Every finding on record at Omnia Health Care LLC

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102 Survey Dates: 05/20/2025, 05/21/2025, 05/22/2025, 05/23/2025, 05/27/2025, and 06/03/2025. Active Census: 46 At this Emergency Preparedness survey, Brightstar Healthcare was found in compliance with the Emergency Preparedness Requirements for Medicaid Participating Providers and Suppliers, 42 CFR 484.102. QR by Area 3 on 6/6/2025.

This visit was for a Federal and State licensure complaint of a home health provider. Complaint # IN00115639 Survey Dates: 05/20/2025, 05/21/2025, 05/22/2025, 05/23/2025, 05/27/2025, and 06/03/2025. Unduplicated 12-month Skilled Admissions: 64 An Immediate Jeopardy, identified at §484.50 Patient Rights began on 01/28/2025, when it was identified the agency failed to ensure a patient received ordered 24-hour care and passed away on 01/28/2025, while unattended in a house fire. On 01/28/2025 HHA #1 had completed their shift with Patient #1 and left the patient's home between 8:10 - 8:15 AM. Between 8:45-8:50 AM, LPN #1 arrived at Patient #1's place of residence, saw smoke coming from the home and called 911. The patient was left unattended, without a home health staff member, for 35 minutes. Fire Incident and Coroner reports confirmed, Entity 2, a local fire department was dispatched at 8:54 AM, arrived on the scene at 8:59 AM, and the patient was pronounced dead at 9:09 AM. Interview with Person 3, the responding Fire Captain, confirmed patient was found dead and alone in the home. The Administrator and the Director of Nursing were notified of the Immediate Jeopardy on 05/23/2025 at 11:06 AM. The provider submitted a removal plan on 05/26/2025, which was found to be unacceptable, and again on 05/30/2025 at 6:59 PM which was acceptable. The Immediate Jeopardy was removed on 06/03/2025 at 11:55 AM. BrightStar HealthCare is precluded from providing its own home health aide training and competency evaluation program for a period of 2 years beginning 06/03/2025 through 06/02/2027 for being found out of compliance with the Conditions of Participation 42 CFR 484.50 Patient Rights, 484.60 Care Planning, coordination, quality of care, and 484.65 Quality assessment and performance improvement (QAPI). These deficiencies reflect State Findings cited in accordance with 410 IAC 17. See the State Form for State only deficiencies. Abbreviations used: RN - Registered Nurse POC - Plan of Care SOC - Start of Care HHA - Home Health Aide LPN - Licensed Practical Nurses DON - Director of Nursing QR by Area 3 on 6/06/2025.

Condition of Participation: Patient rights. CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient's rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This CONDITION is not met as evidenced by: Based on record review and interview the agency failed to ensure patient rights were maintained; failed to ensure a patient's were free from neglect (see G0430), and failed to ensure services were provided as ordered in the POC (see G0436) for 1 of 1 patient death's reported. The cumulative effect of these systemic problems resulted in the agency’s inability to ensure patients received appropriate care and services, which could result in the agency not providing quality care. These practices had the potential to impact all 46 active home health patients serviced by the agency. Findings include: 1. Review of the clinical record for Patient #1 with a start of care date 06/13/2019, and a recertification period of 12/16/2025 to 02/13/2025, with a primary diagnosis of quadriplegia (paralysis that affects all a person’s limbs and body from the neck down), indicated the patient was bedbound, required complete assist w/transfers, extensive assist w/dressing/grooming, bathing/hygiene, incontinence care, lived alone, and had minimal family/outside supports. The record indicated the patient was to receive home health aide services 24 hours per day, 7 days per week. 2. A review of a Fire Incident report, provided by Person 3, dated 01/28/2025 indicated Entity 2, a local fire department, was dispatched on 01/28/2025 to "residence fire with entrapment" at 8:54 AM, and arrived at Patient #1's home at 8:59 AM. A section titled 'IGNITION' stated, "… Area of Origin … Bedroom … Heat Source … Candle … Item First Ignited … Bedding; blanket, sheet, comforter … Cause of Ignition … Unintentional … Factors Contributing to Ignition 1 … Heat source too close to combustibles … Human Factors Contributing to Ignition … Unattended or unsupervised person …" A review of Entity 5's, a local county coroner office, 'Field Deputy Report', provided by Person 3, dated 01/29/2025 confirmed Patient #1's time of death was pronounced at 9:09 AM. A review of Entity 5's 'Report of Examination', provided by Person 3, dated 01/29/2025, indicated Patient #1 had cocaine and cannabis in their system. “CAUSE OF DEATH Arteriosclerotic and hypertensive cardiovascular disease … MANNER OF DEATH Natural … COMMENT Based upon the scene and circumstances of the death as currently known, combined with the autopsy and toxicology findings, the cause and manner of death are determined as above …” 3. On 05/21/2025 at 10:33 AM, in an interview with HHA 1, indicated on their last shift with Patient #1, they left the home between 8:10-8:15 AM, and it was not uncommon for HHA 1 to leave the patient, and the next aide was not yet there. On 01/28/2025, HHA 1 did not know who was coming next or when, but knew the next shift was filled. HHA 1 set up the patient's bedside table with needed items, including the patient's cigarettes, and ensured their candle was "on", noted the patient would have the aides start a new candle if the current one "was almost finished" and had a candle going all the time to be able to light their cigarettes independently. HHA 1 indicated when she left the patient, they were awake, sitting up in bed, smoking. On 05/21/2025 at 8:36 AM, during an interview, Person 3, the responding Fire Captain with Entity 2, a local fire department, confirmed 01/28/2025 Patient #1 was found dead and alone in their home. On 05/21/2025 at 10:50 AM, during an interview, LPN 1 indicated was scheduled to see Patient 1 on 01/28/2025, arrived between 8:45-8:50 AM to see smoke coming from the home and called 911. On 05/21/25 at 11:08 AM, during an interview, RN 1, case manager for Patient #1, indicated the patient was to have home health aides 24/7, and should not be left alone. When queried as to how the agency ensured 24/7 coverage, indicated 'that's scheduling'. On 05/21/2025 at 11:30 AM, during an interview, the ADMIN and DON indicated they were aware the patient had been left alone at times. On 05/21/2025 at 3:30 PM, during an interview with Administrative Staff 6 and the Administrator, Administrative Staff 6 indicated the patient's schedule was created based on the authorization from Entity 11, the patient's payor source, shifts were 10 hour days with 14 hour nights, and would try to ensure someone could come early or leave later to cover when there might be lapses, however schedules were not overlapped or staggered. The Administrator indicated the AM shift for 1/28/2025 was to start at 8:00 AM, the assigned staff was not available until 10:00 AM. On 05/21/2025 at 3:46 PM, during an interview, the Administrator indicated the agency was aware of the upcoming lapse of coverage the evening of 1/27/2025 and had also informed the patient, who was agreeable. The Administrator indicated the nurse already scheduled to see the patient on 1/28/2025 was contacted to move visit up to 9:00 AM. The Administrator indicated was aware there had been a 35 minute lapse in the patient's care that morning. On 05/22/2025 at 2:45 PM, during an interview, the ADMIN and DON were queried as to how Patient #1 could have gotten drugs in their system while receiving 24-hour care, the DON indicated it was possible an aide was doing laundry in the back of the home or had not been at bedside with patient. Indicated employees have not reported drug use, just hints and smells of marijuana.

Be free from abuse CFR(s): 484.50(c)(2) Be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect and misappropriation of property; This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure a patient's right to remain free from neglect, harm, and death, in 1 of 2 bedbound patients reviewed. (Patient #1) Findings include: 1. A review of an agency policy titled 'Rights and Responsibilities Policy' stated, "… The establishment and revision of the plan of care, including the disciplines that will furnish the care and the frequency of visits … 11. The right to be free from … neglect …" 2. Review of clinical record for Patient #1 with a start of care date 06/13/2019, a recertification period of 12/16/2024 to 02/13/2025, with a primary diagnosis of quadriplegia (paralysis that affects all a person’s limbs and body from the neck down) was bedbound, required complete assist w/transfers, extensive assistance w/dressing/grooming, bathing/hygiene, incontinence care. Lived alone, minimal family/outside supports. Resumption of Care Physician Orders dated 02/21/2024 indicated orders for Home Health Aide services were 24 hours per day 7 days per week. The record evidenced serial home health aide visit notes and skilled nurse visit notes, which indicated home health services had been provided: On 1/23/2025, from 8:00 AM-6:00 PM, and 7:58 PM-6:00 AM. The patient was without an aide present for 1 hour and 58 minutes. On 1/24/2025, from 7:40 AM-6:00 PM, and 6:00 PM-8:00 AM. The patient was without an aide present for 1 hour and 40 minutes. On 1/26/2025, from 8:10 AM-6:09 PM, and 8:04 PM to 6:03 AM. The patient was without an aide present for 8 minutes, and later, for 1 hour and 55 minutes. On 1/27/2025, the patient did not receive care until 5:39 PM-8:15 AM, with an LPN visit occurring 10:37 AM - 11:49 AM. The patient was without care during the day for 10 hours and 24 minutes. On 05/21/2025 at 10:33 AM, during an interview with HHA #1, indicated their last shift with Patient #1, was from 6:00 PM the previous evening, ended at 8:00 AM the morning of 01/28/2025, and had left the home between 8:10-8:15 AM. HHA #1 indicated it was not uncommon to leave the patient alone prior to the next aide arriving. They did not know who was coming for the next shift or when, but knew the next shift was filled. HHA #1 reported they had set up the patient's bedside table with needed items, including the patient's cigarettes, and ensured patient's candle was "on", noted that Patient #1 would have the aides start a new candle if the current one "was almost finished", and the patient had a candle going all the time to be able to light the cigarettes independently. On 05/21/2025 at 11:08 AM, during an interview, the RN Case Manager/Assistant Director of Nursing indicated Patient #1, was to have home health aide services 24 hours per day 7 days per week, and should not be left alone. During an interview on 05/21/2025 at 11:30 AM, the Administrator reported Patient #1 was left alone at times at the Patient's request and confirmed Patient #1 did have an order for 24 hour care. The Administrator indicated missed visits were communicated to the insurance company case managers handling Patient #1's workman's compensation. During an interview on 05/21/2025 at 3:32 PM, Administrative staff #6 reported Patient #1 was to receive 24 hour care for 7 days a week and the shifts where scheduled for 14 hours overnight and 10 hours for days to ensure there were no lapses in service. The shifts were 8:00 AM to 6:00 PM and 6:00 PM until 8: 00 AM. The Administrator also reported on January 28th, 2025 the agency was aware there would be a gap in Patient #1's schedule from 8:00 AM until 10:00 AM. The patient was aware of this the night before and contacted a nurse to come at 9:00 AM and reported the Aide stayed until 8:15 AM with the nurse arriving at about 8:50 AM, leaving a 35 minute gap. On 05/22/2025 at 11:45 AM, during an interview, when queried as to whether they were aware the patient kept a candle lit, the Administrator indicated they were aware. When queried as to whether staff had been educated against keeping the candle lit, indicated no education had been provided to staff. On 05/22/2025 at 1:57 PM, during an interview, HHA 8 indicated they had cared for Patient #1 and would sometimes go and get the patient something to eat, would light cigarettes for the patient as they could not do this for themselves, and stated the patient "would have us pick up candles" at the store and the patient would have to stay by themselves and be alone for that time. When queried as to whether they knew the patient was a 24 hour per day 7 day per week patient, indicated, "I don't know, it was never told to me, if so I would have wanted to know … was under the impression [Patient #1] could be left alone for a bit". On 05/22/2025 at 2:06 PM, during an interview, RN 4 indicated had cared for Patient #1 on occasion and when queried as to whether the patient should have been left alone, stated "probably not, [Patient #1] was completely bedbound". Indicated patient was chain smoker, would light cigarettes with the candle, and had a candle going constantly while awake. When queried as to whether there had been occasions when the aide was not present when RN 4 arrived for a nursing visit, RN 4 confirmed there were times an aide was not present, as their arrival time may have fallen during 4:30 - 5:30 PM, "between day and evening shift". On 05/22/2025 at 2:44 PM, during an interview, HHA 2 confirmed had cared for Patient #1, and would run errands, go out to get food, or get cigarettes for the patient and the patient would be left alone at those times. Indicated the patient was a heavy smoker, could hold a cigarette in his left hand, and could extinguish it in the ashtray. The patient could light the cigarettes themselves with a candle, and kept a candle lit. HHA 2 indicated when they would arrive to the home a candle was going all the time, "before I came, after I left". Indicated was aware this was a 24/7 case, when they arrived sometimes there was another HHA, sometimes not. Same when leaving. Indicated that some evenings there would be an aide to relieve them, but the arrangement did not involve having the next shift come early or stay late to ensure coverage. 410 IAC 17-12-3(b)(4)(A)

Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to provide services as ordered in the Plan of Care for Patient #1 a bedbound patient with quadriplegia (paralysis that affects all a person’s limbs and body from the neck down), for 1 of 2 bedbound patients' clinical records reviewed. (Patient #1) Findings include: 1. A review of an agency policy titled 'Rights and Responsibilities Policy' stated, "… The establishment and revision of the plan of care, including the disciplines that will furnish the care and the frequency of visits …" A review of an agency policy titled, 'Missed Visits Policy' stated, "… Missed visits will be communicated to the client's Licensed Prescriber or designee … Missed visits will be documented as an incident report and uploaded into the client's chart … If a visit is missed for any reason, the clinician should attempt to reschedule it for the same day or week so that the Licensed Prescriber ordered frequency is maintained and would not be considered a missed visit …" 2. A review of the clinical record for Patient #1 with a start of care date of 06/13/2019, a recertification period of 12/16/2025 to 02/13/2025, and a primary diagnosis of quadriplegia (paralysis that affects all a person’s limbs and body from the neck down) the comprehensive assessment dated 12/16/2024 indicated the patient was bedbound, required complete assistance with transfers, extensive assistance with dressing/grooming, bathing/hygiene, incontinence care. The patient lived alone, and had minimal family/outside supports. Review of the record failed to evidence documentation of missed visit or lapses in care being reported to the patient's physician. The record contained 'Resumption of Care Physician Orders' dated 02/21/2024 which evidenced orders for Home Health Aide services 24 hours per day 7 days per week. The record evidenced an authorization from Entity 11 (payor source), dated 12/18/2020 which indicated the patient was to receive home health aide services "24/7". The record contained a plan of care dated 12/16/2024 for the recertification period of 12/16/2024 to 02/13/2025 which failed to evidence the frequency and duration for the home health aide services ordered. The record evidenced serial home health aide visit notes and skilled nurse visit notes, which indicated home health services had been provided: On 1/23/2025, from 8:00 AM-6:00 PM, and 7:58 PM-6:00 AM. The patient was without an aide present for 1 hour and 58 minutes. On 1/24/2025, from 7:40 AM-6:00 PM, and 6:00 PM-8:00 AM. The patient was without an aide present for 1 hour and 40 minutes. On 1/26/2025, from 8:10 AM-6:09 PM, and 8:04 PM to 6:03 AM. The patient was without an aide present for 8 minutes, and later, for 1 hour and 55 minutes. On 1/27/2025, the patient did not receive care until 5:39 PM-8:15 AM, with an LPN visit occurring 10:37 AM - 11:49 AM. The patient was without care during the day for 10 hours and 24 minutes. 3. On 05/21/2025 at 10:33 AM, in an interview with HHA #1, indicated their last shift with Patient #1, was from 6 PM the previous evening, ended at 8 AM the morning of 01/28/2025, and had left the home between 8:10-8:15 AM. HHA #1 indicated it was not uncommon to leave the patient and the next aide would not be there yet, and indicated did not know who was coming for the next shift or when, but knew the next shift was filled. HHA #1 indicated had set up the patient's bedside table with needed items, including the patient's cigarettes, and ensured patient's candle was "on", noted that Patient #1 would have the aides start a new candle if the current one "was almost finished", and the patient had a candle going all the time to be able to light the cigarettes independently. On 05/21/2025 at 11:08 AM, during an interview, RN 1 indicated had been the case manager for Patient #1 who was to have home health aide services 24 hours per day 7 days per week, and should not be left alone. When queried as to how the agency ensured 24-hour coverage, RN 1 indicated 'that's scheduling'. On 05/21/2025 at 11:30 AM, during an interview, the Administrator and DON indicated they were aware the patient had been left alone at times. On 05/21/2025 at 3:30 PM, during an interview, Administrative Staff 6 indicated Patient #1's schedule was created based on the patient's insurance, Entity 11's, authorization, shifts were 10 hour days with 14 hour nights, and would try to ensure someone could come early or leave later to cover when there might be lapses. Schedules were not overlapped or staggered. On 05/21/2025 at 3:36 PM, during an interview, when queried as to whether the MD for Patient #1 had been made aware when the patient's hours could not be fulfilled or visits had been missed, the Administrator indicated that no missed visits had been reported to the MD. On 05/22/2025 at 2:06 PM, during an interview, RN 4 indicated had cared for Patient #1 on occasion and when queried as to whether the patient should have been left alone, indicated "probably not, [Patient #1] was completely bedbound". When queried as to whether there had been occasions when the aide was not present when RN 4 arrived for a nursing visit, RN 4 confirmed there were times an aide was not present, as their arrival may have fallen during 4:30 - 5:30 PM, "between day and evening shift". On 05/23/2025 at 12:51 PM, during an interview with Person 10, a nurse practitioner for Person 12, the physician for Patient #1, indicated there were no records on file of communication from the home health agency notifying the doctor when hours had not been fulfilled or when visits had been missed for Patient #1.

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 record review and interview the agency failed to include all elements required in the Plans of Care (see G0574), and failed to ensure MD was notified with changes in patient's condition (see G0590). The cumulative effect of these systemic problems resulted in the agency’s inability to ensure patients received appropriate care and services, which could result in the agency not providing quality care. These practices had the potential to impact a total 46 active home health patients serviced by the agency. *

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the POC had correct certification periods, duration of services, all services the agency provided, prognosis, hospitalization risk, and rehabilitation potential for 4 of 5 active records reviewed (Patients #3, #4, #5, and #6), and 1 of 2 closed records reviewed (Patient #1). Findings Include: 1. A review of an agency policy titled 'Care Planning Process Policy' stated, "… 3. Based on the assessment and conclusions, the plan of care will include, but not be limited to: … D. Specific services and treatments to be provided … F. Type, frequency, and duration … N. Prognosis …" 2. A review of the clinical record for Patient #1 with a start of care date of 06/13/2019, contained a recertification period of 12/16/2025 to 02/13/2025, contained comprehensive assessment dated 12/16/2024, with a primary diagnosis of quadriplegia (paralysis that affects all a person’s limbs and body from the neck down) indicated the patient was bedbound, required complete assistance with transfers, extensive assistance with dressing/grooming, bathing/hygiene, and incontinence care. The patient lived alone, with minimal family/outside supports. The record contained a 'Home Health Certification and Plan of Care' dated 12/16/2024 which failed to evidence the frequency and duration for home health aide services. The record contained 'Resumption of Care Physician Orders' dated 02/21/2024 which evidenced orders for Home Health Aide services 24 hours per day 7 days per week. The record contained a 'Home Health Certification and Plan of Care' signed and dated by RN 1 on 12/17/2024 for the recertification period of 12/16/2024 to 02/13/2025 (59 days), the document failed to evidence an accurate certification period, and failed to evidence the frequency and duration for the home health aide services ordered. On 05/27/2025 at 10:12 AM, RN 1, when queried regarding recertification periods on the Plan of Care, indicated, the way their system works, the day a recertification assessment is completed, becomes the first day of the new certification period, the agency's electronic medical records system was doing that and, "we can't change that". On 05/27/2025 at 10:51 AM, the DON indicated was aware that certification periods were 60 days long, recert visits needed to be completed in the 5-day window previous to the end of the certification period, and was also aware the agency's electronic medical records system would automatically change the dates of the next certification period. The system would make the first day of new certification period, the day the recertification visit was completed, failing to ensure the certification dates were accurate. The DON indicated the agency had tried to fix this, but there was no way to do so. On 05/27/2025 at 1:10 PM, the DON was queried as to patient plans of care with missing frequency and durations for disciplines, the DON indicated the frequencies and durations were not there, and they should be. 3. Review of the clinical record for Patient #3 revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 10/25/2023 for the certification period of 02/05/2025 through 04/05/2025 and signed by RN 3. Review of the clinical record for Patient #3 revealed a recertification assessment dated 02/05/2025 and signed by RN 3. Review of the clinical record for Patient #3 revealed a recertification assessment dated 04/02/2025 and signed by RN 2. The assessment indicated Patient #3 has a tracheostomy (a surgical procedure where an opening is made in the trachea (windpipe) to create a new airway for breathing), uses a cough vest, and has a feeding tube. Review of the clinical record for Patient #3 revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 10/25/2023 for the certification period of 04/02/2025 through 05/31/2025 and signed by RN 2. The POC evidenced Patient #3 has the following diagnosis but is not limited to, mandibulofacial dysostosis (also known as Treacher Collins Syndrome, which is a rare genetic disorder characterized by malformations of the skull, facial bones, and parts of the ear; it specifically affects the growth of bones in the face leading to underdeveloped cheekbones and jaw), Cleft palate (a birth defect where there's an opening in the roof of the mouth (palate)), and seizure disorder (a neurological (brain) condition characterized by recurrent seizures, which are sudden, brief episodes abnormal electrical activity in the brain that can cause changes in behavior, sensations, awareness, and muscle movements). The POC evidenced a blank surgical procedure subsection. The POC subsection titled "DME and Supplies" evidenced diapers, brace, cane, other - Mickey button (also known as a Mic-Key button, is a low profile, button-like gastrostomy tube, a type of feeding that allows nutrition, fluids, and medication to be delivered directly into the stomach through an opening in the abdominal wall), Infinity pump (a pump used to deliver tube feedings to an individual through a gastrostomy tube), nebulizer (device used to produce a fine spray of liquid used for inhalation of a medication), gloves, and suction. The POC subsection titled "Safety Measures" indicated but is not limited to " … Seizure Precautions …" The POC subsection titled "Orders for Treatment and Discipline" evidenced but is not limited to treatments for the SN to perform, and " … Other, SN Skilled Nursing as needed, attend MD appointments with family as indicated to help with understanding of instructions/changes to care …" The POC failed to evidence an accurate certification period, all pertinent diagnosis, DME: cough vest, tracheostomy supplies, and feeding tube supplies, the seizure plan, aspiration precautions, and the frequency and duration of SN services. During an interview on 05/27/2025 at 2:03 PM, RN 2 indicated they were familiar with Patient #3. When queried about the certification periods, RN 2 indicated they do not enter any dates into the POC. When queried about how they determine which diagnosis to include on the POC, RN 2 indicated they are required to have the principal diagnosis, and then one or two secondary diagnosis. When queried if the presence of a tracheostomy or Mickey button should be included on the POC, RN 2 indicated "100%" When queried if tracheostomy supplies or the cough vest were considered DME, RN 2 indicated yes. When queried about what safety measures should be included for a patient with a Mickey button and tracheostomy, they indicated aspiration precautions. When queried about the frequency and duration of SN services received, RN 2 indicated "I am aware of the requirement for hospice, and it makes sense it carries over into home health" 4. A review of Patient #4's clinical record evidenced POCs with a SOC date of 01/28/2013 and certification periods from 03/15/2025 to 05/13/2025, 05/12/2025 to 07/10/2025, and signed by RN 5. The POC evidenced the following diagnoses: Paralysis (the inability to move a part or more of the body), Depression (constant low mood and lack of interest in activities), Bradycardia (low heart rate), and Bladder disease (a condition causing urinary incontinence). The POC indicated but was not limited to, " … daily HHA and SN for personal care, bowel program catheter management …". The POC included an order with a start date of 09/18/2024 and an end date of 09/21/2024. The order indicated but was not limited to, " … SN … As Needed, SN may cover blister on left lower back and any others that may occur with dry gauze for protection; if blister ruptures, may clean with soap/water, pat dry and cover with hydrocolloid for protection …". The section titled "22. Goals/Rehabilitation Potential/Discharge Plans" had not included an area for rehabilitation potential. The POC failed to evidence the certification periods with the last date of the previous POC, duration of HHA and SN services, frequency of SN services for the bowel program and catheter management, prognosis, the patient's risk of hospitalization, and rehabilitation potential. During an interview with RN 5 on 05/27/2025 at 10:18 AM, they explained they saw the patient 11 to 14 times a week for Patient #4's bowel program and bladder assessment and in the afternoon for catheter care and medication set-up was one time a week. They indicated the HHA performed transfers, brushed teeth, changed bedding, assisted with dressing, meal preparation, ran errands, picked up the patient's medications from the pharmacy, and drive the patient to the doctor's office. They explained certification periods were every 60 days and the POC covered the period. When queried regarding the orders for the blister on the POC, they indicated the patient had not had a blister for a while and had it included on an as needed basis in case it returned. They explained they would call the physician to confirm the order if the blister returned. RN 5 indicated the prognosis, rehabilitation potential, and hospital risk should be included. 5. A review of Patient #5's clinical record evidenced POCs with an SOC date of 08/11/2021 with a certification period from 03/05/2025 through 05/03/2025 and 04/30/2025 through 06/28/2025. The POC evidenced the following diagnoses: Stroke (a medical emergency caused by blood not flowing to the brain appropriately), Chronic Obstructive Pulmonary Disease (a disease causing breathing problems and constricted airflow), Hypertension (high blood pressure), and Aphasia (a neurological condition where the person has difficulty communicating). The POC indicated the patient received HHA services seven hours a day for seven days a week. The section titled "22. Goals/Rehabilitation Potential/Discharge Plans" had not included an area for rehabilitation potential. The POC failed to evidence the certification periods with the last date of the previous POC, duration of HHA services, and rehabilitation potential. During an interview with RN 3 on 05/27/2025 at 11:13 AM, when queried regarding Patient #5's rehabilitation potential, they explained the patient had a "good/fair" rehabilitation potential. They indicated the certifications were 60 days and the next certification period started from the time of the recertification period assessment. They indicated the POC covered the services provided during the certification period on the POC. 6. Review of the clinical record for Patient #6 revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 06/24/2024 for the certification period of 03/24/2025 through 05/22/2025 and signed by RN 4. Review of the clinical record for Patient #6 revealed a recertification assessment dated 03/24/2025 and signed by RN 4. Review of the clinical record for Patient #6 revealed a recertification assessment dated 05/19/2025 and signed by RN 2. The assessment subsection titled "Education/Training" indicated but was not limited to, " … added SN for wound care 3x/week - educated wife and HHA on s/s [signs and symptoms] of wound infection/complication to report …" Review of the clinical record for Patient #6 revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 06/24/2024 for the certification period of 05/19/2025 through 07/17/2025 and signed by RN 2. The POC evidenced Patient #6 has the following diagnosis but is not limited to, peripheral neuropathy (damage to the nerves outside ethe brain and spinal cord resulting in symptoms such as numbness, tingling, or weakness), Parkinsons disease (a progressive neurological disorder characterized by tremors, rigidity, slowness of movement, and balance problems), Ischemic Heart Disease (condition where the heart muscle doesn't receive enough blood and oxygen due to narrowed or blocked arteries), and Hypertension (high blood pressure (the force exerted by blood against the walls of the arteries as it is pumped by the heart throughout the body). The POC subsection titled "Orders for Treatment and Discipline" indicated the SN provides wound care three times a week. The POC failed to evidence an accurate certification period, duration for SN services, and the interventions, frequency, and duration of HHA services. During an interview on 05/27/2025 at 1:32 PM, Person 8, a family member of Patient #6, indicated Patient #6 receives 44 hours per week for the HHA services. During an interview on 05/27/2025 at 1:53 PM, RN 2 indicated they were familiar with Patient #6. When queried about the services Patient #6 received, RN 2 indicated skilled nursing, and HHA was also showing on the patient schedule. When queried if you would want to include what services, frequency, and duration are received, RN 2 indicated the information pulls over from the previous assessment, so if the information was not included previously this could be why the information is missing. When queried how to determine certification periods, RN 2 indicated the dashboard has a date assigned, and they were taught to complete the visit the day before the due date within five days. 410 IAC 17-13-1(a)(1)(D)(iii, iv, v, xiii)

