Every finding on record at Parkview Health at Home LLC

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102. Survey Dates: 03/30, 03/31, 04/01, 04/02, 04/06, 04/07, 04/08, and 04/09/2026 Active Census: 258 At this Emergency Preparedness survey, Parkview Health at Home was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 484.102

This visit was for a Federal Recertification and State Re-Licensure survey of a Home Health Provider. This deficiency report reflects State Findings cited in accordance with 410 IAC 17. The survey was announced as partially extended on 04/06/2026 at 11:25 AM. Survey Dates: 03/30, 03/31, 04/01, 04/02, 04/06, 04/07, 04/08, and 04/09/2026 12-Month Unduplicated Skilled Admissions: 1507 Abbreviations: CNA: certified nurses aide; EMR: electronic medical record; LPN: licensed practical nurse; MSW: masters social worker; OASIS: Outcome and Assessment Information Set; OT: occupational therapist; POC: plan of care; PT: physical therapist; PTA: physical therapy assistant; RN: registered nurse; ROC: resumption of care; SN: skilled nurse; SOC: start of care; ST: speech therapist QR 4/15/2026

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to submit OASIS assessments within 30 days for 47 of 5741 assessments completed in calendar year 2025. Findings include: Review of the Internet Quality Improvement and Evaluation System HHA Error Summary by Agency evidenced 47 of 5741 assessments submitted more than 30 days after the date of assessment. During an interview on 03/30/2026 during the entrance conference, the Administrator indicated the agency had some assessments that were not submitted on time.

Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure patients received all services ordered in the plan of care for 2 of 18 active patients reviewed (Patients #4 and 18). Findings include: 1. Patient #4’s clinical record evidenced an order for an OT evaluation effective 03/16/2026. The OT completed the evaluation on 03/26/2026. The OT failed to ensure Patient #4 received the services as ordered by the physician. During an interview on 04/09/2026 beginning at 02:37 PM, the Administrator indicated an evaluation with an effective date should be done during that calendar week. 2. Patient #18’s clinical record evidenced a POC for certification period 02/05/2026 – 04/05/2026. The POC included an order for SN visits once every other week. The record evidenced a SN visit on 02/04/2026 to complete the recertification assessment. The next SN visit occurred on 02/18/2026, with the next visit on 03/18/2026. The nurse failed to provide a visit every other week. During an interview on 04/09/2026 beginning at 02:37 PM, the Clinical Supervisor indicated Patient #18 should only receive SN visits once per month. The Clinical Supervisor failed to provide a physician order for SN once per month.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the initial assessment was completed within 48 hours of discharge for 1 of 9 active patients with home visits observations (Patient #5). Findings include: 1. Review of the Comprehensive Patient Assessment policy, revised 9/15/25, indicated “… The initial assessment visit must be conducted within 48 hours of referral, or within 48 hour of the patient’s return home, or on the physician/ allowed practitioner-ordered Start of Care (SOC) date…” 2. Review of Patient #5’s clinical record included a referral form dated 3/16/26 for SN, PT, and OT with a facility discharge date of 3/17/26. The record also included a coordination note by Corporate Sales Team Member 1 dated 3/19/26 which indicated the first call was attempted to Patient #9. The clinical record also included an initial comprehensive assessment by RN 8 dated 3/20/26. The record failed to evidence the initial assessment was conducted within 48 hours of the referral. 3. During an interview on 4/08/26 at 11:07 AM, Corporate Sales Team Member 1 relayed she attempted the first call to Patient #5 to schedule the initial assessment on 3/19/26 at 11:09 AM because he was discharged on 3/17/26, but the agency had to get an order for SOC on 3/20/26 due to the agency could not see Patient #5 prior to that due to staffing availability. 4. During an interview on 4/8/26 at 12:11 PM, the Clinical Supervisor relayed Patient #9 had a physician-ordered SOC date. 5. During an interview on 4/8/26 at 12:13 PM, the Administrator relayed if the sales team knows the agency doesn’t have staffing they will notify the physician they can refer elsewhere or provide an order for the SOC date. 410 IAC 17-14-1(a)(1)(A)

