 1. Review of an agency policy dated 2020, titled “OASIS Collection/Transmission” indicated but was not limited to, “The agency shall encode and be capable of accurately transmitting OASIS data for each applicable patient within seven days of completing the OASIS data set electronically … OASIS are collected, encoded, and transmitted on all Medicare and Medicaid patients receiving skilled services ….” 2. Review of OASIS submission reports indicated the agency failed to provide evidence of any skilled OASIS submissions from 03/2024 to 11/14/2024. 3. Review of the active clinical record for Patient #1 with a SOC 07/08/2023, contained a POC for the recertification period 08/31/2024 to 10/29/2024. The agency failed to evidence that OASIS submission occurred within 30 days of completion. Review of OASIS Review of Nurses and More IQIES report titled “OASIS Agency Final Validation” reporting period 11/08/2023 through 11/08/2024, failed to evidence any OASIS assessments submitted for Patient #1. 4. Review of the active clinical record for Patient #2 with a SOC 03/05/2022, contained a POC for the recertification period 10/20/2024 to 12/18/2024. The agency failed to evidence that OASIS submission occurred within 30 days of completion. Review of OASIS Review of Nurses and More IQIES report titled “OASIS Agency Final Validation” reporting period 11/08/2023 through 11/08/2024, evidenced the last OASIS recertification assessment dated 02/19/2024 was submitted on 03/04/2024, but failed to evidence any further OASIS reassessments submitted for Patient #2. 5. Review of the active clinical record for Patient #4 with a SOC 03/17/2021, contained a POC for the recertification period 08/02/2024 to 10/26/2024. The agency failed to evidence that OASIS submission occurred within 30 days of completion. Review of OASIS Review of Nurses and More IQIES report titled “OASIS Agency Final Validation” reporting period 11/08/2023 to 11/08/2024, evidenced the last OASIS recertification assessment dated 02/25/2024 was submitted on 03/04/2024, but failed to evidence any further OASIS reassessments submitted for Patient #4. 7. Review of the active clinical record for Patient #5 with a SOC 02/23/2021, contained a POC for the recertification period 10/05/2024 to 12/03/2024. The agency failed to evidence that OASIS submission occurred within 30 days of completion. Review of OASIS Review of Nurses and More IQIES report titled, “OASIS Agency Final Validation” reporting period 11/08/2023 to 11/08/2024, evidenced the last OASIS recertification assessment dated 02/05/2023 was submitted on 01/15/2024, but failed to evidence any further OASIS reassessments submitted for Patient #5. 8. Review of the active clinical record for Patient #9 with a SOC 01/28/2021, contained a POC for the recertification period 09/09/2024 to 11/07/2024. The agency failed to evidence that OASIS submission occurred within 30 days of completion. Review of OASIS Review of Nurses and More IQIES report titled “OASIS Agency Final Validation” reporting period 11/08/2023 to 11/08/2024, evidenced the last OASIS recertification assessment dated 01/01/2024 was submitted on 01/15/2024, but failed to evidence any further OASIS reassessments submitted for Patient #9. 9. Review of the active clinical record for Patient #10 with a SOC 01/20/2021, contained a POC for the recertification period 10/31/2024 to 12/29/2024. The agency failed to evidence that OASIS submission occurred within 30 days of completion. Review of OASIS Review of Nurses and More IQIES report titled “OASIS Agency Final Validation” reporting period 11/08/2023 to 11/08/2024, evidenced the last OASIS recertification assessment dated 02/29/2024 was submitted on 03/04/2024, but failed to evidence any further OASIS reassessments submitted for Patient #10. 10. Review of the active clinical record for Patient #12 with a SOC 08/10/2023, contained a POC for the recertification period 10/03/2024 to 12/01/2024. The agency failed to evidence that OASIS submission occurred within 30 days of completion. Review of OASIS Review of Nurses and More IQIES report titled “OASIS Agency Final Validation” reporting period 11/08/2023 to 11/08/2024, evidenced the last OASIS recertification assessment dated 02/06/2024 was submitted on 03/04/2024, but failed to evidence any further OASIS reassessments submitted for Patient #12. 11. Review of the active clinical record for Patient #13 with a SOC 08/10/2023, contained a POC for the recertification period 09/19/2024 to 11/17/2024. The agency failed to evidence that OASIS submission occurred within 30 days of completion. Review of OASIS Review of Nurses and More IQIES report titled “OASIS Agency Final Validation” reporting period 11/08/2023 to 11/08/2024, evidenced the last OASIS recertification assessment dated 01/18/2024 was submitted on 03/04/2024, but failed to evidence any further OASIS reassessments submitted for Patient #13. 12. Review of the active clinical record for Patient #14 with a SOC 05/17/2022, contained a POC for the recertification period 11/02/2024 to 12/31/2024. The agency failed to evidence that OASIS submission occurred within 30 days of completion. Review of OASIS Review of Nurses and More IQIES report titled “OASIS Agency Final Validation” reporting period 11/08/2023 to 11/08/2024, evidenced the last OASIS recertification assessment dated 01/02/2024 was submitted on 01/15/2024, but failed to evidence any further OASIS reassessments submitted for Patient #14. 13. Review of the active clinical record for Patient #15 with a SOC 07/08/2023, contained a POC for the recertification period 10/30/2024 to 12/28/2024. The agency failed to evidence that OASIS submission occurred within 30 days of completion. Review of OASIS Review of Nurses and More IQIES report titled “OASIS Agency Final Validation” reporting period 11/08/2023 to 11/08/2024, failed to evidence any further OASIS reassessments submitted for Patient #13. 14. Review of the active clinical record for Patient #16 with a SOC 09/19/2023, contained a POC for the recertification period 11/12/2024 to 01/10/2025. The agency failed to evidence that OASIS submission occurred within 30 days of completion. Review of OASIS Review of Nurses and More IQIES report titled “OASIS Agency Final Validation” reporting period 11/08/2023 to 11/08/2024, evidenced the last OASIS recertification assessment dated 01/15/2024 was submitted on 03/04/2024, but failed to evidence any further OASIS reassessments submitted for Patient #16. 15. Review of the active clinical record for Patient #17 with a SOC 09/19/2023, contained a POC for the recertification period 11/12/2024 to 01/10/2025. The agency failed to evidence that OASIS submission occurred within 30 days of completion. Review of OASIS Review of Nurses and More IQIES report titled “OASIS Agency Final Validation” reporting period 11/08/2023 to 11/08/2024, evidenced the last OASIS recertification assessment dated 01/05/2024 was submitted on 01/15/2024, but failed to evidence any further OASIS reassessments submitted for Patient #17. 16. Review of the active clinical record for Patient #18 with a SOC 10/11/2023, contained a POC for the recertification period 10/05/2024 to 12/03/2024. The agency failed to evidence that OASIS submission occurred within 30 days of completion. Review of OASIS Review of Nurses and More IQIES report titled “OASIS Agency Final Validation” reporting period 11/08/2023 to 11/08/2024, failed to evidence any OASIS reassessments submitted for Patient #18. 17. Review of the active clinical record for Patient #19 with a SOC 10/26/2022, contained a POC for the recertification period 10/15/2024 to 12/13/2024. The agency failed to evidence the OASIS submission occurred within 30 days of completion. 18. Review of the inactive clinical record for Patient #6 with a SOC 03/15/2017 and discharge date 07/11/2024. The record failed to evidence that OASIS submission occurred within 30 days of completion. Review of OASIS Review of Nurses and More IQIES report titled “OASIS Agency Final Validation” reporting period 11/08/2023 through 11/08/2024, failed to evidence any OASIS assessments submitted for Patient #6. 19. Review of the inactive clinical record for Patient #7 with a SOC 10/27/2024 and discharge date 07/16/2024. The record failed to evidence that OASIS submission occurred within 30 days of completion. Review of OASIS Review of Nurses and More IQIES report titled “OASIS Agency Final Validation” reporting period 11/08/2023 through 11/08/2024, failed to evidence any OASIS assessments submitted for Patient #7. 20. Review of the inactive clinical record for Patient #8 with a SOC 5/16/2024, and transfer date 11/04/2024. The record failed to evidence that OASIS submission occurred within 30 days of completion. Review of OASIS Review of Nurses and More IQIES report titled “OASIS Agency Final Validation” reporting period 11/08/2023 through 11/08/2024, failed to evidence any OASIS assessments submitted for Patient #8. Review of OASIS Review of Nurses and More IQIES report titled “OASIS Agency Final Validation” reporting period 11/08/2023 to 11/08/2024, evidenced the last OASIS recertification assessment dated 02/13/2024 was submitted on 03/04/2024, but failed to evidence any further OASIS reassessments submitted for Patient #19. During an interview on 11/14/2024 at 1:07 PM, the DON confirmed OASIS data should have been submitted on skilled patients every 30 days. However, no OASIS assessments had been submitted since March 2024.

HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator's name, business address, and business phone number in order to receive complaints. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure all patients received the contact information for the agency administrator, including the administrator's name and business phone number, in order to receive complaints in 2 (Patients: #1 and 3) of 2 active patients who received home visits. Findings Include: 3. The agency’s admission folder evidenced a letter with the Administrator’s name and contact information. The agency’s admission packet booklet indicated the Administrator was the agency’s previous Administrator, Person 3, and the previous Clinical Manager, Person 4. During an interview with the Administrator and DON on 11/14/2024 at 11:19 AM, they indicated the letter in the admission folder, with the correct name and contact information of the Administrator, had not been sent out to patients. 4. During a home visit at Patient #1’s residence on 11/13/2024 at 1:30 PM, when queried regarding their admission packet, the patient indicated they could not remember if they had one. RN 3 indicated the patient had been readmitted to the agency many times and the admission packet was from the last time they were admitted in 2023. 1. Review of an agency policy dated 2020, titled “Patient Bill of Rights & Responsibilities” indicated but was not limited to, “ …. The Registered Nurse/Licensed Therapist responsible for admission shall: … Instruct the patient/family/caregiver about … the Home Health Agency Administrator, including name, business address, and business phone number … " 2. During a home visit at Patient #3’s residence on 11/13/2024 at 7:00 AM, observed Patient #3’s residence was not apartment #201 per the plan of care address listed of Patient #3 provided by the agency. Patient #3’s apartment #233. When inquired about the patient’s agency information or folder, HHA 2 indicated Patient #3’s folder had been misplaced during the move per Patient #3’s caregiver. Patient #3 shook their head that they had not when asked if they had been provided the Administrator’s contact information for complaints. HHA 2 further confirmed Patient #3 had been at this apartment since May 2024. During an interview on 11/14/2024 at 11:19 AM, when queried regarding the notification process of the administrator's name and contact information for complaints, the DON indicated the patients were not made aware, and they did not send out the letters to notify the patients of changes in Administration in May.

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 agency failed to ensure patients received the frequency of services listed in the POC (G0572), ensure the POCs were individualized, included all necessary parameters, the frequency of services, and reflected the current condition of the patients (G0574), ensure the treatment ordered by the physician was followed according to the POC (G0580), ensure the physician was notified of missed visits and changes in condition (G0590), and ensure patients had a medication list in their homes (G0616). The cumulative effects of these systemic problems resulted in the home health agency’s inability to ensure the provision of quality health care in a safe environment for the Condition of Participation of 42 CFR 484.60, Care Planning, Coordination of Care, and Quality of Care. Findings Include: 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 record review and interview, the agency failed to ensure the patients received the frequency of services listed in the POC for 1 of 4 clinical records (Patient #4) reviewed with patients receiving SN services only, 1 of 2 clinical records (Patient #11) reviewed with a patient receiving HHA services only, and 1 of 2 clinical records (Patient #10) reviewed with patients receiving both HHA and SN services. Findings Include: 3. Review of the clinical record for Patient #10 SOC 01/20/2021, contained a POC for the recertification period 09/01/2024 to 10/30/2024. The plan of care indicated Patient #10 had orders for a HHA for two hours daily and RN for one hour every other week for one certification period. Review of a POC for the recertification period 10/31/2024 to 12/29/2024 indicated #10 had orders for a HHA for two hours daily and a RN for one hour every other week for one certification period. Review of the HHA visit notes evidenced the following: During the week of 09/15/2024 through 09/21/2024, evidenced HHA visits were conducted on 09/16, 09/17, 09/18, 09/19, and 09/20/2024, but failed to evidence HHA visits were conducted on 09/15 and 09/21/2024. During the week of 09/22/2024 through 09/28/2024, evidenced HHA visits were conducted on 09/23, 09/24, 09/25, 09/26, and 09/27/2024, but failed to evidence HHA visits were conducted on 09/22 and 09/28/2024. During the week of 09/29/2024 through 10/05/2024, evidenced HHA visits were conducted on 09/30, 10/01, 10/02, 10/03, and 10/04/2024, but failed to evidence HHA visits were conducted on 09/29 and 10/05/2024. During the week of 10/06/2024 through 10/12/2024, evidenced HHA visits were conducted on 10/07, 10/08, 10/09, 10/10, and 10/11/2024, but failed to evidence HHA visits were conducted on 10/06 and 10/12/2024. During the week of 10/13/2024 through 10/19/2024, evidenced HHA visits were conducted on 10/14, 10/15, 10/16, 10/17, and 10/18/2024, but failed to evidence HHA visits were conducted on 10/13 and 10/19/2024. During the week of 10/20/2024 through 10/26/2024, evidenced HHA visits were conducted on 10/21, 10/22, 10/23, 10/24, and 10/25/2024, but failed to evidence HHA visits were conducted on 10/20 and 10/26/2024. During the week of 10/27/2024 through 11/02/2024, evidenced HHA visits were conducted on 10/28, 10/29, 10/30, 10/31, and 11/01/2024, but failed to evidence HHA visits were conducted on 10/27and 11/02/2024. During the week of 11/03/2024 through 11/09/2024, evidenced HHA visits were conducted on 11/04, 11/05, 11/06, 11/07, and 11/08/2024, but failed to evidence HHA visits were conducted on 11/03 and 11/09/2024. During an interview on 11/14/024 at 1:55 PM, HHA 1 indicated they provide care to Patient #10 every Monday through Friday, according to their schedule. During an interview on 11/14/2024 at 2:30 PM, when asked about the orders on the plan of care for HHA, the DON confirmed Patient #10 had orders for a HHA daily but had not been seen daily. 4. Review of the clinical record for Patient #11 SOC 01/08/2021, contained a POC for the recertification period 08/20/2024 to 10/18/2024. The POC indicated Patient #11 had orders for a HHA for 6-11 hours daily, HHA respite care for 4-6 hours as needed, and Attendant care as needed for 7 hours on Saturday and Sunday for one certification period. Review of a POC for the recertification period 10/19/2024 to 12/17/2024 indicated #11 had orders for a HHA for 6-11 hours daily, HHA respite care for 4-6 hours as needed, and Attendant care as needed for 7 hours on Saturday and Sunday for one certification period. Review of the HHA visit notes evidenced the following: During the week of 09/15/2024 through 09/21/2024, evidenced on 09/15/2024 an Attendant care visit had been conducted. Patient #11 was transferred to the hospital on 09/16/2024 through 09/19/2024. RN 1 completed a Resumption of Care Assessment on 09/20/2024. On 09/21/2024 an Attendant care visit had been conducted, but the failed to evidence any HHA visits had been conducted. During the week of 09/22/2024 through 09/28/2024, evidenced Attendant care visit on 09/22/2024, and HHA visits were conducted on 09/25, 09/26, and 09/27/2024, but failed to evidence HHA visits were conducted on 09/22, 09/23, 09/24, and 09/28/2024. During the week of 09/29/2024 through 10/05/2024, evidenced Attendant care visits for 09/03 and 09/05/2024, and HHA visits were conducted on 09/29, 09/30, 10/01, 10/02, and 10/04/2024, but failed to evidence HHA visits were conducted on 10/03 and 10/05/2024. During the week of 10/06/2024 through 10/12/2024, evidenced Attendant care visits were conducted on 10/06 and 10/12/2024, and HHA visits were conducted on 10/07, 10/08, 10/09, and 10/11/2024, but failed to evidence HHA visits were conducted on 10/06, 10/10, and 10/12/2024. During the week of 10/13/2024 through 10/19/2024, evidenced Attendant care visits were conducted on 10/13, 10/17, and 10/19/2024, and HHA visits were conducted on 10/14, 10/15, 10/16, and 10/18/2024, but failed to evidence HHA visits were conducted on 10/13, 10/17, and 10/19/2024. During the week of 10/27/2024 through 11/02/2024, evidenced Attendant care visits were conducted on 11/02/2024, and HHA visits were conducted on 10/28, 10/29, 10/30, and 11/01/2024, but failed to evidence HHA visits were conducted on 10/27, 10/31, and 11/02/2024. During the week of 11/03/2024 through 11/09/2024, evidenced Attendant care visits were conducted on 11/03 and 11/09/2024, and HHA visits were conducted on 11/04, 11/05, 11/06, and 11/07/2024, but failed to evidence HHA visits were conducted on 11/03, 11/08, and 11/09/2024. On 11/14/2024 at 8:45 AM, 10:44 AM, and 2:59 PM, calls were placed to Patient #11’s caregiver and left messages for a return call. During an interview on 11/14/2024 at 4:05 PM, when queried regarding the HHA orders for Patient #11, RN 1, the case manager for Patient #11, indicated Patient #11 is totally blind and dependent on care needs and requires a HHA daily for showers and assistance with all activities of daily living. During an interview on 11/14/2024 at 4:05, when queried about Patient #11's missed HHA visits, the DON indicated Patient #11 had orders for daily HHA visits and they should have been staffed. 410 IAC 17-13-1(a) 1. An agency policy dated 2020, titled “Patient Assessment, Plan of Care & Assessment Protocol” indicated but was not limited to, “ … Each patient will receive the home health services that are written in an individualized plan of care … the physician is consulted to approve additions or modifications to the original plan … The patient’s physician orders for treatment and services are the foundation of the plan of care. If the HHA misses a visit or a treatment or services as required by the plan of care … the HHA must notify the responsible physician of such missed treatment or service. The physician decides whether the treatment or services may be skipped …” 2. A review of Patient #4’s clinical record evidenced a POC with a SOC of 03/17/2021 and a certification period from 08/28/2024 to 10/26/2024. The POC included the following diagnoses for the patient: Quadriplegia (paralysis in all four extremities of the body), chronic pain, Chronic Embolism and Thrombosis of the left iliac vein (a condition where the vein in the pelvis is compressed and causes blood to pool in the area causing a blood clot), Neurogenic bowel (loss of bowel function because of damage to the nervous system), and Neuromuscular dysfunction of bladder (loss of bladder control due to damaged nerves or brain problems). The POC indicated the patient was to receive 7 hours daily of SN services for the certification period. A review of Patient #4’s clinical record failed to evidence SN visits from 10/18/2024 to 10/23/2024. During an interview with RN 2 on 11/14/2024 at 2:35 PM, they evidenced they were the nurse providing care for Patient #4. They explained they had not provided care for Patient #4 from 10/18/2024 to 10/23/2024 because they were on vacation. RN 2 indicated the patient’s relative took over care during the time they were on vacation. RN 2 explained they thought someone had notified the physician of the missed visits. They indicated “it is on the job of the Director.” During an interview with the DON on 11/14/2024 at 4:00 PM, they evidenced they were on vacation the week Patient #4 had not received services and the physician was not notified. The DON indicated there was no excuse and the “ball was dropped.”