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 providers were promptly notified with patients' changes in condition, in 1 of 2 bedbound patients reviewed. (Patient #1) Findings include: 1. A review of agency policy titled 'Contents of the Clinical Record Policy' stated, "… Q. Statement of any changes in the patient's condition related to care and service … V. Relevant communication to the patient's Licensed Prescriber …" 2. A review of the clinical record for Patient #1 with a start of care date of 06/13/2019, a recertification period of 12/16/2025 to 02/13/2025, and a primary diagnosis of quadriplegia (paralysis that affects all a person’s limbs and body from the neck down) was bedbound, required complete assistance with transfers, extensive assistance with dressing/grooming, bathing/hygiene, and incontinence care. The patient lived alone, with minimal family/outside supports. Medications included but were not limited to: Baclofen (medication used to relax certain muscles) 20 milligrams (mg) tablet, one tablet twice daily by mouth and Lyrica (medication used to treat nerve pain that may associated with injury to the spinal cord, among other causes) 300 milligrams (mg) capsule, one capsule twice daily, by mouth. Skilled nursing visits were ordered daily for wound/skin assessment, vital signs, change dressing around suprapubic catheter site, assess for urinary tract infection, assess, assist with home health aide care as indicated, and report congestive heart failure symptoms. The record contained a plan of care dated 12/16/2024 for the recertification period of 12/16/2024 to 02/13/2025 which failed to evidence vital sign parameters reportable to the physician, had been included. The record contained a nursing visit note dated 12/09/2024 conducted by RN 4, and evidenced the patient's vital signs were: blood pressure 160/90, Temperature: 97.8 Fahrenheit, Pulse: 57, Breaths per minute: 10, and the following: "… Comments/Intervention: Client is very drowsy. HHA stated that the client took only [their] baclofen and lyrica this morning, and stated, "I have never seen [Patient #1] take two of the one medication at the same time" … Arousable by sternal rub. Oriented to person and place. VS (vital signs) Stable … Nurse spoke to patient on the importance of taken medication as prescribed … Notes: … Client was very drowsy during this nursing visit. This RN did not witness the client take any medication, but per HHA, the client took [their] baclofen and lyrica this morning at a higher dose than [the aide] has seen [Patient #1] take before. VS (vital signs) stable …" The record contained a separate document titled 'Narrative Note' dated 12/10/2024 and completed by RN 4 at 3:40 PM on 12/10/2024, which stated, "This RN called and spoke with [Person 13, patient care coordinator for Person 12, Patient #1's physician] regarding the client's prescribed medication usage. At the client visit on 12/9/24, the client required sternal rubbing to be aroused to assess for orientation. The HHA stated the client had only taken his baclofen and lyrica that morning, and more of those medications than [the aide] had seen [patient] take previously. Person 13 made a note and said that [they] would pass the information along to Person 12, the physician, for future appointments." The record contained a nursing visit note dated 12/21/2024 conducted by RN 6, evidenced an elevated blood pressure reading of 162/102, the note also contained instructions, "… check BP … notify MD if issues …" and failed to evidence the nurse had contacted the patient's physician to notify of the elevated reading. 3.On 05/22/2025 at 9:32 AM, during an interview, the DON indicated if there are changes in patients' condition they notify the MD, then if the patient is a workman's compensation case, the workman's compensation case manager is notified. On 05/22/2025 at 1:31 PM, in an interview, RN 6 indicated had cared for Patient #1 on occasion. When queried as to whom would be notified with changes in patients' condition or any concerns, RN 6 indicated would, "call my case manager, the office manager, or the case manager" with Entity 11. When queried as to the whether the physician had been contacted regarding the elevated blood pressure reading for Patient #1 discovered on 12/21/2024, RN 6 indicated had not done so, but it was their current understanding the nurses themselves were to contact the MD directly, and stated the agency had provided this education to staff shortly after the death of Patient #1, which included notifying patients' MDs, for example, when patients were non-compliant with meds or had elevated blood pressure readings. On 05/22/2025 at 2:06 PM, in an interview, RN 4 indicated had cared for Patient #1, and when queried about the 12/09/2024 visit which indicated the patient was very drowsy and required sternal rub for arousal, and whether the patient's provider had been contacted, RN 4 indicated they recalled the visit and indeed the patient responded to the sternal rub and they had stayed with the patient until the patient was stable and vital signs were stable, and had contacted the physician and documented same. On 05/27/2025 at 10:21 AM, in an interview, Person 14, a nurse practitioner for Person 12, Patient #1's physician, indicated they were in receipt of phone message from RN 4, dated 12/10/2024, which indicated during the previous day's nursing visit of 12/09/2024, the patient had required sternal rubbing to be aroused, and Person 14 indicated understood the agency had called emergency medical system (EMS) to respond to incident. 410 IAC 17-13-1(a)(2)

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 ensure the Governing Body approved the frequency and detail of the data collection(see G644) the agency failed to ensure clear expectations for patient safety were established and implemented (see G0660). These practices had the potential to impact all 46 active patients. 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, resulting in non-compliance with Condition of Participation CFR 484.65 Quality Assessment/Performance Improvement. *

Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA's governing body. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the Governing Body approved the frequency and detail of the data collection for 1 of 1 Agency. Findings include: 1. A review of a policy titled, 'Governing Body No. 4-001' stated, "The Governing Body of BrightStar Healthcare will serve as the governing authority for the home services program, which will function according to BrightStar Healthcare's bylaws/processes and will assume full legal authority and responsibility for the operation of BrightStar Healthcare … The Governing Body will review BrightStar Healthcare's … and other information relevant to the quality of patient care (i.e., unusual occurrences in care delivered is also consistently provided through a defined process) at least annually … 2. Meeting minutes will be maintained for each meeting …" 2. A review of the meeting minutes from 05/19/2025 indicated their 2024 year to date discussion included Quality Assessment Performance Improvement (QAPI) review which consisted of policy changes, office staff changes - new RN Case Manager. The record failed to evidence what policy changes occurred and failed to identify the discussion regarding details of QAPI. 3. On 05/22/2025 at 9:15 AM, the Director of Nursing indicated they had created Performance Improvement Projects and new policies Mid-February 2025, but hadn't presented them to the Governing Body for review and approval. 410 IAC 17-12-2(a)

Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA's governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This STANDARD is not met as evidenced by: Based on record review and interview, the Governing Body failed to ensure a program for quality monitors and patient safety were established and implemented with 1 of 1 agency. Findings include: 1. A review of a policy titled, 'Governing Body No. 4-001' stated, "The Governing Body of BrightStar Healthcare will serve as the governing authority for the home services program, which will function according to BrightStar Healthcare's bylaws/processes and will assume full legal authority and responsibility for the operation of BrightStar Healthcare. Procedure 1. The Governing Body will review BrightStar Healthcare's bylaws/processes and other information relevant to the quality of patient care …" A review of a policy titled 'Compliance Plan Policy No. 4-009' stated, "BrightStar Healthcare has established this plan to ensure that quality patient care is provided in a manner that complies with all applicable laws and regulations. It is the policy of BrightStar Healthcare that: … (2) there is periodic monitoring and oversight of compliance with those laws … (5) mechanisms exist to investigate … correct non-compliance. Procedure … 2. The CO oversees the education of personnel regarding proper compliance, the auditing and monitoring of the statutes of compliance, and the reporting, investigation … correction of non-compliance … 3. The CO reports on the compliance plan to the Quality Assurance Performance Improvement (QAPI) and The Governing Body (at least annually) … 5. Periodic audit and monitoring plans will be developed …" A review of a policy 'Sentinel Event Policy No. 4-007' stated, "A sentinel event and associated reporting requirements are part of the organization's overall performance improvement and risk management plan … Definition: Sentinel event: An unexpected occurrence involving death or serious physical …" 2. A review of the Governing Body meeting minutes from 05/19/2025 indicated their 2024 year to date discussion included Quality Assessment Performance Improvement (QAPI) review, policy changes, office staff changes - new RN Case Manager. The record failed to evidence what policy changes occurred and failed to identify the discussion of QAPI. 3. A review of the meeting minutes from the Quarterly Quality Committee meeting Minutes dated 05/19/2025 indicated data collection/tracking of customer satisfaction, clinical quality, infection control, risk management which included falls, hospitalizations, infections, HIPPA Events, Incident Reports - Unusual Event Findings, Medication errors by staff and Near Misses by Staff. Performance Improvement Projects developed were: Infections in clients, LPN's and HHA's must have supervisory visit every 30 days per regulations with state, Call logger not being using correctly, Incident reports, and Missed visits. The record failed to identify what the Incident - unusual event findings were. 4. On 05/22/2025 at 9:15 AM, the Director of Nursing indicated they had created Performance Improvement Projects and new policies Mid-February 2025, but hadn't presented them to the Governing Body for review and approval.