5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the start of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure a complete comprehensive assessment including all ordered disciplines was completed within 5 days of SOC for 2 of 16 active patient records reviewed of patients admitted in 2024 or later (Patient #12 and 14). 3. Patient #14’s clinical record indicated a SOC of 02/05/2026. A physical therapy evaluation occurred on 02/11/2026, six days after the SOC. An MSW evaluation occurred on 02/12/2026, seven days after the start of care. The agency failed to ensure the PT and MSW completed their evaluations within 5 days of the SOC. During an interview on 04/09/2026 beginning at 02:37 PM, the Administrator indicated the PT and MSW evaluations were not completed within the 5 days of the SOC. Findings include: 1. Review of the Comprehensive Patient Assessment policy, revised 9/15/25, indicated “… The comprehensive assessment must be completed within five (5) calendar days after the Start of Care (SOC). This completion must be consistent with the patient’s immediate needs…” 2. Review of Patient #12’s clinical record included a PT SOC date of 3/09/26. The record included a verbal order received on 3/13/26 at 9:18 AM for OT to evaluate the week of 3/16/26. The order failed to indicate a reason for the delay past the five day assessment window. The clinical record failed to evidence a reason for the OT evaluation being more than five days after the PT SOC assessment. During an interview on 4/09/26 at 4:02 PM, OT 2 relayed she believed Patient #12’s OT evaluation was not completed within five days of the SOC because the Patient had a weird phone system and OT 2 having trouble contacting the Patient. OT 2 indicated that information was not documented in the clinical record. During an interview on 4/09/26 at 4:25 PM, the Clinical Supervisor relayed she could see OT 2 had requested orders to move Patient #12’s OT evaluation to the following week but did not see why.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the home health agency failed to ensure the patient’s medications were accurately assessed for 2 of 9 patients with home visit observations (Patient #3 and 9). Findings include: 1. Review of the Comprehensive Patient Assessment policy, revised 9/15/25, indicated “… The comprehensive assessment will accurately reflect the patient’s status across multiple domains and will include, at a minimum, the following information… A review of all current medications to identify potential adverse effects, drug reactions, ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and non-compliance…” 2. Review of the Medication Profile policy, revised 1/21/25, indicated “… The assessment review will identify current medications taken… The current medication regimen will be recorded on the patient medication profile…” 4. A home visit observation of RN 6 providing care for Patient #9 was conducted on 4/02/26 at 1:56 PM. During the visit, Patient #9 relayed they received infusions of Keytruda (a medication used to treat multiple types of cancers) at the infusion clinic every three weeks. Patient #9 also showed their bottle of pregabalin (a medication used to treat nerve pain, fibromyalgia, and seizures) 75 milligrams capsules. Patient #9 relayed they had been taking pregabalin for three years and were still taking it. Patient #9 also relayed they had never taken hydroxyzine, that it had been prescribed in the nursing home but never administered. Patient #9 relayed they did not have hydroxyzine in the home. Review of Patient #9’s clinical record included a medication profile. The medication profile failed to include Keytruda and failed to include pregabalin as an active medication. The medication profile also failed to exclude the hydroxyzine Patient #9 was not taking. During an interview on 4/07/26 at 2:56 PM, RN 7 relayed she completed Patient #9’s SOC assessment on 3/07/26. RN 7 indicated she could not answer why hydroxyzine was included on Patient #9’s medication profile. RN 7 also relayed she did not recall why pregabalin was removed from the Patient’s active medication profile. RN 7 also indicated she was not aware Patient #9 was receiving Keytruda. During an interview on 4/08/26 at 1:31 PM, Patient #9 relayed they had been receiving Keytruda infusions since November of 2025. 410 IAC 17-141(a)(1)(B) 4. A home visit observation with RN 1 and Patient #3 occurred on 03/31/2026 beginning at 11:28 AM. During the visit, RN 1 asked Patient #3 if they were still receiving infusions. Patient #3 confirmed they were receiving infusions. A review of the medication profile provided for the visit failed to include any infusion therapy. During an interview on 04/08/2026 beginning at 10:56 AM, RN 1 stated that Patient #3 received an infusion of fluids. When asked, RN 1 was unsure whether the infusion was required to be listed on the medication profile. Findings include: 1. Review of the Comprehensive Patient Assessment policy, revised 9/15/25, indicated “… The comprehensive assessment will accurately reflect the patient’s status across multiple domains and will include, at a minimum, the following information… A review of all current medications to identify potential adverse effects, drug reactions, ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and non-compliance…” 2. Review of the Medication Profile policy, revised 1/21/25, indicated “… The assessment review will identify current medications taken… The current medication regimen will be recorded on the patient medication profile…” 3. A home visit observation of RN 6 providing care for Patient #9 was conducted on 4/02/26 at 1:56 PM. During the visit, Patient #9 relayed they received infusions of Keytruda (a medication used to treat multiple types of cancers) at the infusion clinic every three weeks. Patient #9 also showed their bottle of pregabalin (a medication used to treat nerve pain, fibromyalgia, and seizures) 75 milligrams capsules. Patient #9 relayed they had been taking pregabalin for three years and were still taking it. Patient #9 also relayed they had never taken hydroxyzine, that it had been prescribed in the nursing home but never administered. Patient #9 relayed they did not have hydroxyzine in the home. Review of Patient #9’s clinical record included a medication profile. The medication profile failed to include Keytruda and failed to include pregabalin as an active medication. The medication profile also failed to exclude the hydroxyzine Patient #9 was not taking. During an interview on 4/07/26 at 2:56 PM, RN 7 relayed she completed Patient #9’s SOC assessment on 3/07/26. RN 7 indicated she could not answer why hydroxyzine was included on Patient #9’s medication profile. RN 7 also relayed she did not recall why pregabalin was removed from the Patient’s active medication profile. RN 7 also indicated she was not aware Patient #9 was receiving Keytruda. During an interview on 4/08/26 at 1:31 PM, Patient #9 relayed they had been receiving Keytruda infusions since November of 2025. 4. A home visit observation with RN 1 and Patient #3 occurred on 03/31/2026 beginning at 11:28 AM. During the visit, RN 1 asked Patient #3 if they were still receiving infusions. Patient #3 confirmed they were receiving infusions. A review of the medication profile provided for the visit failed to include any infusion therapy. During an interview on 04/08/2026 beginning at 10:56 AM, RN 1 stated that Patient #3 received an infusion of fluids. When asked, RN 1 was unsure whether the infusion was required to be listed on the medication profile. 410 IAC 17-141(a)(1)(B)

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the POC was based on the patient’s assessed needs for 1 of 6 patients with a home visit observation who received a skilled service in addition to skilled nursing (Patient #2). Findings include: 1.Patient #2’s clinical record evidenced a SOC of 03/14/2026. The POC for certification dates 03/14/2026 – 05/12/2026 evidenced an order for PT visits for 7 weeks, effective 03/15/2026. The POC also included goals for the PT visits. The POC included an order for OT visits for 5 weeks, effective 03/15/2026. The POC also included goals for the OT visits. The clinical record evidenced an OT evaluation completed on 03/16/2026 and a PT evaluation completed 03/17/2026. The PT and OT developed POC goals prior to assessing Patient #2’s needs. The agency failed to ensure the POC was developed based on the results of the comprehensive assessment. During an interview on 04/07/2026 beginning at 11:23 AM, the Administrator could not explain how the goals were on the POC when the evaluations were after the development of the POC. 410 IAC 17-13-1(a)

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the home health agency failed to ensure all equipment and supplies used by the patient were included in the POC for 1 of 9 patient records reviewed with home visit observations (Patient #8). Findings include: 1. Review of the Plan of Care and Physician and Allowed Practitioner Orders policy, revised 3/05/24, indicated “… The POC must include… Types of supplies… Types of equipment…” A home visit observation of the ST providing care for Patient #8 was conducted on 4/02/26 at 12:32 PM. Observed Patient #8 wearing eyeglasses and bilateral hearing aids. Review of Patient #8’s clinical record included a POC for certification period 2/25/26 to 4/25/26. The POC failed to include eyeglasses or hearing aids. The POC also included Plavix (an antiplatelet medication used to prevent blood clots) 75 milligrams daily. The POC failed to include antiplatelet or bleeding safety precautions. During an interview on 4/08/26 at 11:44 AM, RN 5 relayed she completed Patient #8’s recertification assessment and POC. RN 5 also relayed eyeglasses and hearing aids should be included in the POC but indicated she did not see them listed in Patient #8’s POC. RN 5 indicated Plavix was not a new medication so there were no safety measures specific to it on the current POC. 410 IAC 17-13-1(C)(ii) and (x)

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the SN updated wound care orders for 1 of 2 patients with wounds who had home visit observations (Patient #3). Findings include: 1.Patient #3’s clinical record included a ROC assessment completed by RN 1 on 02/27/2026. RN 1 documented the wound care she did included the use of normal saline to cleanse and pack the wound. An order dated 03/05/2026 indicated RN 1 entered the wrong wound care order on the ROC. The order should have included the use of Vashe (a brand of wound cleanser) instead of normal saline. During an interview on 04/08/2026 beginning at 10:57 AM, RN 1 stated she had used the new order from the hospital discharge instructions when she performed wound care on 02/27/2026. RN 1 acknowledged that she failed to update the wound care orders in the system, which resulted in the note not populating the new order into the “wound care provided” section. 410 IAC 17-13-1(a)(1)(B)(4)