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 POC was individualized and included all the required elements, including the patient’s correct demographics, the discipline, frequency, duration, treatment, and patient-specific parameters when to notify the physician in 4 of 6 active records reviewed. (Patients: #1, 2, 3, and 11) Findings Include: 5. A review of Patient #1’s clinical record evidenced a POC with a SOC of 07/08/2023 and a certification period from 08/31/2024 to 10/29/2024. The POC included the following diagnoses: open wound of the lower leg, Peripheral vascular disease (a condition where there is reduced blood flow to the body because of narrowed or blocked blood vessels), Hypertension (high blood pressure), Type 2 Diabetes Mellitus (a disease where the body is unable to regulate blood sugar appropriately), unspecified open wound of the right lower leg. The section titled “Diabetic Assessment” evidenced the SN was to monitor and record the patient’s blood sugar level. The POC failed to evidence blood sugar parameters when the SN called the physician. The POC indicated the patient received wound care for their left lateral ankle and bilateral wounds on the lower extremities 3 times a week or more often as needed. The wounds were cleansed with Normal Saline or Wound cleanser, Xeroform (a non-occlusive dressing containing antibiotics to promote healing) applied to the wounds, and covered with Mepilex (a dressing containing silver to assist in healing the wound), and secured with circaids (inelastic compression stockings). The bilateral heels were cleansed with soap and water 3 times a week, lotion applied, covered with ABD (abdominal) pads (dressing), and secured with Kerlix (gauze bandage) and Medipore tape (flexible tape). The buttocks and sacrum were cleansed with Comfort Shield wipes 3 times a week and barrier cream applied. The left knee was cleansed with Normal Saline 3 times a week, Xeroform applied, and secured with Mepilex. Patient #1’s clinical record evidenced a document titled “Revision to Plan of Care” dated 08/27/2024 by the DON. The document evidenced the wound care orders were updated on 08/27/2024. The document indicated the patient’s right third toe was cleansed with Normal Saline or Wound Cleanser three times a week and painted with Betadine (a solution used to prevent infection). The patient’s right tibia wound was cleansed with Normal Saline or Wound Cleanser 3 times a week, with Silver Alginate (an antibacterial wound dressing) applied, covered with ABD pads, secured with Kerlix and an Unna boot (a soft bandage), and secured with circaids. The POC with the certification period from 08/31/2024 to 10/29/2024 for Patient #1 failed to include the most current wound care orders from Entity 6, a wound care clinic. A review of Patient #1’s clinical record evidenced a POC with a SOC of 07/08/2023 and a certification period from 10/30/2024 to 12/28/2024. The POC included the following diagnoses: open wound of the lower leg, Peripheral vascular disease (a condition where there is reduced blood flow to the body because of narrowed or blocked blood vessels), Hypertension (high blood pressure), Type 2 Diabetes Mellitus (a disease where the body is unable to regulate blood sugar appropriately), unspecified open wound of the right lower leg. The section titled “Diabetic Assessment” evidenced the SN was to monitor and record the patient’s blood sugar level. The POC failed to evidence blood sugar parameters when the SN called the physician. The POC indicated the patient received wound care for their left lateral ankle and bilateral wounds on the lower extremities 3 times a week or more often as needed. The wounds were cleansed with Normal Saline or Wound cleanser, Xeroform (a non-occlusive dressing containing antibiotics to promote healing) applied to the wounds, and covered with Mepilex (a dressing containing silver to assist in healing the wound), and secured with circaids (inelastic compression stockings). The bilateral heels were cleansed with soap and water 3 times a week, lotion applied, covered with ABD (abdominal) pads (dressing), and secured with Kerlix (gauze bandage) and Medipore tape (flexible tape). The buttocks and sacrum were cleansed with Comfort Shield wipes 3 times a week and barrier cream applied. The left knee was cleansed with Normal Saline 3 times a week, Xeroform applied, and secured with Mepilex. An order dated 10/22/2024 from Entity 6, Patient #1’s wound clinic, evidenced all wounds were cleansed with Wound Cleanser and Normal Saline. The right and left mid-anterior tibia wounds had Medihoney with Alginate (a dressing to assist in wound healing) applied to the wounds, covered with ABD pads, and secured with Kerlix and Medipore tape. The right and left lateral foot and distal ankle wounds had Silver Alginate applied, covered with ABD pads, and secured with Kerlix and Medipore tape. The POC with the certification period from 10/30/2024 to 12/28/2024 for Patient #1 failed to include the most current wound care orders from Entity 6, a wound care clinic. During an interview with RN 3 on 11/13/2024 at 2:00 PM, they explained Patient #1’s wound care orders had changed on 10/24/2024 to the Medihoney with Alginate. They indicated the Blood sugar parameters they used for when to notify the physician was anything less than 70 and greater than 300. The Blood sugar parameters were not listed on the POC. During an interview with RN 3 on 11/14/2024 on 11:50 AM, they indicated they received the new wound care orders on 10/22/2024, when the patient went to the wound care clinic, Entity 6. They indicated the POC needed to be updated to reflect the current wound care orders. 6. A review of Patient #2’s clinical record evidenced a POC with a SOC of 03/05/2022 and a certification period from 10/20/2024 to 12/18/2024. The POC included the following diagnoses: Morbid obesity, Hypertension, Chronic systolic heart failure (a condition where the heart is unable to appropriately pump blood throughout the body), Type 2 Diabetes Mellitus, and open wound of the abdominal wall. The POC failed to evidence heart rate, blood pressure, temperature, respiration, oxygen saturation, and blood sugar parameters. During an interview with RN 1 on 11/14/2024 at 3:38 PM, they indicated Patient #2’s POC should have vital sign and blood sugar parameters for when to call the physician. 410 IAC 17-13-1(a)(1)(D)(iii, ix, and xiii) 1. Review of an agency policy dated 2020, titled “Plan of Care” indicated but was not limited to, “ …. To document physician orders for patient care, treatment, and/or services. To document parameters for physician notification … Patient demographics … ” 2. Review of the clinical record for Patient #3 SOC 07/25/2022, contained a POC for the recertification period 11/11/2024 to 01/09/2025. The POC section titled “Patient’s Name and Address” indicated Patient #3’s residence at 55 Mission Drive, Apartment 201, Indianapolis, Indiana, 46214. During a home visit on 11/13/2024 at 7:00 AM, when knocked on the apartment door, #201 was informed by the female occupant it was not Patient #5’s residence was informed Patient #5’s apartment was across the hallway stairs. During the home visit, Patient 5’s HHA indicated Patient #5 had previously been at apartment 201 during renovations to their current apartment 233. When queried how long Patient #5 had this residence, HHA 2 indicated Patient #5 had been at this apartment since May of 2024. During an interview on 11/13/2024 at 1:46 PM, the DON indicated they were unaware Patient #5's apartment number was incorrect. The DON further confirmed the RN should have notified the agency and corrected the POC to reflect the correct address. 3. A review of the clinical record for Patient #11 SOC 01/08/2024, contained a POC for the recertification period 10/19/2024 to 12/17/2024. The POC indicated the following, but not limited to: Diagnoses of Cerebral Infarction (a stroke), Type 2 Diabetes Mellitus ( a condition in which the body doesn’t use insulin properly, resulting in unusual blood sugar levels), End Stage Renal Disease (a condition where the kidneys no longer work to filter wastes and excess fluid from the blood), Visual Loss, and Long Term Use of Insulin. The section titled “Orders for Disciplines and Treatments” indicated Patient #11 was to receive Attendant care services 7 hours as needed Saturday and Sunday, HHA 6-11 hours daily, and HHA respite 4-6 hours as needed, but failed to list the Skilled Nurse for HHA supervisory visits and frequency. The POC failed to list parameters for when to notify a physician of blood pressure, pulse, temperature, and blood glucose levels. During an interview on 11/14/2024 at 3:58 PM, RN 1 confirmed parameters and RN visit frequency with treatments should be listed on the POC. When queried regarding Patient #11’s POC not including RN frequency and parameters indicated they should have been on the POC.