Documentation of competency evaluation CFR(s): 484.80(c)(5) The HHA must maintain documentation which demonstrates that the requirements of this standard have been met. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure home health aides completed competency testing upon hire with 3 of 3 home health aides. (HHA 1, 2, and 3) Findings include: 1. The record reviews of HHA 1, 2, and 3 failed to evidence written competency testing was conducted upon hire. 2. On 05/23/2025 at 1:38 PM, Administrative Staff 5, human resources, indicated they were unaware a written test for HHA's were a requirement. 3. On 05/27/2025 at 10:10 AM, when queried the DON and Administrator indicated they were unaware a written competency test was required for HHA's upon hire. 410 IAC 17-14-1(I)(2)

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the HHAs practiced within their scope by transporting and running errands for patients for 2 of 5 active clinical records reviewed. (Patients #2 and #4) and 1 of 2 closed records reviewed. (Patient #1) Findings Include: 1. An agency HHA job description indicated but was not limited to, " … Essential Job Functional/Responsibilities … 5. Provide transport to doctor appointment, outside activities and shopping …" 2. A review of the clinical record for Patient #1 evidenced a home health aide care plan which indicated tasks for the aide included, "Action: Complete Errands … Frequency: As Per Client Request … For: Home Health Aide" The record contained serial home health aide notes, dated from 12/11/2024 through 01/27/2025. Each visit evidenced the task titled "complete errands" had been marked "completed". On 05/21/2025 at 10:33 AM, when queried if home health aides should be providing transport or running errands for patients, the Administrator indicated they communicate to patients that the agency does not provide this. When queried if he was aware these items were listed as tasks on Aide Care Plans of current patients, the Administrator indicated was not aware of this, but was aware that it may be occurring, and staff had not been directed to do so. On 05/22/2025 at 1:31 PM, RN 6 indicated Home Health aides provided errands and shopping for agency patients. Indicated was aware patient was to receive 24/7 care. Indicated sometimes Patient #1 would not have an aide present when they arrived for nursing visits, as the aides would sometimes go to the store for Patient #1. On 05/22/2025 at 1:57 PM, HHA 8 indicated had cared for Patient #1, would sometimes go and get the patient something to eat, would light cigarettes for the patient as they could not do this for themselves, stated, the patient "would have us pick up candles" at the store. On 05/22/2025 at 2:06 PM, RN 4 indicated had cared for Patient #1, when queried as to whether the patient should have been left alone, indicated "probably not, [Patient #1] was completely bedbound". Indicated the Case Manager had informed the patient that home health aides could not pick up medications, but RN 4 indicated had been aware aides would pick up food and prescriptions for the patient. 3. A review of the plan of care for Patient #2 indicated a start of care of 04/30/2024 and recertification period of 04/30/2025 and resumption of care on 05/13/2025 with a diagnosis of quadriplegia (the inability to move a part or more of the body) and orders for a home health aide 5-7 days a week for up to 8 hours. A document received from the agency on 05/23/2025 at 2:50 PM titled Plan of Care Active electronically signed by the Assistant Director of Nursing indicated the home health aide duties included but were not limited to the home health aide tasks included "errands." In a section titled "Independent Level of Assistance Who Helps" the plan of care evidenced, "errands complete assist . . . Brightstar . . . transportation complete assist . . . Brightstar." During an interview on 05/23/2025 at 2:34 PM HHA #7 aide for Patient #2, they reported transporting Patient #2 to appointments and shopping. When queried if this was as a home health aide or as part of a separate personal service agency, they reported they were not sure what the difference was. HHA #7 reported they were instructed to do this by Administrative Staff #6. Patient #4's clinical record included a document with a "Plan of Care Effective Date: 05/12/2025" and "Case Type: Personal Care Service". The POC evidenced the HHA provided assistance with errands and transported the patient "As Per Client Request". 4. A review of Patient #4's clinical record evidenced the documents titled "Consolidated Care Notes" for HHA 5's visits. HHA 5 indicated in the visit notes, they completed errands for the patient on 03/24/2025, 03/26/2025, 03/29/2025, 03/31/2025, 04/04/2025, 04/08/2025, 04/09/2025, 04/13/2025, 04/15/2025, 04/17/2025, 04/18/2025, 04/23/2025, 04/24/2025, 04/27/2025, 04/29/2025, 04/30/2025, 05/02/2025, 05/10/2025, 05/11/2025, 05/14/2025, and 05/16/2025 and transported and ran errands for the patient on the visit note dated 04/28/2025. The task was evidenced as completed by "C" (sic Completed). Patient #4's clinical record included "Consolidated Care Notes" for HHA 4. The visit notes evidenced they completed errands and transported the patient for the visits dated 03/24/2025, 04/05/2025, 04/06/2025, 04/07/2025, 04/19/2025, 04/20/2025, 04/21/2025, 05/03/2025, 05/04/2025, 05/05/2025, 05/17/2025, 05/18/2025, and 05/19/2025. The task was evidenced as completed by "C" (sic Completed). Patient #4's clinical record included "Consolidated Care Notes" for Former Employee 6, per Other Roster. The visit notes evidenced they completed errands and transported the patient for the visits dated 03/25/2025, 03/26/2025, 03/27/2025, 03/28/2025, 04/01/2025, 04/02/2025, and 04/03/2025. The task was evidenced as completed by "C" (sic Completed). Patient #4's clinical record included "Consolidated Care Notes" for HHA 9. The visit notes evidenced they completed errands only for the visits dated 04/08/2025, 04/10/2025, 04/30/2025, and 05/06/2025 and errands and transported the patient for the visit dated 04/09/2025. The task was evidenced as completed by "C" (sic Completed). During an interview with HHA 5 on 05/27/2025 at 9:26 AM, they indicated they rarely transported the patient, but occasionally will take Patient #4 to their doctor's appointments. They explained the patient mostly had Person 6, a former HHA, assist them with driving where they needed. HHA 5 explained they knew what tasks they could complete based on the task list on their line. During an interview with RN 5 on 05/27/2025 at 10:18 AM, they indicated the HHA performed transfers, brushed teeth, changed bedding, assisted with dressing, meal preparation, ran errands, picked up the patient's medications from the pharmacy, and drove the patient to the doctor's office. During an interview with RN 3 on 05/27/2025 at 11:13 AM, when queried regarding the tasks HHA's were not able to complete, they indicated the HHAs had to abide by the HHA guidelines by not transporting the patient, and had to stay with the patient.

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 Home Health Aides were supervised no less often than every 14 days, for 2 of 3 active clinical records reviewed with SN and HHA services (Patients #4 and #6) , and for 1 of 2 closed clinical records reviewed. (Patient #1) Findings include: 1. A review of an agency policy titled "Client Supervisory Visit Policy" indicated but was not limited to, " … Unless state regulations are more stringent, client supervisory visits will be performed at the following intervals: For skilled care, visits are to be performed every sixty (60) days (certification period) at a minimum) …" 2. A review of the clinical record for Patient #1 failed to evidence documentation of completed supervisory visits from 12/1/2024 through 01/28/2025. On 05/27/2025 at 10:39 AM, in an interview, the DON indicated supervisory visits of HHA's were conducted every 30 days, and when queried if it made a difference whether the case was skilled or un-skilled, indicated "always 30 days, the RN must supervise". On 05/27/2025 at 1:09 PM, in an interview, the DON submitted a home health aide supervisory visit note for Patient #1 dated 12/16/2024, which failed to evidence the name of the aide being supervised. When queried, the DON indicated there was no name due to the fact the document was a 'draft', and had not been fully completed by the nurse, and confirmed there were no other home health aide supervisory visits 12/16/2024 through 1/27/2025. 3. A review of Patient #4's clinical record evidenced POCs with a SOC date of 01/28/2013 and certification periods from 03/15/2025 to 05/13/2025 and 05/12/2025 to 07/10/2025 signed by RN 5. The POC indicated but was not limited to, " … daily HHA and SN for personal care, bowel program catheter management …". Patient #4's clinical record evidenced HHA supervisory visit notes dated 03/25/2025 by RN 5 and 04/25/2025 by RN 7. The clinical record failed to evidence supervisory visit notes for an HHA were completed every 14 days for a patient receiving SN and HHA services. During an interview with RN 5 on 05/27/2025 at 10:18 AM, they indicated they only performed supervisory visits when asked on the HHA. They explained supervisory visits were done monthly. 4. Review of the clinical record for Patient #6 revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 06/24/2024 for the certification period of 05/19/2025 through 07/17/2025 and signed by RN 2. The POC evidenced Patient #6 has the following diagnosis but is not limited to, peripheral neuropathy (damage to the nerves outside ethe brain and spinal cord resulting in symptoms such as numbness, tingling, or weakness), Parkinsons disease (a progressive neurological disorder characterized by tremors, rigidity, slowness of movement, and balance problems), Ischemic Heart Disease (condition where the heart muscle doesn't receive enough blood and oxygen due to narrowed or blocked arteries), and Hypertension (high blood pressure (the force exerted by blood against the walls of the arteries as it is pumped by the heart throughout the body). The POC subsection titled "Orders for Treatment and Discipline" indicated the SN provides wound care three times a week. Review of the clinical record for Patient #6 revealed a HHA care plan signed by RN 2 and dated 05/19/2025. Review of the clinical record for Patient #6 revealed a document titled "Customer Supervisory Visit Status: Complete" dated 03/24/2025 and signed by RN 4, and visits dated 04/25/2025 and 05/22/2025 and signed by RN 2. The clinical record failed to evidence a supervisory visit was performed every 14 days by an RN. During an interview on 05/27/2025 at 1:53 PM, RN 2 indicated "I don't know the answer to that," when queried about how often supervisory visits should be completed for HHA caring for a patient who also receives SN. RN 2 indicated the dashboard instructs when supervisory visits are due by assigning the visits.

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 execute all of their responsibilities for the day-to-day operations of the home health agency, for 1 of 1 Agency. Findings include: 1. A review of an agency policy titled 'Rights and Responsibilities Policy' stated, "… The establishment and revision of the plan of care, including the disciplines that will furnish the care and the frequency of visits … 11. The right to be free from … neglect …" The Administrator failed to ensure a patient's right to remain free from neglect, when the frequency and duration of services for 24-hour care, 7 days a week was not provided as ordered, periodically subjecting patient to being without the ordered care/services. 2. A review of an agency policy titled, 'Missed Visits Policy' stated, "… Missed visits will be communicated to the client's Licensed Prescriber or designee … Missed visits will be documented as an incident report and uploaded into the client's chart … If a visit is missed for any reason, the clinician should attempt to reschedule it for the same day or week so that the Licensed Prescriber ordered frequency is maintained and would not be considered a missed visit …" The Administrator failed to provide services as ordered in the Plan of Care for Patient #1 a bedbound patient with quadriplegia (paralysis that affects all a person’s limbs and body from the neck down), failed to provide 24-hour care, 7 days per week as ordered. 3. A review of agency policy titled 'Contents of the Clinical Record Policy' stated, "… Q. Statement of any changes in the patient's condition related to care and service … V. Relevant communication to the patient's Licensed Prescriber …" The Administrator failed to ensure providers were promptly notified with patients' changes in condition. 4. A review of a policy titled, 'Governing Body No. 4-001' stated, "The Governing Body of BrightStar Healthcare will serve as the governing authority for the home services program, which will function according to BrightStar Healthcare's bylaws/processes and will assume full legal authority and responsibility for the operation of BrightStar Healthcare … The Governing Body will review BrightStar Healthcare's … and other information relevant to the quality of patient care (i.e., unusual occurrences in care delivered is also consistently provided through a defined process) at least annually 2. Meeting minutes will be maintained for each meeting …" The Administrator failed to ensure the Governing Body approved the frequency and detail of the data collection. 5. A review of a policy titled 'Compliance Plan Policy No. 4-009' stated, "BrightStar Healthcare has established this plan to ensure that quality patient care is provided in a manner that complies with all applicable laws and regulations. It is the policy of BrightStar Healthcare that: … (2) there is periodic monitoring and oversight of compliance with those laws … (5) mechanisms exist to investigate … correct non-compliance. Procedure … 2. The CO oversees the education of personnel regarding proper compliance, the auditing and monitoring of the statutes of compliance, and the reporting, investigation … correction of non-compliance … 3. The CO reports on the compliance plan to the Quality Assurance Performance Improvement (QAPI) and The Governing Body (at least annually) … 5. Periodic audit and monitoring plans will be developed …" The Administrator failed to ensure clear expectations for patient safety were established and implemented. 6. A review of a policy titled 'Tuberculosis Screening of Health Care Workers Policy (2-Step) Policy No. 9-005' stated, "… The requirements contained in this document are minimum requirements and are applicable to all direct employees or contracted staff of BrightStar Healthcare who perform hands-on care … Baseline TB Screening and Testing at Hire: … If employee presents negative TB skin test or TB blood test from >1 year ago, then must have a new 2 step TB skin test or TB blood test with the second TB skin test administered 1 to 3 weeks after the first TB skin test was read … In addition to above, all new employees must also complete a TB Screening Questionnaire …" The Administer failed to ensure TB testing and screenings were completed per their policy. 7. The Administrator failed to ensure home health aides completed competency testing upon hire with 3 of 3 home health aides. 8. On 05/23/2025 at 9:20 AM, the Administrator indicated this as a valuable learning curve and an important opportunity for the agency's growth. 410 IAC 17-12-1 (c)(1)