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure provider orders were received prior to providing services for 1 of 18 active patient records reviewed (Patient #9). Findings include: 1. Review of the Plan of Care and Physician and Allowed Practitioner Orders policy, revised 3/05/24, indicated “… All care and services provided are according to current physician or allowed practitioner orders…” 2. Review of Patient #9’s clinical record included a POC for certification period 3/07/26 to 5/05/26 which was returned signed by the physician on 3/16/26 and included but was not limited to orders effective 3/08/26 for PT one visit per week for one week. A separate physician order form completed by PT 3 on 3/09/26 was returned signed by the physician on 3/16/26 at 3:58 PM with orders for PT effective 3/08/26 for one visit per week for one week then two visits per week for three weeks then one visit per week for four weeks. The record included a coordination note completed by PT 3 on 3/13/26 which indicated PT 3 received a verbal order from the physician on 3/13/26 at 9:13 AM for PT two times per week for three weeks then one time per week for four weeks. The clinical record failed to evidence a valid verbal order was obtained for PT services for Patient #9. The record included a PT visit note completed by PT 3 for a visit on 3/16/26 which began at 2:07 PM, prior to the agency receiving the signed written order for PT services from the physician. During an interview on 4/09/26 at 3:07 PM, PT 3 relayed she did not get the verbal order for the PT frequency for Patient #9. PT 3 relayed a phone nurse had obtained the verbal order, but PT 3 entered the verbal order into the coordination note. During an interview on 4/09/26 at 4:23 PM, the Clinical Supervisor relayed whoever actually spoke to the provider should be the one to put the verbal order into the clinical record.

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure verbal orders were authenticated by the physician for 4 of 18 active patient records reviewed (Patient #5, 9, 10, and 12). Findings include: 1. Review of the Plan of Care and Physician and Allowed Practitioner Orders policy, revised 3/05/24, indicated “… All verbal orders are verified by a ‘read back’ of the complete order by the person receiving the order… All signed physicians’ and allowed practitioners’ POCs and verbal orders received back to the Organization contain the order time and date…” 2. Review of Patient #5’s clinical record included a POC for certification period 3/20/26 to 5/18/26 which included but was not limited to orders for SN one visit per week for five weeks then one visit every two weeks for four weeks and three as needed visits. The POC also included but was not limited to orders effective 3/22/26 for PT one visit per week for four weeks. The POC was signed by the provider and returned to the agency on 3/30/26. The POC included a verbal date and time of 3/23/26 at 9:00 AM. The record also included a coordination note completed by RN 8 which indicated the RN received a verbal order directly from the physician on 3/23/26 at 7:35 AM for SN one time per week for four weeks and then every two weeks for four weeks for neurological checks, hypertension education, genitourinary education, fall risk education, pain assessments, medication education, and skin assessments. The record failed to evidence the verbal order was read back and verified and failed to evidence the order sent to the physician for signature included the time the verbal order was received. A separate physician order form was completed by PT 1 on 3/25/26 with orders for PT effective 3/22/26 for one visit per week for four weeks which indicated it was not to be sent to the physician. The record included a coordination note completed by PT 1 on 3/30/26 which indicated PT 1 received a verbal order through secure electronic messaging directly from the physician on 3/26/26 at 10:35 AM for PT one time per week for three weeks for therapeutic exercise, neuromuscular education, gait training, and therapeutic activity. The clinical record failed to evidence the order sent to the physician for signature included the date and time the verbal order was received. During an interview on 4/06/26 at 3:26 PM, PT 1 relayed she had documented the physician’s orders for Patient #5’s PT services in a coordination note. PT 1 also relayed the verbal order date and time on the separate PT order was the date the verbal order was requested, not the date the verbal order was received. During an interview on 4/09/26 at 4:10 PM, the Clinical Supervisor relayed the verbal order time of 7:35 AM for SN services for Patient #5 was not included in the POC sent to the physician for signature. 3. Review of Patient #9’s clinical record included a POC for certification period 3/07/26 to 5/05/26 which included but was not limited to orders for SN one visit per week for nine weeks and three as needed visits. The POC also included but was not limited to orders effective 3/08/26 for PT one visit per week for one week. The POC was signed by the provider and returned to the agency on 3/16/26. The POC included a verbal date and time of 3/09/26 at 9:00 AM. The record also included a coordination note completed by RN 7 which indicated the RN received a verbal order from the physician’s nurse on 3/09/26 at 11:05 AM for SN one time per week for nine weeks and for PT and OT to evaluate the patient. The record failed to evidence the verbal order was read back and verified and failed to evidence the order sent to the physician for signature included the verbal order time. During an interview on 4/07/26 at 2:56 PM, RN 7 relayed the date and time she received the verbal order for Patient #9’s SN frequency was on 3/09/26 at 11:05 AM and relayed she documented the verbal order in a coordination note. During an interview on 4/09/26 at 3:09 PM, the Clinical Supervisor indicated an order with the time the verbal order was received for Patient #9’s SN frequency was not sent to the physician for signature and indicated the coordination note documenting the verbal order did not specify the verbal order was read back and verified. 4. Review of Patient #10’s clinical record included a POC for certification period 3/20/26 to 5/18/26 which included but was not limited to orders for PT, one visit per week for one week then two visits per week for two weeks then one visit per week for four weeks. The POC was signed by the provider and returned to the agency on 3/20/26. The POC included a verbal date and time of 3/09/26 at 11:58 AM. The record also included a coordination note completed by PT 3 which indicated the PT received a verbal order from the physician’s nurse through secure electronic messaging on 3/23/26 at 8:24 AM for PT frequency and skills to be performed. The record failed to evidence the order sent to the physician for signature included the verbal order time. During an interview on 4/09/26 at 3:13 PM, PT 3 relayed she received the verbal order for Patient #10’s PT frequency on 3/23/26 at 8:24 AM through a secure electronic message and relayed she documented the verbal order in a communication note. 5. Review of Patient #12’s clinical record included a POC for certification period 3/09/26 to 5/07/26 which included but was not limited to orders for PT one visit per week for one week then two visits per week for three weeks then one visit per week for four weeks. The POC was signed by the provider and returned to the agency on 3/27/26. The POC included a verbal date and time of 3/09/26 at 12:00 PM. The record also included a coordination note completed by PT 4 which indicated the PT received a verbal order from the physician’s medical assistant on 3/09/26 at 1:21 PM for PT frequency and skills to be performed. The record failed to evidence the order was read back and verified and failed to evidence the order sent to the physician for signature included the verbal order time. During an interview on 4/09/26 at 4:25 PM, the Clinical Supervisor indicated the verbal time on the POC for Patient #12 was 12:00 PM and relayed the verbal order was documented as received at 1:21 PM in the coordination note. 6. During an interview on 4/07/26 at 4:07 PM, the Administrator relayed the date the verbal order was received should be documented on the order that was sent to the provider for signature. 7. During an interview on 4/09/26 at 4:20 PM, the Clinical Supervisor relayed the verbal date and time on the POC was the date and time the clinician requested the verbal order.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation and interview, the agency failed to ensure hand hygiene was performed after the aide touched a contaminated surface and before providing direct patient care, for 1 of 1 observation of an aide providing care (HHA 1). Findings include: 1.A home visit observation of HHA 1 and Patient #6 occurred on 04/01/2026 beginning at 10:10 AM. During the visit, HHA 1 prepared to provide personal care to Patient #6. HHA completed hand hygiene and donned gloves. Prior to beginning care, HHA 1 moved a trash can closer to her work area. HHA 1 provided care without performing hand hygiene and donning new gloves. During an interview at the end of the home visit, HHA 1 confirmed they did not perform hand hygiene after she touched a contaminated surface. HHA 1 indicated she knew she should have performed hand hygiene. 410 IAC 17-12-1(m)