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 wounds were measured according to the POC for 1 of 2 clinical records reviewed with a SN providing wound care. (Patient #9) Findings Include: 1. An agency policy dated 2020, titled “Patient Assessment, Plan of Care & Assessment Protocol” indicated but was not limited to, “ … Each patient will receive the home health services that are written in an individualized plan of care …” 2. A review of Patient #9’s clinical record evidenced a POC with an SOC of 01/28/2021 and a certification period from 09/09/2024 to 11/07/2024. The POC included the following diagnoses: a stage 4 Pressure Ulcer of the right buttock (large, deep wound that extends to the bones, tendons, and muscles), Paraplegia (loss of function in the lower half of the body), ), Neurogenic bowel (loss of bowel function because of damage to the nervous system), and Neuromuscular dysfunction of bladder (loss of bladder control due to damaged nerves or brain problems), stage 3 Pressure ulcer of the sacral region (a deep wound reaching the fat tissue), and stage 2 pressure ulcer of the left ankle (a scrape, blister, or sore). The POC evidenced wound measurements were recorded weekly for the sacrum, right ischium (pelvis), and left lateral foot wounds. A review of Patient #9’s clinical record failed to evidence wound measurements for the sacrum, right ischium, and left lateral foot wounds in the SN visits from 09/09/2024 to 11/07/2024. During an interview with Patient #9’s case manager, RN 1, on 11/14/2024 at 3:38 PM, they explained another nurse, RN 2 was supposed to perform the wound measurements on Mondays. During an interview with the DON on 11/14/2024 at 4:00 PM, they indicated they reviewed all the SN visit notes for Patient #9 and evidenced the wound measurements had not been completed from 09/09/2024 to 11/07/2024. 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 record review and interview, the agency failed to ensure the physician was notified of a patient's change in condition of 1 of 1 records reviewed with patients in changes in condition. (Patient #5) Findings Include: 1. Review of an agency policy dated 2020, titled “Patient Assessment, Plan of Care & Assessment Protocol” indicated but was not limited to, “ …. Changes in the Plan of Care: The physician is notified promptly and in an appropriate manner of any changes in the patient’s clinical status and/or needs or requests that suggest a need to modify the plan of care … ” 2. Review of the clinical record for Patient #5, SOC date 02/23/2024, contained a recertification assessment dated 10/04/2024 and electronically signed by RN 1. The assessment indicated, but was not limited to, a section titled “Elimination Status.” The elimination status of Patient #5 indicated the patient reported urine yellow/straw in color and listed other conditions of a kidney transplant. In the comment section, RN 1 documented Patient #5’s left arm access, had no thrill or bruit and was used in the past for dialysis. Review of the agency documents titled” Case Conference Communication Notes” dated 04/25/2024 through 11/14/2024 failed to evidence RN 1 notified Patient #5’s physician of the changes in the left vascular access site. During an interview on 11/14/2024 at 3:58 PM, RN 1 indicated Patient #5’s left vascular access had the thrill and bruit prior to RN 1’s recertification visit on 10/04/2024. RN 1 confirmed the agency policy was to call the physician with changes in the patient’s condition, and they had not notified the physician of Patient #5’s vascular access change. 410 IAC 17-13-1(a)(2)

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 and interview, the agency failed to ensure the patients’ medication lists were provided to them for 2 of 2 patients with home visits. (Patients #1 and #3) Findings Include: 3. During a home visit at Patient #3's residence on 11/13/2024 at 7:00 AM, HHA2 and Patient #3 indicated they did not have a medication list for Patient #3 in the home provided by the agency for review. HHA 2 indicated Patient #3 had lived in their apartment since May 2024 and had not received a medication list. During an interview on 11/14/2024 at 3:53 PM, when asked about medication lists and plans of care being provided to patients, RN 1, the case manager for Patient #3, confirmed they had not provided a plan of care or medication list to their patients. 1. An agency policy dated 2020, titled “Plan of Care” indicated but was not limited to, “ … The patient and caregiver will have a copy of written instructions … Patient medication schedule/instructions, including: Medication name, dosage and frequency and which medication will be administered by the agency personnel and personnel acting on behalf of the agency. …” 2. During a home visit at Patient #1’s residence on 11/13/2024 at 1:30 PM, Patient #1 and RN 3 indicated they were unsure what was in their admission packet. They indicated they only received a schedule from the agency. During an interview with RN 3 on 11/13/2024 at 1:30 PM, they indicated the patient had an admission packet from the agency when they were last admitted to the agency. RN 3 indicated they had not updated anything in the admission packet. The patient had no medication list, only what they received from the wound care clinic, Entity 6.

Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA's governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA's performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This CONDITION is not met as evidenced by: Based on record review and interview, the agency failed to use measurable indicators to improve outcomes, patient safety, and quality of care, failed to document the agency had considered the incidence, prevalence, and high-risk/problem-prone areas to select indicators and identify performance improvement projects (G646), failed to take action at performance improvement (G656), failed to evidence documentation of quality improvement projects (G658), and failed to evidence governing body oversight of an ongoing QAPI program for Quality improvement and patient safety is defined, implemented, and maintained with the potential to affect all 15 active patients. (G660) The cumulative effect of these systemic problems resulted in the agency’s inability to ensure patients received appropriate services which could result in the agency not providing quality health care, thus resulting in non-compliance with Condition of Participation CFR 484.65 Quality Assessment/Performance Improvement. Findings Include: 1. An agency policy dated 2020, titled “Quality Assurance Performance Improvement” indicated but was not limited to, “ … The performance improvement plan, is established by the senior management of the organization in collaboration with staff members … with the support and approval of the Governing body and members, is comprehensive in scope and provides a vehicle to monitor patient care, treatment and services … that may adversely impact patient care, treatment and services … The Agency develops, implements, evaluates, and maintains and effective, ongoing, agency wide, data driven QAPI program. … The agency must maintain documentary evidence of its QAPI program and be able to demonstrate its operation. … The Agency’s Quality Assessment Performance Improvement plan is evaluated at least annually by the Governing body and members … The agency will conduct performance improvement projects (PIP’s) …” 2. A review of a document titled “Quality Assurance Performance Improvement Committee Meeting dated 01/24/2024 failed to evidence performance improvement plans. The document evidenced the meeting was in regard to the fourth quarter of the 2023 QAPI program. The agency failed to provide further information regarding a QAPI program. 3. During an interview with the Administrator and DON on 11/14/2024 at 10:47 AM, they evidenced they had not had any QAPI meetings since January of this year with the current Administrator and DON. The DON indicated they were unable to remember the agency’s PIPs. When queried regarding the PIPs, the Administrator evidenced they had not reviewed the QAPI plan or the PIPs and were unaware they needed to review it. The DON indicated they had tracked falls, hospitalizations, and infections and addressed concerns individually for the patients as the incidents occurred. They evidenced they were unable to find any governing body meeting minutes for the discussion on QAPI and an approved program. 410 IAC 17-12-2(a)

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on record review and interview, the RN failed to ensure the HHA assignments of duties were consistent with patient-specific care needs and the aide's skills in 1 of 2 record reviews with HHA and RN services being provided. (Patient: #10). Findings Include: 1. Review of an agency policy dated 2020, titled “Patient Assessment, Plan of Care & Assessment Protocol” indicated but was not limited to, “ …. When patients are ordered and/or agree to Home Health Aide services, the Registered Nurse shall complete a Home Health Aide Plan of Care/Instruction Sheet; a copy is left in the patient’s home … The Aide Plan of Care is reviewed with Aide before the initial Aide visit and is reviewed and updated during each on-site supervisory visit and more often … ” 2. Review of the clinical record for Patient #10, SOC date 01/20/2021, contained a POC for the recertification period 09/01/2024 to 10/30/2024, electronically signed by RN 1, dated 08/30/2024. The POC indicated Patient #10 had orders for a HHA two hours daily for showers and ADL assistance, and a RN one hour every other week to prefill medications. A review of the agency document titled “Paraprofessional Assignment Sheet” indicated Patient #10 had HHA services two hours a day, five days a week, related to right-sided weakness from an old stroke. HHA tasks listed included: Ambulation: passive range of motion to the right shoulder, arm, and wrist every visit; Oral Care: brush teeth assist following care and meals every visit; Fall Risk: stand-by assistance for transfers to wheelchair every visit; Fall Risk: wheelchair seat belt check ensure the seat belt is fastened, clear pathways every visit; Glucose Testing: Assist client in testing Glucose 3 times every week help client test before lunch instead of breakfast on Mondays/Wednesdays/and Fridays. Call the RN supervisor with a blood glucose level below 70 or above 300. Document results on care notes number of hours since he last ate; Transfer: Wheelchair lock with transfers every visit; Transfer: Transfer pivot and transfer with assistance every visit; Toenail Care: Clean may file no clipping every visit; Skin: Lotion every visit; Nutrition: Mela prep offer fluids, no added salt, low salt no concentrated sweet diet every visit. Bath: Complete shower. Place the bag over the client's right lower leg where his incision is and secure it with coverall tape at the top to keep it dry during showering every visit; Dressing: all clothing every visit; Hair: Shampoo in the shower every visit; Hair Brush after shower every visit: Homemaking Support: Wash client’s dishes with meals; tidy client’s bathroom; and trash disposal every visit. During an interview on 11/14/2024 at 1:55 PM, when queried regarding the care HHA 1 provided and Patient #10's care plan being followed, HHA 1 indicated the care plan was not correct, and RN 1 had been aware. HHA1 further indicated they had never checked Patient #10’s glucose; it was out of their scope that the RN checked it during their visits. During an interview on 11/14/2024 at 4:35 PM, RN 1 indicated the HHA care plan should be current and updated per the patient’s specific needs, and the HHA should be instructed on those needs. During an interview on 11/14/2024 at 2:30 PM, the DON confirmed the HHA care plan for Patient #10 had the incorrect frequency, and the HHA did not check Patient #10’s blood sugars. 410 IAC 17-13-2(a)