Make patient and personnel assignments, CFR(s): 484.105(c)(1) Making patient and personnel assignments, This ELEMENT is not met as evidenced by: Based on record review and interview, the DON failed to ensure services was continuously available for a 24 hour, 7 days a week case 1 of 1 - 24 hour care patient. (Patient #1) Findings include: 1. A review of a policy titled 'Responsibilities/Supervision of Clinical Services Policy No. 4-003' stated, "… services will be available 24 hours a day, seven (7) days a week. The Director of Nursing (DON) or registered nurse designee will be responsible for the clinical direction of the organization and will take reasonable steps to ensure that: 1. Services are continuously available 2. Care and services provided by organization personnel ,,, are coordinated and integrated …" 2. On 05/21/2025 at 11:30 AM, during an interview, the ADMIN and DON indicated they were aware Patient #1 had been left alone at times. 3. During an interview on 05/21/2025 at 3:32 PM Administrative staff #6 reported Patient #1 was to receive 24 hour care for 7 days a week and the shifts where scheduled for 14 hours overnight and 10 hours for days to ensure there were no lapses in service. The shifts were 8:00 AM to 6:00 PM and 6:00 PM until 8: 00 AM. 4. On 05/21/2025 at 3:32 PM, the Administrator indicated on 01/28/2025, the agency was aware there was a gap in Patient #1's schedule from 8:00 AM until 10:00 AM and had made the patient aware the night before and contacted a nurse to come at 9:00 AM and reported the Aide stayed until 8:15 AM, the nurse arrived at about 8:50 AM, leaving a 35 minute gap. 5. On 05/22/2025 at 11:24 AM, the DON indicated they had not been involved with scheduling and assigning patients to staff members, they leave it up to the schedulers. 410 IAC 17-14-1(a)(1)(K)

This visit was for a Federal and State complaint survey of a Home Health Agency. Survey dates: 1/3, 1/4, 1/5, and 1/6/2022 Complaint #: 61442; Substantiated with findings These deficiencies reflect State findings cited in accordance with 410 IAC 17. Refer to the State Form for additional State findings. QR by Area 3 on 1-17-2022

Before discharge for cause HHA must: CFR(s): 484.50(d)(5) The HHA determines, under a policy set by the HHA for the purpose of addressing discharge for cause that meets the requirements of paragraphs (d)(5)(i) through (d)(5)(iii) of this section, that the patient's (or other persons in the patient's home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the HHA to operate effectively is seriously impaired. The HHA must do the following before it discharges a patient for cause: This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to implement their policy that required a series of actions were taken prior to discharging a patient for cause, for 1 of 1 policies reviewed, which affected 1 (Patient #3) of 4 patients whose closed clinical record was reviewed. Findings include: 1. Review of an undated Policy titled “Section 02.23 – Discharge” stated, “6. The physician will be involved in the discharge plan and specific ongoing care needs will be identified and addressed as part of the plan.” “10. To avoid charges of ‘abandonment’ at the time of discharge, agency documentation should include the following (not meant to be all-inclusive): - Evidence that the decision was not made unilaterally. The patient, family and physician participated in the decision to discharge the patient from the agency.” “If there are unmet needs and the agency is no longer able to meet those needs, documentation will demonstrate that appropriate notice was given (verbal and written) and referrals made as indicated.” “Documentation of all communication with the client, including the rationale for discharge, will be kept in the client file with copies sent to the primary care physician ... 13. The physician will be informed of the change in status and an order will be sent to the physician for confirmation of discharge.” 2. A review of the clinical record for patient #3, evidenced home health aide orders for care, 7 days a week, 14 hours per day. Patient #3's diagnoses included Multiple Sclerosis (MS - disease in which the immune system eats away the protective covering of the nerves), Cerebrovascular Accident (CVA - damage to the brain from interruption of its blood supply), early onset dementia, dysphagia (difficulty swallowing), gastrostomy-tube with enteral feedings (tube inserted through the belly to bring nutrition directly to the stomach), indwelling urinary catheter (tube inserted into urethra to drain urine from the bladder), and wound to coccyx (tailbone area). The date of the last care visit was 11/17/2021. The date of discharge was 11/17/2021. A review of the clinical record failed to evidence the agency had not made the decision to discharge patient #3 for cause unilaterally. The clinical record failed to evidence documentation the patient, family and physician participated in the decision to discharge patient #3 from the agency. The clinical record failed to evidence how patient #3's needs were met in the absence of agency services. The record failed to evidence documentation that demonstrated appropriate notice was given (verbal and written) and referrals were made to obtain necessary care. The clinical record failed to evidence documentation of the communication with the patient/patient's caregiver, to include the rationale for discharge, and failed to evidence compliance with agency policy to keep documentation in the patient's file with copies sent to the primary care physician. Review of the record failed to evidence the physician was informed of the change in status and failed to evidence an order was obtained from the physician for confirmation of discharge. 3. The Complaint binder was submitted for review on 1/4/2022 at 10:00 AM. A review of the entry for patient 3 consisted of printed out emails and copies of cell phone text messages between the person F (a member of patient #3's family and main caregiver) and the administrator. The headers of the pages revealed print dates of 1/3/2022 and 1/4/2022 respectively, although the pertinent dates of the entries ranged from 10/21/2021 to 11/23/2021. The contents of the binder failed to evidence further documentation pertaining to patient #3. 4. During an interview on 1/05/2022 at 1:40 PM, employee D, alternate clinical manager, stated the ordering physician had not been contacted in relation to concerns regarding patient 3 and caregiver, nor was the physician contacted regarding patient #3's impending discharge. 5. On 1/5/2022 at 11:29 AM, the surveyor left a message with the provider’s office inquiring if this home health agency had contacted the provider’s office regarding the anticipated discharge of patient 3, for cause, who still required ongoing services. On 1/6/2022 at 12:48 PM, nurse K for Dr. J (the ordering provider for patient 3) returned the telephone call and left a voicemail which stated, “I don’t see where anybody from Brightstar Home Care has contacted us (regarding patient 3) … I don’t see anything in here….”

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 ensure the patient's ordering provider was notified of the Home Health Agency's intention to discharge a patient for cause in 1 (patient 3) of 4 closed clinical records reviewed. Findings include: 1. Review of Policy titled “Section 2.39 – Reporting patient’s condition to Physician” dated 05/2010, stated “…Clinicians will establish and maintain ongoing communication with the physician to ensure safe and appropriate care for the patient.” “3. The patient’s physician will be contacted when there are significant changes in the patient’s condition, such as…. changes in the expectations of treatments or goals. 4. All conferences or attempts to communicate with physician will be documented in the clinical record ... A. Documentation of physician notification will include: 1. Date and time contacted 2. Patient name 3. Name of physician notified or his/her representative 4. Reason for notification 5. Physician response 6. Action taken or orders obtained 7. Professional signature or title. B. Documentation of attempted physician notification will include: 1. Date and time 2. Patient name 3. Name of physician attempting to notify 4. Reason for notification 5. Name of person taking message.” 2. Review of an undated Policy titled “Section 02.23 – Discharge” stated “6. The physician will be involved in the discharge plan and specific ongoing care needs will be identified and addressed as part of the plan.” “10. To avoid charges of ‘abandonment’ at the time of discharge, agency documentation should include the following (not meant to be all-inclusive): - Evidence that the decision was not made unilaterally. The patient, family, and physician participated in the decision to discharge the patient from the agency.” “If there are unmet needs and the agency is no longer able to meet those needs, documentation will demonstrate that appropriate notice was given (verbal and written) and referrals made as indicated.” “Documentation of all communication with the client, including the rationale for discharge, will be kept in the client file with copies sent to the primary care physician ... 13. The physician will be informed of the change in status and an order will be sent to the physician for confirmation of discharge.” 3. A review of the clinical record for patient 3, evidenced home health aide orders for care, 7 days a week, 14 hours per day. Patient 3's diagnoses included Multiple Sclerosis (MS - a disease in which the immune system eats away the protective covering of the nerves), Cerebrovascular Accident (CVA - damage to the brain from interruption of its blood supply), early-onset dementia, dysphagia (difficulty swallowing), gastrostomy-tube with enteral feedings (a tube inserted through the belly to bring nutrition directly to the stomach), an indwelling urinary catheter (a tube inserted into the urethra to drain urine from the bladder), and wound to the coccyx (tailbone area). The date of the last care visit was 11/17/2021. The date of discharge was 11/17/2021. A review of the clinical record failed to evidence documentation of notification of patient, family representative, and physician that discharge for cause was being considered. The clinical record failed to evidence documentation of ongoing communication with the ordering physician to ensure safe and appropriate care for patient #3. The clinical record failed to evidence documentation of all conferences or attempts to communicate with the physician. The clinical record failed to evidence documentation physician was involved in the discharge plan. Further review of the clinical record failed to evidence the agency had not made the decision to discharge patient #3 for cause unilaterally. The clinical record failed to evidence documentation the patient, family, and physician participated in the decision to discharge patient #3 from the agency. The clinical record failed to evidence compliance with agency policy to keep documentation in the patient's file with copies sent to the primary care physician. A review of the record failed to evidence the physician was informed of the change in status and failed to evidence an order was obtained from the physician to discharge for cause. 4. In an interview on 1/03/2022 at 2:52 PM, person F, the caregiver of patient #3, stated the current administrator “started pulling away staff” from patient #3’s case without explanation. The patient had previously had received regular visits both day and night for over a year without issue. Person F, the caregiver for patient #3, stated the patient was not able to care for self, related to medical diagnoses (CVA and MS), which required position changes every 2 hours while in bed. Person F, the caregiver stated, “they [this agency] did not discharge [patient 3], period. They [this agency] just stopped coming.” 5. During an interview on 1/5/2022, at 1:40 PM, employee D, alternate clinical manager, stated the ordering provider had not been contacted in relation to concerns regarding patient 3 and caregiver, nor was the physician contacted regarding impending discharge for cause. Employee D stated the agency reached out to and worked with entity L, a community resource agency, regarding the concerns with the behavior a family member of patient #3. 6. On 1/5/2022 at 11:29 AM, the surveyor had left a message with the provider’s office to inquire if this agency had contacted the provider’s office regarding the impending discharge for cause of patient 3. On 1/6/2022, at 12:48 PM, nurse K for Dr. J (the ordering provider for patient 3) returned a call and left a voicemail which stated, “I don’t see where anybody from Brightstar Home Care has contacted us [regarding patient 3] …I don’t see anything in here….” 410 IAC 17-12-2(i)

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 implement their policy to ensure the patient's caregiver was provided with the phone numbers and names of other Home Health agencies when the agency determined to discharge a patient for cause in 1 (patient 3) of 4 closed clinical records reviewed. Findings include: 1. Review of an undated Policy titled “Section 02.23 – Discharge” evidenced the policy stated, “10. To avoid charges of ‘abandonment’ at the time of discharge, agency documentation should include the following (not meant to be all-inclusive): - If there are unmet needs and the agency is no longer able to meet those needs, documentation will demonstrate that appropriate notice was given (verbal and written) and referrals made as indicated.” 2. A review of the clinical record for patient #3, evidenced home health aide orders for care, 7 days a week, 14 hours per day. Patient #3's diagnoses included Multiple Sclerosis (MS - disease in which the immune system eats away the protective covering of the nerves), Cerebrovascular Accident (CVA - damage to the brain from interruption of its blood supply), early onset dementia, dysphagia (difficulty swallowing), gastrostomy-tube with enteral feedings (tube inserted through the belly to bring nutrition directly to the stomach), indwelling urinary catheter (tube inserted into urethra to drain urine from the bladder), and wound to coccyx (tailbone area). The date of the last care visit was 11/17/2021. The date of discharge was 11/17/2021. The clinical record failed to evidence how patient #3's needs were met in the absence of agency services. The record failed to evidence documentation that demonstrated appropriate notice was given (verbal and written) and referrals were made to obtain necessary care. The agency failed to document the patient/caregiver/family member were provided with contact information of other home health agencies. 3. In an interview on 1/3/2022 at 2:52 PM, person F, the caregiver/family member for patient #3, stated the reason for the complaint was, “neglect of [patient 3]”, and the current administrator “started pulling away staff” from the patient’s case without explanation. The patient had previously been receiving regular visits both day and night for over a year without issue, and that patient was not able to care for self, related to medical diagnoses (CVA and MS), which included the requirement of position changes every 2 hours while in bed, “they [this agency] did not discharge [patient 3], period; they [this agency] just stopped coming.” Person F, further stated that names and numbers of alternate Home Health agencies were not provided by the agency.