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 home health agency failed to ensure HHAs were supervised by an RN at least every 14 days for 4 of 7 active patient records reviewed of patients receiving HHA services (Patient #7, 13, 15, and 16). 2. Patient #7’s clinical record evidenced a POC for the certification period 01/11/2026 – 03/11/2026, which indicated Patient #7 should receive HHA visits twice a week for 8 weeks. The record included supervisory visits on 02/17/2026 and 03/10/2026. The record indicated Patient #7 received HHA visits on 03/05/2026 and 03/09/2026. The HHA performed these visits without RN supervision. During an interview on 04/08/2026 beginning at 10:01 AM, RN 2 indicated supervisory visits were due every other week and there was a missing supervisory visit between 02/17/2026 and 03/10/2026. During an interview on 04/09/2026 beginning at 02:37 PM, the Clinical Supervisor indicated there was no supervisory visit between 02/17/2026 and 03/01/2026. Findings include: 1. Review of the Supervision of Home Health Aides policy, revised 3/10/26, indicated “… If the patient receives skilled nursing care, the Registered Nurse (RN), or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days…” 3. Review of Patient #13’s clinical record included HHA visit notes dated 2/25/26, 3/06/26, and 3/18/26. The clinical record failed to include any HHA supervisory visits. During an interview on 4/09/26 at 4:21 PM, the Clinical Supervisor relayed there were no HHA supervisory visits conducted for Patient #13. 4. Review of Patient #15’s clinical record included HHA visit notes on 2/03/26, 2/10/26, and 2/13/26. The record also included a SN visit note dated 1/26/26 which included HHA supervisory visit documentation. The record included an RN recertification with SN note dated 2/23/26, 28 days later, which included HHA supervisory visit documentation. The clinical record failed to include an HHA supervisory visit at least every 14 days. During an interview on 4/08/26 at 10:12 AM, RN 2 relayed she could not look back in the EMR to the previous certification period to see whether an HHA supervisory visit was conducted for Patient #15 between 1/26/26 and 2/16/26. During an interview on 4/08/26 at 12:20 PM, the Clinical Supervisor relayed the type of supervisory note in the EMR for Patient #15 on 2/02/26 did not give the ability to document the HHA’s name or the supervisory questions. 5. Review of Patient #16’s clinical record included HHA visit notes dated 2/18/26, 2/25/26, 3/11/26, 3/19/26, 3/27/26, and 4/02/26. The clinical record included a SN visit note dated 2/17/26 which included HHA supervisory visit documentation. The record failed to include any further HHA supervisory visits as of 4/08/26, 50 days later. During an interview on 4/08/26 at 2:17 PM, RN 4 relayed she conducted HHA supervisory visits at least every 30 days including for patients receiving skilled services. RN 4 also relayed Patient #16 had not received an HHA supervisory visit after the one conducted on 2/17/26. RN 4 further indicated the supervisory visit on the 3/17/26 SN visit note should have been for the HHA but was conducted for a nurse trainee. During an interview on 4/08/26 at 2:58 PM, the Clinical Supervisor relayed there were no HHA supervisory visits conducted for Patient #16 after the one on 2/17/26. 6. During an interview on 4/08/26 at 12:11 PM, the Clinical Supervisor relayed HHA supervisory visits should be conducted every 14 days.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on observation, record review and interview, the home health agency failed to ensure skilled professionals documented accurate information of patient assessment for 2 of 7 active records reviewed (#1, 2) 1. Review of an agency policy dated 9/7/2021, titled “Home Health Initial and Comprehensive Assessment” indicated “… comprehensive assessment must accurately reflect the patient’s status ….” 2. Review of an agency policy dated 9/7/2021, titled “Home Health Ongoing Assessment- Reassessment” indicated “… comprehensive assessment … assessment of homecare patients that reflects, accurately, the patient’s current health status ….” 3. A home observation visit was conducted with registered nurse (RN) H and clinical director C on 9/7/2021 at 1:00 PM, with patient #1. RN H asked patient to describe urine. Patient indicated they were not able to describe urine. RN H listened to patient’s bowel sounds. Clinical record review was completed on 9/7/2021 for patient #1, start of care 8/31/2021, certification period 8/31/2021- 10/29/2021, with a primary diagnosis of encounter for change of nonsurgical wound dressing, other pertinent diagnoses (but not limited to) included cellulitis (bacterial skin infection) of left and right lower limb (lower leg). An agency document titled “SN [skilled nurse] Routine Visit” dated 9/7/2021 by RN H indicated “… Clinical Assessment … Genitourinary … urine is clear, yellow, odorless … Gastrointestinal … bowels moving regularly with soft brown stool ….” The documentation failed to evidence an accurate description of patients’ urinary and bowel status as they were not visualized by the nurse or reported by the patient. During an interview on 9/8/2021 at 3:35 PM, when asked if the description of urine would be documented if the patient did not describe urine and the RN did not observe, the clinical/quality manager B indicated the electronic medical record (computer software) defaults to urine within normal limits as indicated in the skilled nurse visit record. When asked if a description of bowel movement would be documented if the nurse did not assess, the clinical director C indicated the documentation defaults to within normal limits when there are no issues. 4. Clinical record review was completed on 9/9/2021 for patient #2, start of care 1/7/2021, certification period 9/4/2021- 11/2/2021, with a primary diagnosis of multiple sclerosis. An agency document titled “Home Health Certification and Plan of Care” dated 9/1/2021 by RN H indicated “... activities permitted … bedrest ….” An agency document titled “SN Recertification OASIS” dated 9/1/2021 by RN H stated “… activities permitted … complete bedrest … ambulation assist: non-ambulatory … 60 day summary … patient progress toward goals/outcomes achieved … ambulates [moves about environment] safely with or without assist devices ….” This document failed to evidence an accurate description of patients’ ambulatory status. During an interview on 9/10/2021 at 1:00 PM, when asked if ambulation is a reasonable outcome for a patient on bedrest, clinical/quality manager B indicated this was a documentation error. 17-14-1(a)(1)(E)-RN