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (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) 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 paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure HHAs were supervised every 2 weeks for 2 of 2 clinical records reviewed who received both SN and HHA services. (Patients #2 and #10) Findings Include: 3. Review of the clinical record for Patient #10, SOC date 01/20/2021, contained a POC for the recertification period 09/01/2024 to 10/30/2024. The POC indicated Patient #10 had orders for a HHA for two hours daily for showers and ADL assistance, and a RN one hour every other week to prefill medications. Review of the agency documents titled “Supervisory Visit Note” evidenced the following: During the week of 09/15/2024 to 09/21/2024, RN 1 completed a HHA supervisory visit on 09/17/2024. During the week of 09/29/2024 to 10/05/2024, RN 1 completed a HHA supervisory visit completed on 10/01/2024. During the week of 10/13/2024 to 10/19/2024, RN 1 completed a visit on 10/15/2024 but failed to evidence a HHA supervisory visit had been completed. During the week of 10/27/2024 to 11/02/2024, RN 1 completed a recertification visit on 10/29/2024 but failed to complete a HHA supervisory visit. During an interview on 11/14/2024 at 4:05 PM, RN 1 confirmed that HHA visits on skilled patients were to be conducted every two weeks and non-skilled patients every thirty days. 1. An agency policy dated 2020, titled “Approved Treatment and Patient Care Activities” indicated but was not limited to, “ … Functions of the Registered Nurse … Instructs and supervises … home health aides as appropriate and in accordance with applicable laws, regulations, standards, and Agency policies …” 2. A review of Patient #2’s clinical record evidenced a POC with a SOC of 03/05/2022 and a certification period from 10/20/2024 to 12/18/2024. The POC indicated the patient received HHA services one hour each day, 5 times a week, for showers and ADL assistance and SN services one hour weekly for medication administration. A review of Patient #2’s clinical record evidenced an HHA supervisory visit on 10/15/2024 during RN 1’s recertification assessment. A review of Patient #2’s clinical record evidenced RN 1 conducted SN visits on 10/21/2024, 10/28/2024, 11/04/2024, and 11/11/2024. RN 1 failed to complete HHA supervisory visits during the visits. During an interview with the DON on 11/14/2024 at 9:20 AM, they indicated HHA supervisory visits were supposed to be completed every 30 days for patients receiving SN and HHA services. During an interview with RN 1 on 11/14/2024 at 3:38 PM, they indicated HHA supervisory visits were to be conducted every two weeks for patients receiving skilled services.

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: Based on record review and interview, the Governing Body failed to ensure the agency had governing body meeting minutes and an ongoing QAPI program (G942) and ensure the Administrator was responsible for all day-to-day responsibilities (G948). The cumulative effect of these systemic problems resulted in the agency’s inability to ensure patients received appropriate services which could result in the agency not providing quality health care, thus resulting in non-compliance with Condition of Participation CFR 484.105 Organization and Administration of Services. Findings Include: 410 IAC 17-12-1(a)(2)

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on record review and interview, the governing body failed to ensure the agency had a current and on-going QAPI program. Findings Include: 1. An agency policy dated 2020, titled “Governing Body Composition” indicated but was not limited to, “ … Frequency of Meetings: The Governing body will receive reports no less than quarterly and this will be documented in the Governing body minutes. … The Governing body’s activities and responsibilities include … establish and maintain an effective agency-wide Quality Assessment Performance Improvement …” 2. The agency failed to provide Governing Body meeting minutes. During an interview with the Administrator on 11/13/2024 at 2:18 PM, they indicated they would have to reach out to the owner because the Governing Body meeting minutes were with the Owner in another state. 3. A review of a document titled “Quality Assurance Performance Improvement Committee Meeting dated 01/24/2024 failed to evidence performance improvement plans. The document evidenced the meeting was in regard to the fourth quarter of the 2023 QAPI program. The agency failed to provide further information regarding a QAPI program. During an interview with the Administrator and DON on 11/14/2024 at 10:47 AM, they evidenced they had not had any QAPI meetings since January of this year with the current Administrator and DON. The DON indicated they were unable to remember the agency’s PIPs. When queried regarding the PIPs, the Administrator evidenced they had not reviewed the QAPI plan or the PIPs and were unaware they needed to review it. The DON indicated they had tracked falls, hospitalizations, and infections and addressed concerns individually for the patients as the incidents occurred. They evidenced they were unable to find any governing body meeting minutes for the discussion on QAPI and an approved program. 410 IAC 17-12-1(b)(1)

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on record review and interview, the Administrator failed to ensure was aware of the Conditions of Participation, maintained a grievance log, and was involved in QAPI. Findings Include: 1. An agency policy dated 2020, titled “Agency Administration” indicated but was not limited to, “ … Duties of the Administrator … Responsible for all day to day operations … Organizes and directs the Agency’s ongoing functions …” 2. An agency policy dated 2020, titled “Job Description Administrator/Alternate Administrator” indicated but was not limited to, “ … Duties and Responsibilities: Meets regularly with the Governing body … Plans, coordinates, directs and oversees the operation of the Agency. … Maintains up-to-date knowledge of applicable state and federal laws, regulations and ensures Agency compliance with and adherence to applicable laws, regulations, and standards. …” 3. The agency failed to provide current Governing Body meeting minutes. During an interview with the Administrator on 11/12/2024 at 2:18 PM, they indicated the only binder with the Governing body meeting minutes was the one with the agency evaluation from 2022. They indicated they communicated with the Owner and had no documentation of their conversations. 4. The agency failed to maintain a grievance log. (See G484) During the entrance conference on 11/12/2024 at 9:28 AM with the Administrator and DON, they indicated there was a form online and they were unsure where it was kept. During an interview with the Administrator and the DON on 11/14/2024 at 4:00 PM, they indicated they were unsure where the complaint form was. The DON provided a copy of the complaint form at the exit conference. 5. A review of a document titled “Quality Assurance Performance Improvement Committee Meeting dated 01/24/2024 failed to evidence performance improvement plans. The document evidenced the meeting was concerning the fourth quarter of the 2023 QAPI program. The agency failed to provide further information regarding a QAPI program. During an interview with the Administrator and DON on 11/14/2024 at 10:47 AM, they evidenced they had not had any QAPI meetings with the current Administrator and DON. When queried regarding the PIPs, the Administrator evidenced they had not reviewed the QAPI plan or the PIPs and were unaware they needed to review it. They evidenced they were unable to find any governing body meeting minutes for the discussion on QAPI and an approved program. 6. During an interview with the Administrator on 11/14/2024 at 10:44 AM, they admitted they were unaware of the Conditions of Participation. 410 IAC 17-12-1(c)(1)

A Focused Emergency Preparedness Survey was conducted by the Indiana State Department of Health in accordance with 42 CFR 494.102 due to recent developments of the COVID-19 pandemic. Survey dates: 8/9, 8/10, 8/11, and 8/12/21 Facility #: 005375 Provider #: 157214 At this Focused Infection Control Emergency Preparedness survey, in regards to staffing and implementation of staffing, & infection control, Nurses and More, Inc. was found not to be in compliance with 42 CFR 484.102 Emergency Preparedness Requirements for Medicare Participating Providers and Suppliers for Home Health Agencies. Quality Review Completed on 9/27/21 by Area 3

Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years (annually for LTC).] At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to develop and implement COVID-19 emergency preparedness policies and procedures which addressed staff strategies during COVID-19 emergency. Findings Include: Record review on 8/11/2021 of the agency's emergency preparedness plan failed to evidence strategies during and emergencies and the COVID-19 emergency. During an interview on 8/11/21 at 2:30 PM, the alternate clinical manager stated, "It is the patient and families responsibility to take care of patient if we cannot staff it. They must have a Plan B and emergency plan." During an interview on 8/11/21 at 2:32 PM, the alternate administrator/clinical manager indicated there was not a policy and procedure which addressed staffing strategies in the event of an emergency included in the agency's policy and procedure binder. The alternate administrator/clinical director further stated, "We do not have any contracts with other contacts for emergency staffing. I understand now regarding contracts with staffing during an emergency. We are Plan B."