Discharge Planning CFR(s): 484.58(a) Standard: Discharge planning. An HHA must develop and implement an effective discharge planning process. For patients who are transferred to another HHA or who are discharged to a SNF, IRF or LTCH, the HHA must assist patients and their caregivers in selecting a post-acute care provider by using and sharing data that includes, but is not limited to HHA, SNF, IRF, or LTCH data on quality measures and data on resource use measures. The HHA must ensure that the post-acute care data on quality measures and data on resource use measures is relevant and applicable to the patient's goals of care and treatment preferences. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure an effective discharge planning process, to include coordination of care and assistance to patients and their caregivers in the procurement of another provider's service appropriate for the patient, for 1 of 4 closed records reviewed. (Patients #6) Findings Include: 3. A review of the clinical record for patient #6 revealed a comprehensive assessment dated 6/20/21, for the recertification period of 6/24/21 - 8/22/21. The comprehensive assessment evidenced a section labeled "Other goals to include:" which indicated "Son thinking about LTAC (Long Term Acute Care) for pt. [patient]. Will notify office of decision." The document failed to evidence the patient's physician was notified of the potential for discharge to an LTAC and failed to evidence the agency provided information or assistance to assist the patient and caregiver in finding an appropriate LTAC or SNF (Skilled Nursing Facility). A review of the clinical record failed to evidence documentation of discharge planning that included agency assistance in finding an appropriate LTAC or SNF when a higher level of care was required. A review of a document titled "Case Conference/Coordination of Care", dated 4/22/21, evidenced "Care Planning: Cont. [continue] w/ [with] POC [Plan of Care] @ this time. Discussed all options for when client requires a higher level of care." The document also evidenced a section labeled "Recertification Report" which indicated "Son [and] wife at risk for caregiver burnout." The sections for Personal Care Support, Coordination of Care, Discharge Planning, Interdisciplinary Referral, and Required Follow Up were blank. The document failed to evidence the agency discussed potential discharge of the patient to an LTAC or SNF, failed to evidence the physician was involved in any discharge planning, failed to evidence what options were discussed related to when the patient needed a higher level of care, and failed to evidence documentation of discharge planning that included information to assist the patient and caregiver in choosing an appropriate LTAC or SNF. Review of a second "Case Coordination/Care Planning" document, dated 6/20/21, indicated "Son is experiencing caregiver burnout D/T (due to) he works 5 days/week and is the main caregiver for his father when he's not working," The Personal Care Support, Coordination of Care, Discharge Planning, and Interdisciplinary Referral sections were blank. The document failed to evidence the agency provided information or discharge planning related to appropriate LTACs or SNFs, included the physician in discharge planning, and assisted the caregivers in finding an appropriate LTAC or SNF. A review of a document titled "Discharge Summary" evidenced a reason for discharge of "Transfer/Admit to other agency/organization" and indicated patient #6 was discharged to Entity I (Long Term Acute Care Facility), with a discharge date of 7/29/21. During an interview on 1/5/22 at 2:38 PM, person E (a primary caregiver for patient #6) indicated they began contacting skilled nursing facilities approximately 1 - 2 months prior to the patient's actual discharge from the agency. Person E stated entity L (a case management company) assisted in finding an LTAC for the patient. Person E also stated they didn't know that the agency could have helped find an appropriate LTAC. Person E denied knowledge of the agency's discharge/transfer policies and stated no one from the agency had discussed discharge planning. Person E indicated working with entity L to locate an appropriate facility because they thought entity L managed the patient's overall care and the agency only managed the patient's home health aide services. On 1/5/22 at 12:38 PM, the administrator confirmed there were no additional documents available and stated the clinical record provided to the surveyor was the complete clinical record. 1. Review of a undated Policy titled, “Discharge Policy 02.23,”…stated, “…4. Patient’s needs for continuing care to meet physical and psychological needs are identified and patients are told in a timely manner of the need to plan for discharge or transfer to another level of care/organization. 5. Patients are informed of the reason for discharge…6. The physician will be involved in the discharge plan…8. A discharge plan shall be developed that is documented in writing and includes written/verbal instruction regarding the patient’s ongoing care needs…10. …if there are unmet needs and the agency is no longer…documentation will demonstrate that appropriate notice was given (verbal and written) and referrals are made…Patients and/or their legal representative or other individual responsible…at least five (5) calendar days…Documentation of all communication with the client, including the rationale for discharge will be kept in the client file with copies sent to the primary physician...13. The physician will be informed of the change…and an order will be sent…” 2. Review of an undated Policy titled, “Transfer 02.24”, stated…”1. Patient transfer may be needed, hospitalization occurs…transferred to another service provider…2. A written summary, including the patient’s discharge…will indicate …has transferred and will be documented and kept in the patient’s clinical record. 3. The patient’s physician will be notified and an order obtained…”

Discharge or Transfer Summary Content CFR(s): 484.58(b)(1) Standard: Discharge or transfer summary content. The HHA must send all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure a complete and accurate discharge summary was provided to the receiving facility or health care practitioner that included all necessary medical information and post-discharge goals of care for 3 of 4 closed records reviewed. (Patients 6, 7, and 8) Findings include: 3. A review of the clinical record for patient #6, discharge date 7/29/21, revealed a plan of care for the certification period of 6/24/21 - 8/22/21, which evidenced a primary diagnosis of multiple sclerosis (a degenerative and often terminal disease causing damage to the covering of the spinal cord and nerves), and secondary diagnoses of hypertension (high blood pressure), and type 2 diabetes (impairment in the way the body regulates and uses sugar). The patient used a Hoyer lift (a mechanical lift used for patients who are unable to bear weight) for transfer, a bedside commode, and both manual and electric wheelchairs. The patient was oriented with periods of forgetfulness. Functional limitations included endurance and ambulation with a prognosis of fair. The patient received home health aide services 11 hours per day, 5 days per week for bathing, dressing, catheter care, transfer/mobility assistance, safety, light housekeeping, and range of motion. A review of the 60-day clinical summary revealed the patient required maximum hands-on assistance w/ with all ADLs (activities of daily living). Patient #6 also needed assistance with feeding at times. The patient had generalized weakness in all extremities, was non-weight bearing, wheelchair-bound while up, incontinent at night, and required medication set up and reminders. The patient's goals included that the patient will perform self-care activities within ability; the patient will remain safe in own home; the patient will experience no new skin breakdown; the patient will be free of signs/symptoms of depression, and the patient will be free of falls. A review of a discharge summary evidenced a last date of service of 7/28/21, with a discharge date of 7/29/21. A section labeled "Summary of Care Provided/Patient Physical, Psychosocial, and Functional Status" evidenced "HHA (home health aide) to assist w/ (with) ADLs. Client requires [sic] use of ceiling lift for all transfer. W/C (wheelchair) bound. A&O (alert and oriented) w/ periods of forgetfulness." A section labeled "Condition at Discharge" evidenced "stable", and indicated a copy of the discharge summary, plan of care, and medication list was faxed to the physician. A section labeled "Discharge Planning" evidenced "patient D/C (discharged) to [Name of entity I] (Long Term Acute Care Facility)." The discharge summary failed to include the patient's full and accurate current medical information including, but not limited to, current diagnoses, current physical condition, functional status/limitations, mental/psychosocial status, nutritional needs, diabetic needs, pain status, fall risk, knowledge/education related to illness, support systems, reason for transfer, progress toward goals, and post-treatment goals; and failed to evidence that a complete and accurate discharge summary was sent to the facility to which the patient was transferred. 4. A review of the clinical record for patient #7 revealed a plan of care for the certification period of 11/22/20 - 1/20/21, which indicated a primary diagnosis of cerebral palsy (impaired muscle coordination and other disabilities, often caused by brain injury or lack of oxygen to the brain), and secondary diagnoses of Shprintzen Goldberg Syndrome (a rare connective tissue disorder with head/facial, skeletal, and cardiac anomalies), esophageal reflux (a condition where stomach acid flows backward through the esophagus to the throat and/or mouth), scoliosis (curvature of the spine), and pneumonitis due to aspiration (inflammation of the alveoli, or air sacs, in the lungs caused by the passage of food or liquid into the airway and/or lungs). The patient utilized a wheelchair, shower bench, depends, low bed, and received g-tube (gastrostomy tube) feedings (liquid nutrition via a special tube inserted through the abdomen and into the stomach). Functional limitations included incontinence, contracture, hearing, endurance, ambulation, speech, and nutrition. Patient #7 was alert and nonverbal with a prognosis of good. The patient received home health aide services for bathing, dressing, personal care, elimination, g-tube care, assistance with mobility/transfer, range of motion, positioning, safety, meal preparation, and oral feedings. The 60-day summary evidenced the patient lived with a parent and required 24-hour care. A review of the discharge summary evidenced a last date of service of 1/18/21. The patient was discharged 1/19/21; The discharge summary indicated the reason for admission to homecare as Shprintzed Goldberg Syndrome and scoliosis. The summary of care and patient's physical, psychosocial, and functional status evidenced "HHA (home health aide) to assist w/ ADLs.." A section labeled "Condition at Discharge" indicated "stable." A section labeled "Discharge Planning" evidenced "N/A" (not applicable). The discharge summary evidenced that a copy of the plan of care and current medication list was sent to the physician on 1/24/21. The discharge summary failed to include the patients full and accurate current medical information including, but not limited to, current diagnoses, current physical condition, functional status, mental/psychosocial status, nutritional needs, pain status, knowledge/education related to illness, progress toward goals, and post-treatment goals: and failed to evidence where the patient was transferred and/or who would be responsible for the patient's continued care needs. 5. On 1/5/22 at 2 PM, the agency's discharge summary process was reviewed with the administrator. The administrator stated the clinician sends a discharge summary to the patient's physician upon discharge. The administrator also stated not being aware a discharge summary was required to be provided to the facility or hospital receiving the patient and was not sure of the content required for a discharge summary. 1. Review of an undated Policy titled, “Discharge Policy 02.23,”…stated, “…4. Patient’s needs for continuing care to meet physical and psychological needs are identified...need to plan for discharge or transfer to another level of care/organization...6. The physician will be involved....and specific ongoing care needs will be identified and addressed as part of the plan. 8. A discharge plan shall be developed that is documented in writing and includes written/verbal instruction regarding the patient’s ongoing care needs..." 2. A review of the closed clinical record of patient #8 on 1/5/2021, evidenced a start of care date of 6/14/2020, and contained a Physician Notification form dated 8/4/2020 stating the patient had been admitted to entity G (a hospital) on 7/31/2020, would be discharging from entity G, then be admitted to a rehabilitation facility, entity H, and the home health agency’s services for patient #8 were on hold. The record failed to evidence a discharge summary being sent to entity G. Review of a Physician Notification form dated 2/1/2021, evidenced the notification stated the patient was admitted to entity G on 01/27/2021, and the agency's services were on hold. The record failed to evidence a discharge summary had been sent to entity G. Review of a Discharge Summary document that was dated 7/29/21, stated the patient was being discharged, the patient had been at a rehabilitation facility since approximately 2/1/21, and the agency was notified on 7/26/2, the patient would not be returning home. The document revealed the patient had been on hold since 1/27/21.