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102 Survey dates: May 4, 5, 6, 7, 10, 11, 12, 13, 19, 20, 21; (2021) Facility number: IN008347 Provider number: 157423 Current census: 434 At this Emergency Preparedness survey, Parkview Home Health and Hospice was found not in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 484.102 The cumulative effect of these systemic problems resulted in the home health agency being found out of compliance with the condition: 42 CFR 484.102

Establishment of the Emergency Program (EP) CFR(s): 484.102 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must establish and maintain a [comprehensive] emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements: *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This CONDITION is not met as evidenced by: Based on record review and interview, the agency failed to evidence it developed and maintained emergency preparedness policies and procedures based on its emergency plan, the facility and community-based hazard vulnerability assessment (HVA), or the communication plan (E-0013); failed to evidence emergency preparedness policies/procedures which addressed actions required by the agency if unable to contact staff or patients, what surrounding facilities it had transfer agreements with to ensure patient care was continued, or outline of timelines for transfer of patients, and under what conditions patients would be moved (E-0021); failed to evidence a policy based on the emergency plan that addressed the use of volunteers in an emergency or other emergency staffing strategies, which included the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency (E-0024); failed to evidence it developed and maintained a written emergency communication plan that contained how the facility coordinated patient care with other healthcare providers, and with state and local public health departments to protect patient health and safety in the event of a disaster (E-0029); failed to maintain an emergency preparedness communication plan that included the requirement to include names and contact information for staff, entities providing services under arrangement, patients' physicians, and volunteers (E-0030); and failed to evidence the integrated plan was based on an individual facility-based risk assessment as well as a documented community-based risk assessment to develop and maintain its emergency preparedness plan, policies and procedures, and testing based in the agency's identified risks (E-0042). The cumulative effect of these systemic problems resulted in the home health agency's inability to ensure the provision of adequate preparation to meet the needs of patients and participants during disasters and emergency situations, for the Condition of Participation 42 CFR 484.102 Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers.

Development of EP Policies and Procedures CFR(s): 484.102(b) (b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility's geographic area. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to evidence it developed and maintained emergency preparedness policies and procedures based on its emergency plan, the facility and community-based hazard vulnerability assessment (HVA), or the communication plan. Findings include: Review of a document revised 12/17/2019 and again on 8/1/2020 titled "Parkview Home Health and Hospice Emergency Management Plan" stated "... the response procedures address the prioritized emergencies ... Utilize the Emergency Management Plan Binder for guidance ... Ensure staff receive appropriate training and education on emergency management ... Refer to HIM [health information management] Disaster Operation and Recovery Plan Policy ...." Review of an agency powerpoint document dated 10/19/2020 titled "Emergency Preparedness" evidenced policy and procedures were a mandatory component of emergency preparedness, and stated "... We revised or created policies to address situations specific to the pandemic ...." Emergency preparedness documents were reviewed when received from the agency on 5/4/2020, 5/5/21, 5/6/21, and 5/12/21 and the documents failed to evidence emergency preparedness policies and procedures. Upon survey exit, a policy/procedure for COVID-19 was not submitted, or any other emergency preparedness policies or procedures.

HHA- Procedures for Follow up Staff/Pts. CFR(s): 484.102(b)(3) [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years.] At a minimum, the policies and procedures must address the following:] (3) The procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency. The HHA must inform State and local officials of any on-duty staff or patients that they are unable to contact. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to evidence emergency preparedness policies/procedures which addressed actions required by the agency if unable to contact staff or patients, what surrounding facilities it had transfer agreements with to ensure patient care was continued, or outline of timelines for transfer of patients, and under what conditions patients would be moved. Findings include: Review of a document revised 12/17/2019 and again on 8/1/2020 titled "Parkview Home Health and Hospice Emergency Management Plan" stated "... Communicates with local, state, and federal emergency officials through the designated Hospital Incident Commander ... regarding ... on-duty staff that we are unable to contact ... Phone patients whose visits must be postponed ... check on their condition / needs ... Each supervisor will maintain a list of employees who have been notified and are available ... Contact preferred extended care facilities ... Contact home care agencies that we have a Memorandum of Understanding (MOU) for their availability ...." The plan failed to evidence actions to contact staff or patients such as (but not limited to) calling alternate/emergency contacts for patients and staff, or timeframe to allow return contact prior to contacting designated Hospital Incident Commander; failed to identify preferred extended care facility providers or MOUs with any home care agencies; and failed to evidence under what conditions patients would be moved. During an interview on 5/5/2021 at 10:30 AM, surveyor requested all additional emergency preparedness documentation. Upon survey exit, emergency preparedness policies/procedures which addressed actions required by the agency if unable to contact staff or patients, what surrounding facilities it had transfer agreements with to ensure patient care was continued, or outline of timelines for transfer of patients, and under what conditions patients would be moved failed to be submitted for review. During an interview on 5/21/2021 at 3:21 PM, the clinical and quality manager indicated she thought she submitted everything related to emergency preparedness that the surveyors requested.

Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years (annually for LTC).] At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to evidence a policy based on the emergency plan that addressed the use of volunteers in an emergency or other emergency staffing strategies, which included the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. Findings include: 1. Review of a document revised 12/17/2019 and again on 8/1/2020 titled "Parkview Home Health and Hospice Emergency Management Plan" failed to evidence the plan addressed the use of volunteers in an emergency or other emergency staffing strategies, which included the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. 2. During an interview on 5/21/2021 at 3:21 PM, the clinical and quality manager indicated she thought she submitted everything related to emergency preparedness that the surveyors requested. Upon survey exit, nothing more was submitted for review.

Development of Communication Plan CFR(s): 484.102(c) (c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years (annually for LTC). This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to evidence it developed and maintained a written emergency communication plan that contained how the facility coordinated patient care with other healthcare providers, and with state and local public health departments to protect patient health and safety in the event of a disaster. Findings include: 1. Review of a document revised 12/17/2019 and again on 8/1/2020 titled "Parkview Home Health and Hospice Emergency Management Plan" stated "... Communications Plan / Notification of Agency personnel ... The Agency Incident Commander will notify the Parkview Emergency Preparedness Coordinator and/or Executive On-Call of the need to activate Emergency Management Plan ...." The document, under the heading of "Communications Plan / Notification of Agency personnel" failed to evidence how the facility coordinated patient care with other healthcare providers, and with state and local public health departments to protect patient health and safety in the event of a disaster. The agency failed to evidence a specific communication plan with all required elements was included in the emergency preparedness program. 2. During an interview on 5/21/2021 at 3:21 PM, the clinical and quality manager indicated she thought she submitted everything related to emergency preparedness that the surveyors requested. Upon survey exit, nothing more was submitted for review.