This visit was for a Federal and State Complaint, and Focused Infection Control Survey of a home care agency. Complaint #: IN 00346517: Substantiated. Federal and State Deficiencies were cited. Complaint #: IN 00344359: Substantiated. Federal and State Deficiencies were cited. Complaint #: IN 00343924: Substantiated. Federal and State Deficiencies were cited. Survey Date: 8/9, 8/10, 8/11 and 8/12/21 Facility #: 005375 Provider #: 157214 Medicaid #: 100265410A This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Quality Review Completed on 9/27/21 by Area 3

Advise the patient of discharge for cause CFR(s): 484.50(d)(5)(i) (i) Advise the patient, representative (if any), the physician(s) or allowed practitioner(s), issuing orders for the home health plan of care, and the patient's primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) that a discharge for cause is being considered; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to notify physicians, health care professionals/ agencies who will be responsible for providing on going care receive all of the discharge information and the patient's pertinent care needs in 4 of 4 discharged records reviewed. (Patients #3, 6, 9, 11) 4. On 08/10/2021, a review of patient #3 records revealed a start of care date of 03/24/2018 with a certification period of 07/06/2021 through 09/03/2021. The record contained a discharge summary that failed to identify if it was sent to the physician, family or other agency. The record failed to evidence discharge orders from the patient's physician. During an interview with family member, Person L on 08/10/2021 at 9:45 AM, when queried regarding the discharge from the agency, Person L stated "we didn't know we were going to be discharged until 07/30/2021, when the nurse was here. We were told during the visit that the agency was discharging [Name of Patient # 3] then we were discharged the next week." When queried whether patient #3 received a letter, Person L stated "we received nothing from that agency." The record failed to evidence discharge orders from the patient's physician and failed to provide a discharge summary to the physician and patient's family. 5. On 08/12/2021, a review of patient #11 records revealed a start of care date of 07/10/2016 with a certification period of 06/14/2021 through 08/12/2021. The record contained a discharge/ transfer summary that failed to identify if it was sent to the physician, family or other agency. The record failed to evidence discharge orders from the patient's physician. During an interview with Person I, family member of patient #11, on 08/12/2021 at 10:35 AM, when queried regarding discharge from agency, Person I stated they received a phone call from Employee B on 07/26/2021 stating they need to find another agency. When queried if Employee B instructed them on different agencies or provided any paperwork of any kind, Person I stated "No agency names or phone numbers were given to us, nothing was given to us. They discharged us on 07/26/2021." 410 IAC 17-12-2(i) Findings include: 1. Review of an undated agency policy titled, "Subject: Patient Transfer/Discharge" Standard HH5-6A indicated "...Decisions for Discharge and Response...The HHA(Home Health Agency)will arrange a safe and appropriate transfer to other care entities when the needs of the patient exceed the HHA's capabilities...The HHA will assist the patient/representative in choosing an alternative entity by identifying those entities in the patient's geographic area that may be able to meet the patient's needs based on the patient's acuity...Once the patient chooses an alternative entity, the HHA will contact that entity to facilitate a safe transfer. The HHA will ensure timely transfer of patient information to the alternate entity to facilitate continuity of care such as ensuring patient information is provided to the alternate entity prior to or simultaneously with the initiation of patient services at the new entity..." 2. The clinical record of patient #6 was reviewed on 8/10/21 and indicated a new start of care date 11/18/21. The record contained a plan of care for recertification period of 3/22/21 to 5/20/21. The clinical record on further review contained a recertification plan of care for recertification 3/22/21 to 5/20/21 with start of care date 1/21/21. The record failed to evidence a discharge summary or evidence of information being providing to the alternate agency taking over the home health aide care for patient #6 During an interview on 8/11/21 at 2:13 PM with the alternate clinical manager confirmed that the agency did not send the plan of care out to the agency who was taking over home health aide care. The alternate clinical director stated," We did not do a transfer or discharge summary patient #6 was readmitted for skilled nurse only. We did not send our plan of care and what services we provided. I just found out we cannot send out our transfer and discharge summaries in our EMR (Electronic Medical Record). I was just now trying to send one out and it would not print for me." 3. The clinical record of patient #9 was reviewed on 8/9/21 and indicated a start of care date 6/26/17. The clinical record contained an agency document dated 1/28/21 titled, “Revision to Plan of Care" that indicated patient #9 was discharged for non-compliance and family will provide care. The agency failed to evidence a 30 day notice of discharge letter, failed to evidence assistance with an alternate care giver and/or agency, and failed to evidence coordination of care with community agencies involved in patient #6 care. During an interview on 8/9/21 at 12:06 PM patient #9 confirmed the agency discharged patient without a notice of discharge immediately without helping her find alternative care. During an interview on 8/9/21 at 12:32 PM Entity A stated, "Patient #9 called me to let me know Nurses and More discharged her without a notice and care. We are looking into another agency for her PA (Prior Authorization) hours for staffing." During an interview on 8/10/21 at 12:50 PM with Former Employee B, the caregiver and home health aide for patient #9, confirmed that patient #9 was discharged without notice or help finding another agency to provide care.

Provide contact info other services CFR(s): 484.50(d)(5)(iii) (iii) Provide the patient and representative (if any), with contact information for other agencies or providers who may be able to provide care; and This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to evidence patients/ representatives with other agencies information and assistance to other health care agencies who might be able to provide care in 4 of 4 discharged patient records. (Patient #3, 6, 9, 11) 4. A review of clinical record patient 08/10/2021 #3 evidenced this was a discharged record with a start of care date on 03/24/2018 which included diagnoses of but not limited to Cerebral Palsy and incontinence of feces. A review of the plan of care for the certification period of 07/06/2021 through 09/03/2021 revealed the patient was to receive 6 hours of home health aide services daily to assist with transfers, bathing, incontinent care, and meals. The review of patient #3 records failed to evidence discharge orders from the patient's physician nor a summary of assisting the patient with finding another agency. During an interview with family member Person L of patient #3 on 08/10/2021 at 9:45 AM, when queried regarding discharged from the agency, Person L stated "we didn't know we were going to be discharged until 07/30/2021 when the nurse was here, we were told during the visit that the agency was discharging [Name of patient # 3], then we were discharged the next week." When queried whether patient #3 received a letter, Person L stated, "we received nothing from that agency." 5. A review of clinical record patient #11 on 08/12/2021 evidenced this was a discharged record with a start of care date on 07/10/2016 which included diagnoses of but not limited to osteoarthritis and diabetes mellitus type II, patient #11 is living with an elderly family member, Person L, who is providing care. A review of the plan of care for the certification period of 06/14/2021 through 08/12//2021 revealed the patient was to receive attendant care services 3 hours a day, 5 days a week to assist dressing, housekeeping, and meal prep. The review of patient #11 records failed to evidence discharge orders from the patient's physician nor a summary of assisting the patient with finding another agency. During an interview with Person I, a family member of patient #11 on 08/12/2021 at 10:35 AM, when queried regarding discharge from the agency, Person I stated they received a phone call from employee B on 07/26/2021 stating they need to find another agency. When queried if employee B instructed them on different agencies, Person I stated "no agencies names or phone numbers were given to us. They discharged us on 07/26/2021." Findings Include: 1. Review of an undated agency policy titled, "Subject: Patient Transfer/Discharge" Standard HH5-6A indicated "...Decisions for Discharge and Response...The HHA(Home Health Agency)will arrange a safe and appropriate transfer to other care entities when the needs of the patient exceed the HHA's capabilities...The HHA will assist the patient/representative in choosing an alternative entity by identifying those entities in the patient's geographic area that may be able to meet the patient's needs based on the patient's acuity...Once the patient chooses an alternative entity, the HHA will contact that entity to facilitate a safe transfer. The HHA will ensure timely transfer of patient information to the alternate entity to facilitate continuity of care such as ensuring patient information is provided to the alternate entity prior to or simultaneously with the initiation of patient services at the new entity..." 2. The clinical record of patient #6 was reviewed on 8/10/21 and indicated a start of care date 11/18/16 that indicated diagnosis but was not limited to paraplegia. The record contained a plan of care for the recertification period of 11/26/21 to 1/24/21 which indicated orders for a home health aide 6 hours daily, 5 hours in the am and 1 hour in the pm. During an interview on 8/11/21 at 2:13 PM stated, " We did not do a transfer or discharge summary patient #6 was readmitted for skilled nurse only. The home health aide services were going to be provided by another agency." During an interview on 8/10/21 at 12:56 P.M. with Person E, caregiver for patient #6, confirmed they had to find alternative care for patient #6. The family was not provided with any names of alternative agencies or assistance finding alternative agencies. 3. The clinical record of patient #9 was reviewed on 8/9/21 and indicated a start of care date 6/26/17that indicated a diagnosis but was not limited to paraplegia. The record contained a plan of care for the recertification period of 12/07/21 to 2/4/21 that indicated orders for home health aide services 6 hours daily, 3 hours in the A.M., and 3 hours in the P.M. The clinical record contained an agency document dated 1/28/21 titled, "Revision to Plan of Care" indicated the patient was discharged immediately. During an interview on 8/9/21 at 12:06 PM with patient #9 confirmed the agency failed to provide names of alternative agencies and assistance for care needs. During an interview on 8/10/21 at 12:50 PM with Former Employee B, and caregiver for patient #9, confirmed patient #9 was not given a list of alternative agencies for care or assistance when discharged immediately from the agency.