Discharge plans communication CFR(s): 484.60(c)(3)(ii) (ii) Any revisions related to plans for the patient's discharge must be communicated to the patient, representative, caregiver, all physicians or allowed practitioner's issuing orders for the HHA 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). This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure discharge plans were communicated with the responsible physician and/or patient representative (if any) for 3 of 4 closed records reviewed. (patients #3, 6, 7). Findings include: 6. A review of the comprehensive assessment for patient #6, completed on 6/20/21, for the certification period of 6/24/21 - 8/22/21, evidenced "Son thinking about LTAC (Long Term Acute Care) for pt. (patient). Will notify office of decision." A section titled "Summary Checklist" indicated the care plan was reviewed, but failed to evidence if it was reviewed with the physician or if the physician was notified that the patient's son was contemplating placement of the patient in a long-term care facility. A section titled "Communication and Coordination of Care" indicated "Home Health Aide", but failed to evidence the content or type of care coordination done with the home health aide and failed to specify the home health aide with whom care coordination occurred. The "physician" option in the section was blank, and failed to evidence potential discharge plans were communicated to the physician. A review of the most recent plan of care, completed 6/20/21 by employee D (Registered Nurse),for the certification period of 6/24/21 - 8/22/21, evidenced a 60-day progress summary which indicated no changes at this time, and stated the physician was "notified of current findings." A section titled "Discharge Plans" included "1. When the client no longer has a need of services. 2. When the client moves to a location outside of the agency service area. 3. When the client needs a higher level of care." The 60-day progress summary and plan of care failed to evidence whether the physician was notified that the patient's son was contemplating transferring the patient to a long-term care facility. A review of a document titled "Case Conference/Coordination of Care", dated 4/22/21, indicated coordination of care participants of "home health aide" only, and failed to evidence care coordination with the physician, skilled nurse, case manager, personal service agency, or other services. The document also indicated "Discussed all options for when client requires a higher level of care" but failed to evidence if discharge to an LTAC was discussed and whether plans were discussed with the patient's physician and caregivers. A section titled "Progress and Barriers Toward Goals" indicated "continue to monitor" but failed to evidence what was being monitored, the progress and barriers toward goals, and whether the plans to continue monitoring were communicated with the patient's physician and primary caregivers. A review of a second case conference note, dated 6/20/21 indicated the patient's primary caregiver was experiencing caregiver burnout due to working full time while being the primary caregiver to patient #6 when not at work, and indicated the son was trying to keep the patient at home, but "gets overwhelmed at times." A section titled "Progress and Barriers Toward Goals" was blank. The document failed to evidence discharge planning that included notification to the physician concerning changes or difficulties in the patient's level of care, or that a skilled facility was being considered by the patient's caregiver. A review of the discharge summary evidenced a last date of service of 7/28/21, with a discharge date of 7/29/21. The discharge summary indicated that a copy of the discharge summary, plan of care, and medication list was faxed to the physician on 7/29/21. 7. A review of the comprehensive assessment for patient #7, completed 11/20/21, for the certification period 11/22/20 - 1/20/21, indicated the care plan was reviewed/updated and was developed/reviewed with patient involvement. Communication and coordination of care included the skilled nurse and family. The assessment failed to evidence whether discharge planning was discussed with the patient, caregiver, and physician. A review of a plan of care completed 11/20/21, evidenced "no changes made at this time" and indicated the physician was notified of findings. The plan of care failed to evidence that discharge planning was discussed with the patient, caregiver, and physician. A review of a "Case Conference/Coordination of Care" document, dated 11/20/20, evidenced coordination of care participants included the skilled nurse, home health aide, and patient. The document failed to evidence coordination of care occurred with the patient, caregiver, or physician. Sections labeled "Discharge Planning", "Interdisciplinary Referral", "Care P"lanning, and "Coordination of Care" were blank. The document failed to evidence discharge planning occurred, including concerns, changes in care, and family involvement; and failed to evidence whether the physician was notified of any concerns, changes, or discharge plans. A review of a second case conference note, dated 1/17/21, evidenced the registered nurse suggested using a Hoyer lift, however, the patient's mother/primary caregiver refused. The "Coordination of Care Participant" section was blank and failed to evidence if the patient's aide, nurse, case manager, or physician was included in coordination of care or discharge planning. The "Recertification Report" section indicated "Client doing well at this time. No changes at this time." Additional documentation at the bottom, separately dated 1/19/21, indicated "RN (Registered Nurse) notified our caregiver arrived to clients [sic] home for scheduled shift and notified by family that a new company was providing care." The document failed to evidence if the patient's caregiver or physician was contacted concerning refusal of services and immediate discharge. A review of the discharge summary evidenced the last date of service was 1/18/21, with a discharge date of 1/19/21. A copy of the discharge summary, plan of care, and current medication list was faxed to the physician on 1/24/21. 8. On 1/5/22 at 2 PM, the administrator was interviewed concerning the agency's discharge/transfer process. The administrator stated a discharge summary is sent to the patient's physician upon discharge. The administrator was but was not aware that a discharge summary should be provided to the transfer facility or new home health organization. When queried as to how the agency communicated plans and changes, including discharge or the patient, the administrator stated the agency was told by previous surveyors to stop using communication or progress notes, so the agency uses the call logger in the ABS Scheduling system to log phone calls. The administrator also stated that employees text and email each other, the patients, and their caregivers. When queried as to where the documentation of the texts and emails were kept, the administrator stated she could print out the emails and provide screenshots of the texts for applicable patients. When queried as to whether the agency provided the complete clinical record for patients #6 and 7 the administrator stated the complete record was provided for both patients. 1. Review of an undated Policy titled “Section 02.23 – Discharge” page 1 of 2 stated, “6. The physician will be involved in the discharge plan and specific ongoing care needs will be identified and addressed as part of the plan.” “10. To avoid charges of ‘abandonment’ at the time of discharge, agency documentation should include the following (not meant to be all-inclusive): - Evidence that the decision was not made unilaterally. The patient, family and physician participated in the decision to discharge the patient from the agency.” “If there are unmet needs and the agency is no longer able to meet those needs, documentation will demonstrate that appropriate notice was given (verbal and written) and referrals made as indicated.” “Documentation of all communication with the client, including the rationale for discharge, will be kept in the client file with copies sent to the primary care physician.” Page 2 of 2 states “13. The physician will be informed of the change in status and an order will be sent to the physician for confirmation of discharge.” 2. On 1/04/2022 the clinical record of patient #3 was reviewed. The record failed to evidence any documentation of communication with ordering provider in relation to any concerns or barriers staff experienced related to providing care for patient. Clinical record also failed to evidence any documentation of communication with ordering provider regarding agency’s intent to discharge patient for cause. 3. Complaint binder was submitted for review on 1/04/2022 at 10:00 AM. Entry for patient 3 consisted of printed out emails and copies of cell phone text messages between complainant and administrator. Headers of pages revealed print dates of 1/3/2022 and 1/4/2022 respectively. Contents of the binder failed to evidence any other forms or documents pertaining to patient. 4. During an interview on 1/05/2022 at 1:40 PM, employee D, alternate clinical manager, stated that the ordering provider had not been contacted in relation to concerns regarding patient 3 and caregiver, nor was physician contacted regarding impending discharge. 5. On 1/06/2022 at 12:48 PM, nurse K for Dr. J (ordering provider for patient 3) returned call and left voicemail which stated, “I don’t see where anybody from Brightstar Home Care has contacted us {regarding patient 3} …I don’t see anything in here….” (On 1/05/2022 at 11:29 AM, surveyor left message with provider’s office inquiring if agency had contacted provider’s office regarding discharging patient 3 from service).

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure coordination of care included the patient, the patient's representative (if any), and the patient's caregivers, as appropriate in 4 of 8 records reviewed. (Patient #1, 6, 7, & 8) Findings include: 6. An agency document titled, 'Patient Update' dated 11/09/202 written by office support staff F, stated, " [Home health aide H] ...considered discontinuing the case, but [he/she] feels bad Ms. Nancy. [Home health aide I] also has made accommodations [him/herself] by bringing his own toilet paper and hand soap and even brought [his/her] own wipes to clean [patient 3] up as needed. [Home health aide I] truly does not want to get [him/herself] into a situation all because [complainant] will not answer [his/her] phone." The record failed to evidence documentation of efforts made by the agency to coordinate care to resolve reported problems in 1 (patient 3) of 1 closed record reviewed. An agency document titled, 'Customer Complaint' dated 11/11/2021 written by office support staff F, stated, "[Person F, caregiver for patient 3] called to say that [he/she] always has tissue paper next door at [his/her] house, and [he/she] only buys the small packs because they always come up missing from [patient 3's] place. [Person F] states [he/she] knows that [home health aide J] was the one who reported to the office that [patient 3] did not have tissue, but [home health aide J] should have called [person F] first and not the office because [person F] would have brought some right over... I know [person F] blames [home health aide J] for reporting the toilet paper, but [home health aide J] only reported that [patient 3] did not have any briefs in the home last night to change [patient 3]. The record failed to evidence documentation of efforts made by agency to coordinate care to resolve reported problems in 1 (patient 3) of 1 closed record. A review of the clinical record for patient #3, evidenced home health aide orders for care, 7 days a week, 14 hours per day. Patient #3's diagnoses included Multiple Sclerosis (MS - disease in which the immune system eats away the protective covering of the nerves), Cerebrovascular Accident (CVA - damage to the brain from interruption of its blood supply), early onset dementia, dysphagia (difficulty swallowing), gastrostomy-tube with enteral feedings (tube inserted through the belly to bring nutrition directly to the stomach), indwelling urinary catheter (tube inserted into urethra to drain urine from the bladder), and wound to coccyx (tailbone area). The date of the last care visit was 11/17/2021. The date of discharge was 11/17/2021. Review of the clinical record failed to evidence documentation of care coordination efforts made to resolve the concerns reported by staff members, home health aides I and J, related to lack of supplies in the home of patient 3. Review of complaint log on 1/05/2022, failed to evidence documentation that employee complaints were addressed, failed to evidence documentation that the agency made efforts to coordinate care in order to resolve reported problems reported by employees I and J regarding patient 3 and person F in 1 (patient 3) of 1 closed record reviewed. 3. A review of the clinical record for patient #1 revealed a plan of care for the certification period of 12/11/21 - 2/8/21. The patient lived alone in an independent senior living community and received home health aide services under Medicaid Prior Authorization (a type of insurance) for 35 hours/week for bathing, personal care mobility assistance, safety, positioning, light housekeeping. A review of the 60-day progress summary evidenced that on 12/7/21 "the registered nurse collaborated with the patient, family, case manager, and physician to determine the scope of services, visit frequencies, and duration for the recertification period of 12/11/21 - 2/8/22. The patient and family agree with the scope of service as outlined in this plan of treatment including ordered disciplines, visit frequency, and duration." The plan of care evidenced orders may be accepted by person M (a physician) and person N (a physician) but failed to evidence if findings were reviewed with all physicians for care coordination purposes, and failed to evidence the plan of care was provided to the additional physicians for review. The plan of care failed to evidence a frequency and duration for services, or what frequency and duration were discussed with the patient, family, and physician. The plan of care also failed to evidence care coordination was discussed with the patient, caregiver, and physician including, but not limited to, the patient's health, mental, and psychosocial status, discharge plans, care preferences, goals and progress toward goals, and satisfaction with services. The plan of care also failed to evidence care coordination occurred with the patient's waiver agency. A review of a verbal order dated 12/7/21 at 3 PM, and signed by employee D, evidenced person O (primary care physician) was notified of the assessment findings and agreed and approved of the need for services. The order indicated "The physician, patient/caregiver, and nurse have collaborated in the development of the plan of care as listed below" and evidenced orders may be accepted from person M (a physician) and person N (a physician), but failed to evidence care coordination occurred with persons M and N, failed to identify the caregiver with whom care coordination occurred, failed to specify the care coordination was discussed, and failed to include previously identified "family" in the care coordination. The verbal order evidenced a frequency and duration of "HHA - 35 hour/week" and 15 hours/week of waiver but failed to evidence care coordination with a personal services agency. A review of a document titled "Case Conference/Coordination of Care", dated 12/7/21, evidenced coordination of care participants included skilled nurse, patient, and family, but failed to evidence care coordination that included the patient's aide(s), primary caregiver, and all physicians involved, and failed to evidence which family members participated in the care coordination meeting. The document evidenced fall prevention, hospitalization risk, and the emergency room visit on 11/27/21, but failed to evidence care coordination with the patient, family, and physicians related to seizure safety and treatment, such as a seizure plan or an emergency call button. Options for personal care support, care planning, medication management, coordination of care, discharge planning, interdisciplinary referral, and dietary/nutritional needs were blank. The option for identification of patient concerns, health problems, functional challenges and barriers, and safety issues was also blank. Patient progress towards goals and/or barriers to progress evidenced "ongoing" and failed to include coordination of care with the patient, family, and physicians concerning the patient's goals and progress. The document also failed to evidence care coordination with the personal service agency that provided the waiver services. 4. A review of the clinical record for patient #6, discharge dater of 7/29/21, evidenced a comprehensive assessment dated 6/20/21, for certification period 6/24/21 -8/22/21. The assessment evidenced "Son thinking about LTAC (Long Term Acute Care) for pt. (patient). Will notify office of decision." The assessment also indicated "Care Plan Developed" and "Care Plan Reviewed", and evidenced communication and coordination of care occurred with the home health aide. The assessment failed to evidence if the home health aide was the patient's agency-provided caregiver, and what care coordination was discussed with or provided by the aide. The assessment also failed to evidence care coordination with the physician, nurse, case manager, primary caregiver, or personal service agency, and failed to evidence care coordination related to discharge planning and assistance with identifying an available and appropriate LTAC. A review of the plan of care, dated 6/24/21 - 8/22/21, evidenced the patient lived with a son, who was the primary caregiver. The patient required maximum assistance for all care, meal prep, and feeding, was chairbound, forgetful, and required a mechanical lift. The plan of care failed to evidence the physician was notified that the caregiver was experiencing "burnout" and considering placement of the patient in a long-term care facility, and failed to evidence care coordination occurred with all parties to prepare for possible discharge. A review of a document titled "Case Conference/Coordination of Care", dated 6/20/21, evidenced "Son is experiencing caregiver burnout .... Son trying to keep pt (patient) in home w/ (with) him but gets overwhelmed at times." The document failed to evidence care coordination involved the physician, skilled nurse, the agency provided aide, personal service agency, or primary caregiver to discuss the potential transfer to a facility, the caregiver burnout, or the patient's increased level of care. 5. A review of the clinical record for patient #7 revealed a plan of care for the certification period of 11/22/20 - 1/20/21. The patient lived at home with the mother, was non-verbal, received g-tube feedings (gastrostomy tube - a catheter placed through the patient's abdomen into the stomach in order to receive liquid nutrition), and required 24-hour care. The plan of care indicated on 11/20/21 the registered nurse collaborated with the physician, case manager, and caregiver "to determine the scope of services, visit frequencies, and duration." The plan of care failed to evidence the patient's current medical, psychosocial, nutritional, functional, pain, communication, and safety statuses were discussed with all parties, and failed to evidence ongoing care needs were discussed. A review of a discharge summary, for discharge date 1/19/21, evidenced the patient was "stable" and was transferred/admitted to other agency/organization. A copy of the discharge summary and medication list was sent to the physician on 1/24/21. The discharge summary failed to evidence case coordination that included notifying the physician of the reason for transfer and the patient's current medical information, environment, care needs, goals, and progress toward goals. 410 IAC 17-12-2(g) 1. Review of a Policy titled, “Care Coordination Policy 02.19” dated 12/19, stated “Policy: Upon admission to BrightStar Care of Indianapolis, each patient will be assigned a designated care manager…to facilitate communication…The Director of Nursing (DON) or care manager will act as a liaison with other organizations...to ensure effective coordination of related services...Procedure ...H. Proper communication upon….including the opportunity for questions between the giver and receiver of patient information…I. Integration of services, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness..J. Coordination of care deliver to meet the patient’s needs....8. will communicate changes in a timely manner...10. The transmission of patient care information will be timely, accurate, and standardized...4. The Director of Nursing (DON) or designee will be responsible for the coordination, and ongoing communication between service providers...D. Sharing relevant information to facilitate coordination..." 2. A review of the closed clinical record of patient #8 on 1/5/2021, evidenced a start of care date of 6/14/2020 which contained a Physician Notification form dated 8/4/2020 stating the patient was admitted to entity G on 7/31/2021, would be discharging from entity G, be admitted to a rehab facility, entity H, and the agency’s services for the patient was on hold. The record failed to evidence care coordination or any kind of communication in the clinical record between the agency and entit