Names and Contact Information CFR(s): 484.102(c)(1) [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years (annually for LTC).] The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to maintain an emergency preparedness communication plan that included the requirement to include names and contact information for staff, entities providing services under arrangement, patients' physicians, and volunteers. Findings include: 1. Review of a document revised 12/17/2019 and again on 8/1/2020 titled "Parkview Home Health and Hospice Emergency Management Plan" stated "... Communications Plan / Notification of Agency personnel ... The Agency Incident Commander will notify the Parkview Emergency Preparedness Coordinator and/or Executive On-Call of the need to activate Emergency Management Plan ...." The document, under the heading of "Communications Plan / Notification of Agency personnel" failed to evidence the requirement that the plan must include names and contact information for staff, entities providing services under arrangement, patients' physicians, or volunteers. 2. During an interview on 5/21/2021 at 3:21 PM, the clinical and quality manager indicated she thought she submitted everything related to emergency preparedness that the surveyors requested. Upon survey exit, nothing more was submitted for review.

Integrated EP Program CFR(s): 484.102(e) (e) [or (f)]Integrated healthcare systems. If a [facility] is part of a healthcare system consisting of multiple separately certified healthcare facilities that elects to have a unified and integrated emergency preparedness program, the [facility] may choose to participate in the healthcare system's coordinated emergency preparedness program. If elected, the unified and integrated emergency preparedness program must- [do all of the following:] (1) Demonstrate that each separately certified facility within the system actively participated in the development of the unified and integrated emergency preparedness program. (2) Be developed and maintained in a manner that takes into account each separately certified facility's unique circumstances, patient populations, and services offered. (3) Demonstrate that each separately certified facility is capable of actively using the unified and integrated emergency preparedness program and is in compliance [with the program]. (4) Include a unified and integrated emergency plan that meets the requirements of paragraphs (a)(2), (3), and (4) of this section. The unified and integrated emergency plan must also be based on and include the following: (i) A documented community-based risk assessment, utilizing an all-hazards approach. (ii) A documented individual facility-based risk assessment for each separately certified facility within the health system, utilizing an all-hazards approach. (5) Include integrated policies and procedures that meet the requirements set forth in paragraph (b) of this section, a coordinated communication plan, and training and testing programs that meet the requirements of paragraphs (c) and (d) of this section, respectively. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the integrated emergency preparedness plan with the hospital ensured the licensed home health agency met all the requirements of an integrated health system's plan. Findings include: 1. Review of a document revised 12/17/2019 and again on 8/1/2020 titled "Parkview Home Health and Hospice Emergency Management Plan" stated "... The agency is part of [hospital D] health system ... The agency partners with [hospital D] for disaster training and response ... The Agency utilizes a Hazard and Vulnerability Assessment Tool (HVA) as a risk assessment tool. This tool allows the agency to identify the types of emergencies which are most likely to occur ... Hazard and Vulnerability Assessment Tool (HVA) ... allows the Agency to take a systemic approach to identify hazards or risks ... prioritize planning efforts ... Emergencies that can be predicted (i.e. major snow event) ... Collaborate with managers and supervisors to establish an operations plan for this event ...Ensure staff receive appropriate training and education on emergency management at hire and ... (at least annually) ...." 2. Review of an agency powerpoint document dated 10/19/2020 titled "Emergency Preparedness" evidenced policy and procedures were a mandatory component of emergency preparedness, and stated "... We revised or created policies to address situations specific to the pandemic ...." 3. Review of an undated document received on 5/4/2020 titled "COVID-19 Emergency Response After Action Report DRAFT ... Parkview Home Health and Hospice ... [clinical and quality manager D]" evidenced the first case of COVID-19 occurred on 3/8/2020 in the agency's service area, and then the agency began admitting patients with COVID-19 for services, hospital D implemented an allocation system to ensure all departments were ordering PPE (personal protective equipment) appropriately, and stated "... Developed standard work surrounding clinicians that either refused to see COVID-19 patients or had a physician recommendation to not see COVID-19 patients ... Implemented screening calls prior to home visits ... 3/10/2020 ... Implemented patient screening tool ... 3/14/2020 ... Implemented temperature screening of employees that may have been exposed ... 3/16/2020 ... Implemented Employee Sick Log ... Implemented employee temperature screening BID [twice daily] ... 3/19/2020 ... Updated patient screening tool ... 3/24/2020 Implemented return to work guidelines established by [hospital D] ... 4/21/2020 Implemented mask wearing for all visits ... 7/3/2020 Universal Masking in office ... 7/7/2020 N95 mask usage clarification ...." The agency failed to submit policies or procedures related to topics addressed in this document. 4. Review of an undated document received on 5/6/2021 titled "Emergency Preparedness and Joint Commission Aide Test" evidenced it was an answer key for the test, and stated "... What are the four mandatory components to an emergency preparedness program? ... Emergency Plan ... Policies and Procedures ... Communications Plan ... Training and exercise ...." The document failed to evidence questions related to disaster training, staff roles during a disaster, or response. 5. Review of a document dated 2021 titled "Hazard and Vulnerability Assessment Tool Parkview Home Health & Hospice 2021 TECHNOLOGIC EVENTS" evidenced electrical failure, communications failure, and information systems failure were highlighted as the highest risks. The assessment evidenced 0% risk of internal flooding. 6. Review a document dated 1/21/2020 titled "Utility Failure FSE [full scale exercise] ... After Action Report/Improvement Plan", submitted by the alternate administrator, evidenced a full scale exercise was conducted based on internal flooding (water main break), which the agency did not address on its hazard vulnerability assessment, and failed to identify the participants of the exercise. 