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 record review and interview, the agency failed to ensure all patients received services as ordered per the plan of care in 7 out of 12 patients. (Patients #3, 5, 6, 8, 9, 11, 12) 7. A review of clinical record patient #3 evidenced this was a discharged record with a start of care date on 03/24/2018 which included diagnoses of but not limited to Cerebral Palsy and incontinence of feces. A certification period of 07/06/2021 through 09/03/2021 revealed the patient was to receive 6 hours of home health aide services daily. Services provided on July 6, 2021 were 4 hours and 51 minutes, on July 7, 2021 were 4 hours and 7 minutes, on July 8, 2021 were 4 hours and 47 minutes, on July 9, 2021 were 4 hours and 23 minutes, July 10, 2021 were 4 hours and 12 minutes, on July 11 2021 were 4 hours, on July 12, 2021 missed visit, on July 13, 2021 were 48 minutes, on July 14, 2021 were 4 hours and 10 minutes, on July 15, 2021 were 4 hours and 52 minutes, on July 16-17, 2021 missed visits occurred, on July 18, 2021 were 4 hours and 30 minutes, on July 19, 2021 were 5 hours and 10 minutes, July 20, 2021 were 5 hours, on July 21, 2021 were 5 hours, on July 22, 2021 were 3 hours and 25 minutes, on July 23, 2021 were 5 hours and 36 minutes, on July 24, 2021 were 4 hours and 15 minutes, July 25, 2021 were 5 hours, July 26, 2021 were 4 hours and 43 minutes, July 28- Aug 1, 2021 missed visits occurred, and on Aug 2, 2021 were 4 hours and 43 minutes. The patient was discharged on August 3, 2021. The agency failed to provide 6 hours daily of home health aide services. An interview was conducted on 08/10/2021 at 9:45 AM with patient #3 family member other L. When queried whether patient #3 received all services on the plan of care, other L stated no. An interview was conducted on 08/10/2021 at 1:58 PM with other G. When queried if agency was staffing the patient #3 according to the plan of care, other G stated no, and I really don't understand why. 8. A review of clinical record patient #11 evidenced this was a discharged record with a start of care date on 07/10/2016 which included diagnoses of but not limited to osteoarthritis and diabetes mellitus type 11. Patient is living with an elderly family member other L who is providing care. The certification period reviewed was 06/14/2021 through 08/12//2021 revealed the patient was to receive attendant care services 3 hours a day, 5 days a week. Services provided on 06/14/2021 and 06/15/2021 missed visits occurred, on 06/17/2021 were 1 hour and 20 minutes, on 06/28/2021 were 2 hours and 22 minutes, on 06/29/2021 were 2 hours and 30 minutes, on 06/30/2021 2 hours and 21 minutes, on 07/01/2021 were 2 hours and 29 minutes, on 07/02/2021 a missed visit occurred, on 07/05/2021 were 2 hours and 36 minutes, on 07/06/2021 were 2 hours, and on 07/07/2021 a missed visit occurred. The patient was discharged 07/23/2021. The agency failed to provide 3 hours of attendant care services 5 days a week. An interview was conducted on 08/12/2021 at 10:35 AM with patient #11 family member other I. When queried whether patient #11 received all services on the plan of care, other I stated no. 9. A review of clinical record patient # 12 evidenced this was a active record with a start of care date on 03/25/2021 which included diagnoses but not limited to paraplegia and neurogenic bowel. The certification period reviewed was 07/23/2021 through 09/20/2021 revealed the patient was to receive attendant care services 2 hours daily and home health aide services 3 hours daily. Services provided on July 23, 2021 were 1 hour and 54 minutes of home health aide services, on July 24, 2021 were 1 hour and 10 minutes of home health aide services, on 07/25/2021 were 1 hour of home health aide services, and attendant care service was missed, on 07/26/2021 were 2 hours of home health aide services, on 07/31/2021 were 2 hours home health aide services, on 08/01/2021 were attendant care was a missed visit and 2 hours of home health aide services, and on 08/06/2021 were attendant care was a missed visit with 1 hour of home health aide services. The agency failed to provide attendant care services 2 hours daily and home health aide services 3 hours daily. An interview was conducted on 08/12/2021 at 2:25 with patient #12 family member other M. When queried whether patient #12 receives all services on the plan of care, other M stated no. An interview was conducted on 08/10/2021 at 3:15, when queried about missed visits, employee A stated each patient is to have a backup plan, so if agency cannot staff, the patient will have help. An interview was conducted on 08/12/2021 at 11:05, when queried about missed visits, employee C stated that several patients are having issues with staffing. Indiana Code 410 AC 17-13-1-(d)(iii) Based on record review and interview, the agency failed to ensure all patients received services as ordered per the plan of care in 6 out of 12 patients. (Patients #3, 5, 6, 8, 9, 12) Findings Include: 1. Review of an undated agency policy titled, "Subject: Patient Assessment, Plan of Care & Assessment Protocol" Standard HH5-2A, HH5-2B, HH5-2C, HH5-2C.01, HH5-2C.02, HH5-2E, HH-3A, HH5-3B, HH5-4A, HH5-5A, HH5-8B, HH5-11A stated,"...Procedure:...The patient's physician orders for treatments and services are the foundation of the plan of care. If the HHA (Home Health Agency) misses a visit or a treatment or service as required by the plan of care, which results in any potential for clinical impact upon the patient, then the HHA must notify the responsible physician of such missed treatment or service. The physician decides whether the treatment or service may be skipped or whether additional intervention is required by the HHA due to the clinical impact on the patient..." 2. Review of an undated agency policy titled, "Subject: Plan of Care" Standard HH-2A.01, HH5-2E, HH5-3A, HH5-3B, HH5-4A, H5-5A, HH5-8A, HH5-11A stated, "Purpose: To promote the effectiveness of patient care management, the organization and delivery of care, treatment, and services, and the ability to evaluate patient outcomes...To document physician orders for patient care, treatment and/or services..." 3. The clinical record of patient #5 an active record, was reviewed on 8/11/21 with the start of care date of 4/7/15. The record contained a plan of care for the recertification period of 7/4/21 to 9/1/21 that revealed diagnoses, Multiple sclerosis, Dependence on wheelchair, Unspecified urinary incontinence, and anxiety disorder, unspecified. The plan of care further revealed orders for HHA (Home Health Aide) 10-14 hours daily- 5-7 hours during the day 7 days/wk(week)5-7 hours/night x 5 nights/wk for bathing, dressing, incontinence care, nutrition, foot care, hair care, oral care, safety, and shave. Review of the home health aide notes revealed the following: week one on 7/4/21 no visits made, on 7/6/21 no PM visit, on 7/7/21 no PM visit, week two on 7/17/21 no AM or PM visits, week 3 on 7/18/21 no AM or PM visits, on 7/24/21 no AM visit, week 4 on 7/25/21 no AM visit, week 5 on 8/7/21 no AM visit, week 6 on 8/8/21 no AM visit. The agency failed to evidence patient was provided 5-7 hours during the day 7 days a week and 5-7 hours at night of home health aide services were provided as ordered on the plan of care. Review of an agency document titled "Complaint Report" revealed Patient #5 filed a complaint on 7/8/20 at 4:30 PM indicated, " Staffing. Client is concerned as his schedule has been adjusted for staffing shortage due to COVID Pandemic. Action/ Outcome/ Resolution: Encouraged client and healthcare representative, Person H, to reach out to some volunteers and let them know they are needed during the pandemic-client has a trust fund created for his care needs." Review of an agency document titled "Complaint Report" revealed Patient #5 filed a complaint on 10/1/20 at 10:30 AM indicating a concern about ongoing staffing for the weekend. the document further indicated the client would reach out to family and friends that could assist and possibly be on standby for other weekends as well. During an interview on 8/11/21 at 11:00 AM with Person H, caregiver of patient #5, when queried about patient #5's staffing complaints stated, " They missed a lot of shifts overnight seems to be problematic patient #5 has MS (Multiple sclerosis) and no use of [Name of patient #5's] hands or feet. It puts a heavy burden on our family." During an interview on 8/11/21 at 2:33 PM, with the alternate administrator/clinical manager and alternate clinical manager, when queried about missing visits stated, "It is and patient and family's responsibility to have a "Plan B" if we cannot staff them." 4. The clinical record of patient #6 was reviewed on 8/10/21 and indicated a start of care date 11/18/16. The record contained a plan of care for recertification period of 11/26/21 to 1/24/21 that indicated diagnoses Paraplegia, Personal history of urinary (tract) infections, Neuromuscular dysfunction of bladder, unspecified, Essential hypertension, Chronic pain syndrome Chronic obstructive pulmonary disease, unspecified, Constipation, unspecified, Nicotine dependence, cigarettes,,, Altered mental status unspecified, Gastro-esophageal reflux disease without esophagitis, Major Depressive disorder, single episode, unspecified and Pressure ulcer of sacral region stage 2. The plan of care further revealed orders for a HHA (Home Health Aide) 6 hours daily; 5 hours in the AM and 1 hour in the PM. for ambulation, bathing, dressing, hair care, foot care, fingernail care, incontinence care, and nutrition. Review of the home health aide notes revealed the following: week 4 on 12/14/20 2 hours in the AM 1 hour in the PM, 12/17/20 no PM visit was made, week 5 on 12/21/20 no am visit was made and the PM visit was made from 2:16 PM to 3:01 PM, and on week 7 on 1/4/21 no AM visit was made. The agency failed to evidence 5 hours of home health aide services were provided in the AM and 1 hour in the PM as ordered on the plan of care. During an interview on 8/10/21 at 12:26 PM with Person E, caregiver for patient #6, when queried about care and staffing of patient #6 stated, "Patient #6 is not a current patient now. Patient #6 went a whole week without care luckily, we pulled friends together and paid out of pocket for help. I spoke to the Former Employee N about staffing because I could not help due to COVID-19. I was quarantined along with my family. I am a nurse. Former Employee N told me I needed a "Plan C" with no compassion. The office lacked compassion then as well." During an interview on 8/12/21 at 10:50 AM, when queried about care, patient #6 stated," I am no longer with their home health. To be honest they have an administration issue. I did not have daytime care about three months ago maybe, it has been a while. I am incontinent and depend on staff. I cannot move from my arm pits down I am a paraplegic. I struggled. I only have a nurse from there now who is nice, [Name of Employee C]. I changed agencies for my home health aides. I was with them since 2014. Things changed after Former Employee N came in. My [Name of Person E] tried to talk to Former Employee N and have one of the nurses come help me from the office. They had a lot in the office that could have helped. Former Employee N told her it was her responsibility." During an interview on 8/12/21 at 11:05 AM with Employee C, RN (Registered Nurse) for patient #6, when queried about staffing issues stated, "Patient #6 is with another agency now. I would go in and patient #6 would go days without a home health aide and I would clean her up. Patient #6 has a wound that heals then breaks open again. I have been treating and keeping her out of the hospital. Former Employee N was rude to the patient's and families. Former Employee N was rude to caregivers. Former Employee N would take patients to be admitted to our agency and when questioned about us being short on staffing, would say, 'oh well'." 5. The clinical record of patient #8 was reviewed on 8/10/21 with a start of care date of 1/14/14. The record contained a plan of care for the recertification period of 6/4/21 to 8/2/21, which revealed diagnoses, Lennox-Gastaut syndrome without epilepticus [seizures]; Intellectual disabilities; Autistic disorder; Cerebral palsy; Epilepsy; Encephalopathy; abnormalities of gait and mobility. The plan of care further revealed orders for Respite Hourly RN (Registered Nurse) 4-8 hours daily 2 times weekly for 60 days and SN (Skilled Nurse) Hourly 9-10 hours daily 5 times weekly for 60 days for nursing to assess vital signs, administer medication and treatments, SN to assist with all ADLs, SN to monitor seizure activity and document duration & type of activity, maintain airway and client's safety during activity. Review of SN notes revealed the following: week 1 SN visits on 5/5/21 and 5/7/21, week 2 SN visits on 5/10/21, 5/11/21, 5/12/21 and 5/14/21, week 3 SN visits on 5/17/21, 5/18/21, 5/19/21 and 5/21/21, week 4 SN visits on 5/24/21, 5/25/21, 5/26/21 and 5/28/21, week 5 SN visits on 5/31/21, 6/1/21, 6/2/21 and 6/4/21, week 6 SN visits on 6/7/21, 6/8/21, 6/9/21 and 6/11/21,week 7 SN visits on 6/14/21, 6/15/21, 6/16/21 and 6/18/21, and week 8 SN visits on 6/21/21, 6/22/21, 6/23/21 and 6/25/21. The agency failed to evidence skilled nursing services were provided as ordered on the plan of care. During an interview on 8/10/21 at 9:29 AM with Person D, caregiver of patient #8, when queried about care and staffing stated, "My patient [#8] needs a nurse. There was a lot of complaints going on. The agency was doing good until they changed management and were rude to the employees and patients." 6. The clinical record of patient #9 was reviewed on 8/9/21 and indicated a start of care date 6/26/17. The record contained a plan of care for recertification period of 12/07/21 to 2/4/21 that indicated diagnoses of Paraplegia, unspecified, Neuromuscular dysfunction of bladder, unspecified, Post traumatic stress disorder, unspecified, Neurogenic bowel, not elsewhere classified, and Major depressive disorder, single episode, unspecified. The plan of care further revealed orders for HHA 6 hours a daily; 3 hours in the AM and 3 hours in the PM to assist with transfers, personal care including bathing, grooming, dressing, hair/nail/skin/foot care. HHA to provide incontinence care. Review of the home health aide notes revealed the following: week 5 on 1/15/21 no AM visit, week 8 on 1/19/21 no PM visit, 1/20/21 no PM visit, 1/22/21 no AM visit, and 1/23/21 no AM visit was made. The agency failed to provide home health aide services for 6 hours daily 3 hours for AM care and 3 hours for PM care. During an interview on 8/9/21 at 12:06 PM with patient #9 when queried about agency and staffing stated, "I never had any issue with them until they got a new manager. They would not provide another home health aide to staff me if Former Employee B was sick or called off. The agency told me if Former Employee B didn't see me that they could not send anyone else." The findings were reviewed with the Alternate Administrator/Clinical Manager, and the Alternate Clinical Manager on 8/12/21 from 3:07 PM to 4:47 p.m. in which they had no further information or documentation to provide.