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure clinical notes documented pertinent communication with patients, their families/caregivers, physicians, personal service agencies, and other applicable persons/entities as part of the clinical record for 1 of 1 active records reviewed (patient #1) and 2 of 4 closed records reviewed (patients #6, 7). Findings include: 1. A review of the clinical record for patient #1, start of care date 3/7/17, evidenced a plan of care for the certification period 12/11/21 – 2/8/22, which indicated the patient lived alone in an independent senior community, had a history of seizures, required assistance with all aspects of activities of daily living, received 35 hours per week of home health aide services from the agency, and received attendant care services for 15 hours per week. The plan of care also evidenced the patient was seen in the emergency department on 11/27/21, due to a seizure, and returned home the same day, with no changes in medication. The plan of care indicated that on 12/7/21, the registered nurse collaborated with the patient, family, case manager, and physician to determine the scope of services visit frequencies, and duration for the recertification period of 12/11/21 – 2/8/22. The plan of care failed to evidence who the patient’s primary caregivers were, what agency provided attendant care, and what services were received and failed to evidence care coordination or review of the plan of care by all physicians. Continued review of the clinical record failed to evidence communication notes, progress notes, or another appropriate form that included documentation including, but not limited to, when and how the patient’s seizure was reported, who reported the seizure, follow-up as to the quality and duration of the seizure, the cause of the seizure, if the agency notified an emergency caregiver, if care coordination occurred with the personal service agency, if the emergency alert necklace was used, if the patient was transported by ambulance, and if the agency notified all physicians involved. A review of a document titled “Case Conference/Coordination of Care evidenced the document was an every 60-day case conference. Participants included skilled nurse, patient, and family. Options for “telephone Contact”, “Care Coordination”, “Follow-up”, and “Other” were blank. The document evidenced fall prevention measures were discussed, the patient’s risk of hospitalization was a score of 8, and the patient went to the emergency room on 11/27/21 for a seizure. The patient’s weight was steady. The document failed to evidence care coordination occurred with all physicians on the plan of care, the personal service agency, agency-provided staff, including the patient’s home health aide(s), or the case management company. Further review of the clinical record for certification period 12/11/21 – 2/8/21 failed to reveal communication notes, progress notes, or other similar forms the evidenced documentation of receipt of information, communication, care coordination, or follow-up related to the patient’s seizure, or related to day-to-day management of the patient’s care needs and scheduling with the patient, staff, caregivers, physicians, and other entities as applicable. 2. A review of the clinical record for patient #6, discharge date 7/29/21, revealed a discharge summary and evidenced the patient discharged to entity I (a long-term care facility), but failed to evidence documentation of communication with the patient, caregiver, physician, case management company, or long-term care facility concerning the patient’s progression toward discharge. Continued review of the clinical record failed to evidence documentation of communication notes, progress notes, or other appropriate forms which documented the day-to-day management of the patient leading to discharge including, but not limited to, care coordination with physician, family, personal service agency, the agency provided aide services, increased level of care, follow-up, and notification of and preparation for pending discharge. 3. A review of the clinical record for patient #7 evidenced a discharge summary with a discharge date of 1/19/21. The discharge summary indicated the patient’s primary caregiver only wanted one caregiver. The summary also indicated the registered nurse suggested a mechanical lift to transfer the patient, and the patient’s primary caregiver stated he/she lifted the patient just fine. Continued review of the same document evidenced an entry added on 1/19/21, which indicated the registered nurse was notified the agency caregiver arrived at the patient’s home for a scheduled shift and was notified by the family that a new company was providing care. Continued review of the clinical record failed to evidence communication notes, progress notes, or other appropriate forms which documented the day-to-day management of the patient including, but not limited to, follow-up concerning the caregiver’s request for only 1 agency caregiver, and follow-up concerning the need for a mechanical lift and the caregiver’s response. The record also failed to evidence follow-up concerning the reason a new company was initiated, and if the caregiver had a possible complaint about care. 4. On 1/3/21 at 2:49 PM, the administrator was interviewed concerning the agency policy and process for maintaining a clinical record. The administrator stated the agency did not use an EMR (electronic medical record) and maintained all patient records on paper, in a binder. When the binder was thinned or a patient was discharged, the paper note was scanned to a cloud storage, and the paper record was stored offsite in a secure storage facility. When queried as to how the agency documented day-to-day communication about patients, the administrator stated the scheduling software contained a call logger, where calls were documented. When queried as to whether the call logger was part of the clinical record and could be accessed by all authorized individuals or provided to the patient upon request, the administrator stated all office employees and case managers had access to the call logger, but not all could print. When queried as to where calls not related to scheduling were documented, the administrator stated they could be logged in the call logger. When queried as to the clinical notes that showed documentation of day-to-day communication and follow-up about a patient, the administrator stated that during the previous recertification survey, the surveyors told them they should no longer document using communication notes, so they stopped. The administrator also stated that office staff and clinicians text and email patients, physicians, caregivers, employees, and entity L (a case management company). When asked if the texts and emails were part of the clinical record, the administrator stated whoever they were sent to could print them out or send screenshots of texts if requested. When queried as to how the surveyor would know if a text or email existed, and to whom it was sent, if there was no record of it in the paper chart, the administrator had no further information. On 1/6/22 at 3:15 PM, the administrator was interviewed concerning the clinical record and preparing clinical notes and stated during a previous survey, the surveyors told them they should not document on communication notes, but they were not told why. The administrator verified that all closed records given to the surveyors during this survey were complete, there was no additional paperwork available, and all active records were complete for the time period and items requested. The administrator was queried as to the content of the texts and emails provided for patient #3, and stated, “That’s not even everything.” The administrator stated there were texts and emails from the patient’s daughter, who called the administrator a “C” and other foul language and made threats. The administrator stated, “I didn’t even give you everything. I’m not giving you things where she calls me foul names.” When queried as to whether there was further documentation for patient #3’s record, the administrator stated, “I’m not giving you that stuff. It’s horrible.” The surveyor queried as to whether there was more documentation for the clinical records reviewed for this survey, and the administrator stated all records were complete as requested. When queried as to the emails and texts not given for patient #3, the administrator stated she would not give those emails or texts.

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure continuing communication with all physicians and/or other health care practitioners involved with the patient’s plan of care for 2 of 4 active records reviewed (patients #1, 5) and 2 of 4 closed records reviewed. (patient #6, 7) Findings include: 3. A review of the clinical record for patient #1 evidenced a plan of care for the certification period of 12/11/21 - 2/8/22 indicated "May accept orders from person M ( a physician) and person N (a physician)." The record failed to evidence the plan of care was reviewed with person M and person N for collaboration of care and review of findings and failed to evidence the plan of care was sent to all physicians for review. Further review indicated the patient went to the emergency department on 11/27/21 due to a seizure. The patient returned home the same day with no medication changes. The record failed to evidence that all physicians on the plan of care were notified of the patient's seizure and subsequent trip to the emergency department. A review of a document titled Case Conference/Coordination of Care evidenced care coordination participants included the skilled nurse, patient, and family, but failed to evidence the physician responsible for the plan of care and the physician's also contributing to the plan of care were consulted for care coordination and informed of the patient's seizure and subsequent visit to the emergency department on11/27/21. 4. A review of the clinical record for patient #6 evidenced a comprehensive assessment dated 6/20/21, for the certification period of 6/24/21 - 8/22/21, which indicated the patient's son was thinking about placing the patient in a long term care facility. The record failed to evidence the agency notified the physician responsible for the plan of care of the patient's change in level of care and the potential for discharge to a long-term care facility. A review of a document titled "Case Conference/Coordination of Care, indicated "Son is experiencing caregiver burnout ...Son trying to keep pt (patient) in home w/ (with) him but gets overwhelmed at times." The record failed to evidence the physician responsible for the plan of care was notified of the patient's increased level of care, the caregiver's burnout necessitating the possible transfer of the patient to a long-term care facility. 5. A review of the clinical record for patient #7 evidenced a document titled "Case Conference/Coordination of Care", dated 1/17/21, which indicated the registered nurse suggested a mechanical lift to transfer the patient.. A separate entry at the bottom, dated 1/19/21, evidenced the registered nurse was notified that the agency caregiver arrived at the patient's home for a scheduled shift and was informed a new agency was providing services. The document failed to evidence the physician responsible for the plan of care participated in care coordination, was notified of the need for a mechanical lift, or was notified that the patient had terminated services without notice and was receiving services from another agency. 410 IAC 17-14-1(a)(1)(G) 1. A review of an undated Policy titled, “Clinical Record & Documentation 02.13”, stated, “…7. Phone calls or other communication with patients, families…will be documented in the chart…9. When services are not provided, the reason for the missed visit will be documented…and reported to the physician…” 2. A review of the clinical record of patient #5 on 1/3/2021, evidenced a start of care date of 2/8/2021 which contained a plan of care with a certification period of 11/14/2021 through 1/12/2022, with orders for Skilled Nursing 8 hours a day, 5 days a week, to administer tube feedings and medications during school hours and assessment of the patient per shift. A review of skilled nursing visits revealed missed visits occurred on 11/15/2021, 11/16/2021, 11/24/2021, 11/25/2021, 11/26/2021, 12/09/2021, 12/10/2021, 12/13/2021 through 12/17/2021, and 12/24/2021. The clinical record failed to evidence the physician was notified of missed visits.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure a completed discharge or transfer summary was written and sent to the primary care physician or other health care professional who was responsible for the patient's care after discharge within 5 business days of the patient's discharge or within 2 business days of a planned transfer to another facility, for 2 of 4 closed records reviewed. (patients #5 and 8) Findings include: 3. A review of the clinical record for patient #5 revealed a discharge summary, with a discharge date of 7/29/21, which indicated the patient was transferred to entity I (a long-term care facility), and indicated a copy of the discharge summary was sent to the physician. The document failed to evidence a completed copy of the discharge summary was sent to entity I, who was responsible for providing ongoing care to the patient after discharge from the home health agency. 410 IAC 17-15-1(a)(6) Review of a undated Policy titled, “Discharge Policy 02.23,”…stated, “…4. Patient’s needs for continuing care to meet physical and psychological needs are identified...8. A discharge plan shall be developed that is documented in writing and includes written/verbal instruction regarding the patient’s ongoing care needs…" 1. Review of an undated Policy titled, “Transfer 02.24”, stated…”1. Patient transfer may be needed, hospitalization occurs…transferred to another service provider…2. A written summary, including the patient’s discharge…will indicate …has transferred and will be documented and kept in the patient’s clinical record. 3. The patient’s physician will be notified and an order obtained…” 2. A review of the closed clinical record of patient #8 on 1/5/2021, evidenced a start of care date of 6/14/2020, which contained a Physician Notification form dated 8/4/2020, which stated the patient was admitted to entity G (an acute care hospital) on 7/31/2020, would be discharged from entity G, and then be admitted to a rehabilitation facility, entity H, and the agency’s services for the patient were on hold. This record failed to evidence a discharge summary was sent to entity G. Review of a Physician Notification form dated 2/1/2021, revealed patient #8 was admitted to entity G on 1/27/2021, and the agency's services were on hold. This record failed to evidence a discharge summary was sent to entity G. Review of a Discharge Summary document dated 7/29/2021, evidenced patient #8's most recent certification period had been 12/20/2021 to 2/17/2021, with last date of service 1/27/2021, and stated patient was "d/c'd [discharged] from services while at rehab[ilitation] facility due to patient requires 24 hour care" The document indicated patient #8 had been on hold since 1/27/2021. During an interview on 1/6/2022 at 12:09 PM, employee D, alternate clinical manager, stated not having realized when a patient had been admitted to a hospital, that a discharge summary is required be submitted to that entity.