7. Review of an additional document dated 1/21/2020 titled "Utility Failure FSE ... After Action Report/Improvement Plan" by clinical and quality manager D submitted another document which contained different report content for the same exercise, evidenced a full scale exercise was conducted based on internal flooding (water main break), which the agency did not address on its hazard vulnerability assessment, failed to identify the participants of the exercise, and stated "... Before the exercise ... Sign in when you arrive ... Complete the participant feedback form ...." 8. During an interview on 5/4/2021 at 10:42 AM, the agency's emergency preparedness plan was requested. At 1:55 PM, the administrator and clinical and quality manager D submitted the following documents titled "Parkview Home Health and Hospice Emergency Management Plan", "Parkview Home Health and Hospice Surge Plan", "Continuity of Operations (COOP) Emergency Operations Plan - Annex 15", "Parkview Home Health and Hospice - Essential Functions", and a "Hazard and Vulnerability Assessment Tool Parkview Home Health & Hospice 2021" multi-paged agency assessment with events including hazardous materials, technologic events, naturally occurring events, and human related events. 9. During an interview on 5/4/2021 at 4:15 PM, when queried if all emergency preparedness documentation was submitted, the alternate administrator indicated emergency drills and fire drills were all electronic. Copies were requested and later submitted for review. During this time, surveyor observed a red binder titled "Emergency Preparedness Binder". When queried what the red binder was on the shelf behind the front secretary's desk, the alternate administrator indicated she didn't know, she didn't want to comment, indicated (surveyor) could see after she reviewed it, and walked away with the binder. (Surveyor) followed and queried why she wouldn't submit the binder for review. She indicated she didn't want (surveyor) taking the binder out of the agency, but then submitted the binder for review. The binder evidenced a document dated 11/20/2020 with staff contact information, and directions for the secretary in case of an emergency. The binder failed to evidence any policies or procedures. 10. During an interview on 5/4/2021 at 4:28 PM, the administrator stated "... We don't keep an emergency preparedness binder ....", the clinical and quality manager stated "... Everything is electronic ...." When queried if the binder observed at 4:15 PM was the only emergency preparedness binder for the entire agency, the administrator stated "... I can't say that ....", and the clinical and quality manager stated "... I can check with each department ... we have a down time binder ... [which was requested] ... we don't have an emergency preparedness binder ...." When queried who initiated an emergency event, the administrator stated "... We work as an incident command team ...." When queried who was the incident commander, the administrator stated "... Me ... Joint Commission asks for different things than you are ...." At 4:53 PM, clinical an quality manager D submitted a document titled "COVID-19 Emergency Response After Action Report DRAFT ... Parkview Home Health and Hospice ... [clinical and quality manager D]" During this time, at 4:53 PM, clinical and quality manager D submitted a 19 page document titled "Home Health and Hospice Q & A", with a post-it-note attached which stated "Q&A Covid". 11. During an interview on 5/5/2021 at 10:30 AM, surveyor requested all emergency preparedness documentation, and clinical and quality manager D indicated they were in progress of getting documents, they were looking for (fire) drills, and stated "... We gave you papers [from yesterday] and [COVID-19] after-action plan ... we'll get you the fire drills ...." During this time, staff present for interview was queried once fire drills were submitted, would that represent the complete emergency preparedness documentation, the administrator stated "... Well we also did a simulated relocation exercise ..." and excused herself to obtain a copy (which was submitted). At 10:46 AM, the alternate administrator submitted a document dated 1/21/2020 titled "Utility Failure FSE [full scale exercise] ... After Action Report/Improvement Plan". At 11:43 AM, clinical and quality manager D submitted another document dated 1/21/2020 titled "Utility Failure FSE ... After Action Report/Improvement Plan", which contained different report content. At 12:27 PM, clinical and quality manager D submitted two documents dated 4/11/2019 and 12/22/2020 titled "Incident Report ... Safety/Fire Drill ...." 12. On 5/6/2021 at 11:22 AM, clinical and quality manager D submitted the following emergency preparedness documents: a policy dated 9/2020 titled "Computer Downtime Process", an untitled document titled "During EPIC [agency medical record software] Downtime", an undated document titled "EPIC Downtime available Reports"; an undated document titled "Emergency Management Plan Activation ... What to do as a Field Clinician"; an undated document titled "Emergency/Disaster Plan", which was part of the patient's home folder, with blank spaces to be completed by clinician and patient; 17 documents paper clipped, with a post it note attached which stated "Emergency Preparedness Education", which failed to include policies/procedures; a 19 page document with contact information of District 3 hospital corporate members, ambulatory surgery centers, dialysis units, health departments, long term care facilities, emergency management agencies, rural health clinics, home health/hospice agencies, mental health providers, primary health clinics, group homes, emergency medical service providers, and healthcare coalition contacts; and, a list of agency employees dated 3/18/2021 with home address and phone contact information. 13. On 5/12/2021 at 3:15 PM, clinical and quality manager D submitted a document dated 1/2019 titled "Winter Weather Snow Storm Event ... After-Action Report ...." and a document dated February 15-17, 2021 titled "Winter Weather Snow Storm Event ... After-Action Report". 14. During an interview on 5/21/2021 at 3:21 PM, when queried if the agency had a policy on hostage situation or violent environment, the clinical and quality manager stated "... I believe in one of the policies I gave you ... I'd have to go back and look ....", and indicated she thought she submitted everything related to emergency preparedness that the surveyors requested. When queried the date the agency activated its emergency plan for COVID-19, the clinical and quality manager stated "... I'll look for it ...." When queried about a policy/procedure for COVID-19, the clinical and quality manager indicated she would submit it. Upon survey exit, a policy/procedure for COVID-19 was not submitted, or any other emergency preparedness documents.