Information to the state survey agency CFR(s): 484.100(a) Standard: The HHA also must disclose the following information to the state survey agency at the time of the HHA's initial request for certification, for each survey, and at the time of any change in ownership or management: This STANDARD is not met as evidenced by: Based on observation, record review, and interview the agency failed to disclose the correct operating hours of the Nurse's and More, Inc. office hours.Findings Include: During the entry to Nurse's and More Inc., a Home Health Agency, on 08/09/21 at 8:00 AM the survey team observed the window decal on the agency entry revealed, "Hours Monday-Friday 8:00 AM-5:00 PM." Review of an undated agency policy titled, "Subject: Organization Information & Communication" Standard HH1-1B.01 stated, "Policy: The Home Health Agency will respond to requests for information from regulatory or accrediting bodies within the requested time frames. The Home Health Agency will inform all appropriate local, state, and federal regulatory agencies and accrediting bodies of the following: Any change or transfer of ownership ...Any change in address, physical location, and/or contact information ..." During an interview during the Entrance Conference when queried about the office hours the alternate administrator/clinical manager and alternate clinical director stated, "Our office is open Monday through Friday 8:00 AM to 4:00 PM." During an interview on 8/9/21 at 3:23 PM when queried about the correct office hours and what is on record with the state the alternate administrator/clinical manager stated, "It has been that way since the space was leased, they knew they were supposed to change it but hadn't got around to it." The alternate administrator/clinical director requested info on how to send a letter to the state with new hours. The findings were reviewed with the Alternate Administrator/Clinical Manager and the Alternate Clinical Manager on 8/12/21 from 3:07 PM to 4:47 p.m. in which they had no further information or documentation to provide. 410 IAC 17010-1(d)

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: The agency FAILED to provide a discharge summary to the primary care professional and to other health care professional who will be responsible for providing care and services to the patient after discharge from agency in 3 of 4 closed records reviewed. (Patients #3, 9, 11) 1. A review of clinical record patient #3 on 08/10/2021 evidenced this was a discharged record with a start of care date on 03/24/2018 which included diagnoses of but not limited to Cerebral Palsy and incontinence of feces. On the review of patient #3 records failed to contain discharge summary that contained patient specific information with type of service that was provided. During an interview with family member other L of patient #3 on 08/10/2021 at 9:45 AM, when queried regarding discharging from agency and discharge summary, L stated we didn’t receive anything from that agency. 2. A review of clinical record patient #11 on 08/12/2021 evidenced this was a discharged record with a start of care date on 07/10/2016 which included diagnoses of but not limited to osteoarthritis and diabetes mellitus type II. On the review of patient #11 records failed to contain a discharge summary that contained patient specific information with the type of service that was provided. During an interview with other I, family member of patient #11 on 08/12/2021 at 10:35 AM, when queried regarding a discharged summary that they could give to other agency, other I stated, they did not receive any paperwork from agency. Findings include: 1. Review of an undated agency policy titled, "Subject: Patient Transfer/Discharge" Standard HH5-6A indicated "...Decisions for Discharge and Response...The HHA(Home Health Agency)will arrange a safe and appropriate transfer to other care entities when the needs of the patient exceed the HHA's capabilities...The HHA will assist the patient/representative in choosing an alternative entity by identifying those entities in the patient's geographic area that may be able to meet the patient's needs based on the patient's acuity...Once the patient chooses an alternative entity, the HHA will contact that entity to facilitate a safe transfer. The HHA will ensure timely transfer of patient information to the alternate entity to facilitate continuity of care such as ensuring patient information is provided to the alternate entity prior to or simultaneously with the initiation of patient services at the new entity..." 2. The clinical record of patient #9 was reviewed on 8/10/21 with a start of care of 6/26/17. The record contained a plan of care for the recertification period of 12/07/20 to 2/4/21 that indicated the diagnoses of Paraplegia, unspecified, Neuromuscular dysfunction of the bladder, Post traumatic stress disorder, Neurogenic bowel and Major depressive disorder. The clinical record contained an agency document dated 1/28/21 titled "Revision to Plan of Care" that revealed "Discharge client from Nurses and More..." The record failed to evidence a discharge summary provided to the patient's primary healthcare representative or Entity A. During an interview on 8/9/21 at 12:32 PM with Entity A when queried about patient #9 and care from agency stated, "Patient #9 called me and let me know they discharged her without notice and care was the first report I received. We are looking into another agency for her PA (Prior Authorization) hours for staffing."