This was a federal and state home health recertification survey. The administrator was notified the survey was partially extended on 5/20/2021 at 4:36 PM Survey dates: May 4, 5, 6, 7, 10, 11, 12, 13, 19, 20, 21; (2021) Facility number: IN008347 Provider number: 157423 Current census: 434 This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Refer to State Form for additional State Findings. Based on the Condition-level deficiencies during the May 21, 2021 survey, Parkview Home Health and Hospice was subject to a partial or extended survey pursuant to section 1891(c)(2)(D) of the Social Security Act on 5/20/2021. Therefore, and pursuant to section 1891(a)(3)(D)(iii) of the Act, Parkview Home Health and Hospice is precluded from operating or being the site of a home health aide training and/or competency evaluation programs for the two years beginning May 21, 2021 and continuing through May 21, 2023 for being found out of compliance with the Conditions of Participation 42 CFR 484.60 Care Planning, Coordination of Services, and Quality of Care.

Property and person treated with respect CFR(s): 484.50(c)(1) Have his or her property and person treated with respect; This ELEMENT is not met as evidenced by: Based on record review and interview, the home care agency failed to ensure the patients' care preferences were respected for 1 of 1 records reviewed from the agency complaint log regarding the use of face masks during the COVID-19 pandemic (#8). Findings include: Review of a document submitted on 5/4/2021 as part of the agency's emergency preparedness program dated 4/2/2020, titled "Home Health and Hospice Q [question] & A [answer]" stated "... [Q] Are we cleaning off the plastic clear face shield masks or do we get a new one each time? ... [A] Please clean and reuse ... [Q] What masks can we use? ... [A] ... [administrator] was able to obtain 200 cloth masks that can be worn to help prevent you from giving something [germs] to others ... If a patient asks you to wear a mask and they do not have symptoms [of COVID-19], you can wear the cloth mask ...." Review of a document submitted on 5/4/2021 as part of the agency's emergency preparedness program dated 4/9/2020, titled "Home Health and Hospice Q & A" stated "... [Q] I have concerns about caring for patients without wearing a mask ... and I would like to do everything possible to protect my patients ... [A] You now have the option to wear a cloth mask for all patients ...." Review on 5/21/2021 of an "American Cancer Society" web reference https://www.cancer.org/treatment/treatments-and-side-effects/physical-side-effects/low-blood-counts/infections/preventing-infections-in-people-with-cancer.html titled "Watching for and Preventing Infections" stated "... Cancer and cancer treatments can weaken the immune system ... The immune system is a complex system the body uses to resists infection by germs, such as bacteria or viruses ... When the immune system is weakened, there is a higher risk for infection. Because of this, infection is a common complication of cancer and cancer treatment and certain types can be life-threatening if not found and treated early ...." Clinical record for patient #8 was reviewed on 5/21/2021, start of care date 4/11/2020, certification period 4/11/2020 - 6/9/2020, primary diagnosis malignant neoplasm (cancer) of upper-outer quadrant of left female breast, evidenced a document dated and signed by RN (registered nurse) X on 4/11/2020 titled "SN [skilled nurse] Start of Care OASIS [Outcome and Assessment Information Set]" stated "... Patient does not want to go to the hospital ... due to COVID-19 ... Wear face mask and gloves in home per patient request ...." Review of an agency document dated 4/13/2020 titled "Complaint log" evidenced family called agency to report a complaint that nurse did not wear a mask during care, while in the home, and RN (On Call) Y informed family agency was following hospital D's (not agency's) policy and CDC (Centers for Disease Control and Prevention) guidelines related to PPE during pandemic. Family was not satisfied with agency response and cancelled home care services, and indicated they would "just take the risk" and take the patient to a clinic for care. During an interview on 5/5/2021 at 10:00 AM, all documentation related to emergency preparedness was requested. Upon survey exit, no agency policies for COVID-19 and PPE were submitted for review. During an interview on 5/21/2021 at 3:00 PM, clinical manager D indicated personnel protective equipment (PPE) policies changed rapidly with COVID-19, the incident command at hospital D sent policies out to agencies, then agency staff would meet to determine how they would apply the policy/policies. During this time, clinical director B stated "... At first, masking wasn't even recommended ... We tried to make sure all staff did the same for all patients ....", Clinical Supervisor U stated "... while trying to preserve PPE ....", and clinical manager D stated "... There was nothing else we could do at that point ...." 17-12-3(b)(4)(B)

Have a confidential clinical record CFR(s): 484.50(c)(6) Have a confidential clinical record. Access to or release of patient information and clinical records is permitted in accordance with 45 CFR parts 160 and 164. This ELEMENT is not met as evidenced by: Based on observation, record review and interview, the agency failed to ensure all patients' had a confidential clinical record and paper documents were maintained in a locked area with restricted access to protect the privacy of protected health information (PHI). Findings include: Review of an agency policy dated 01/2021 titled "Medical Records" stated "... The medical record shall be ... property of [hospital D] ... which shall seek to safeguard it from unauthorized use, access, loss, or destruction ... whether ... in paper or electric form, shall be protected ...." During the entrance conference on 5/4/2021 at 10:42 AM, clinical manager D indicated the agency utilized both electronic medical records (EMR) and paper, but once the papers were scanned into the EMR, they were shredded. The administrator indicated she didn't know where paper clinical record documents were stored prior to being scanned into the system, Clinical Manager D indicated they were stored in a tray, and nursing supervisor F indicated the tray was in a locked supply room. During a tour of the agency on 5/4/2021 at 12:39 PM, the supply room door was observed open, no one was in the room, there was an empty tray on a table just inside the door labeled "filing," the sign posted outside the door indicated the room was open 8:00 AM - 5:00 PM, and indicated the door was locked after 5:00 PM. During this time, the administrator (who gave the tour) asked why a tour was requested, indicated she was never asked to give a tour, asked if entrance conference questions were new for surveys, and indicated she never experienced this much depth on survey. On 5/6/2021 at 1:10 PM an additional supply room observation was made. The door was open, no one was in the room, the tray contained a stack of clinical record documents, and patient #1's name was easily visible from the doorway on the top document. 17-12-3(b)(2)(E)

Patient's needs CFR(s): 484.55(c)(4) The patient's medical, nursing, rehabilitative, social, and discharge planning needs; This ELEMENT is not met as evidenced by: Based on record review and interview, the registered nurse failed to ensure the comprehensive assessment contained patient specific discharge planning for 18 of 18 records reviewed. Findings include: 1. Review of a policy dated 9/2020 titled "Home Care Discharge and Transfer Process" stated "... Planning for discharge will begin early in the home health episode ... The purpose of discharge planning is to ensure the patient and/or caregivers are ready and able to manage the patient's health needs once the Agency is no longer in the home ...." 2. Record review for patient #6 was completed on 5/20/2021, start of care date 8/30/2020, certification period 8/30/2020 - 10/28/2020, and a primary diagnosis disarticulates (infection or inflammation of pouches that can form in the intestines) of intestine, part unspecified, with perforation and abscess without bleeding. A document titled "Home Health Certification and Plan of Care" dated 8/30/2020 - 10/28/2020 indicated the patient received skilled nursing (SN) twice for 1 week, then once weekly for 2 weeks for management of an abdominal drain and stated "... Discharge patient when goals are met and pt [patient]/caregiver are able to manage healthcare needs ...." The start of care comprehensive assessment completed on 8/30/2020 titled "SN Start Of Care No- OASIS" stated "... Discharge ... when goals are met and pt/caregiver are able to manage healthcare needs ...." 3. Record review for patient #7 was completed on 5/21/2021, start of care date 7/21/2020, certification period 7/21/2020 - 9/18/2020, which indicated a primary diagnosis aftercare following surgery for neoplasm (cancer), other pertinent diagnosis (but not limited to) encounter for change or removal of drains. A document titled "Home Health Certification and Plan of Care" dated 7/21/2020 - 9/18/2020 evidenced the patient received SN services 3 times weekly for 4 weeks to provide (but not limited to) draining of a tube inserted into the patient's lung, and dressing changes, and stated "... Discharge Plans ... Pt will increase strength and all goals will be met ...." The start of care comprehensive assessment completed on 7/21/2020 titled "SN Start Of Care OASIS" stated " ... Pt will increase strength and all goals will be met ...." 4. Record review for patient #8 was completed on 5/21/2021, start of care date 4/11/2020, certification period 4/11/2020 - 6/9/2020, and a primary diagnosis of malignant neoplasm (cancer) of upper-outer quadrant of left female breast. A document titled "Home Health Certification and Plan of Care" dated 4/11/2020 - 6/9/2020 which evidenced the patient received SN once on 4/11/2020, then monthly for 2 months to flush her port (a small, implantable reservoir under the skin for direct intravenous access) and stated "... Discharge once patient/caregiver are able to perform self care and goals are met ...." The start of care comprehensive assessment dated 4/11/2021 titled "SN Start of Care OASIS" stated, "... Patient does not want to go to the hospital for port flush due to COVID-19 ...." but failed to evidence what specific discharge plans were present for patient #8. 5. Record review for patient #14 was completed on 5/20/2021, start of care date 4/29/2021, certification period 4/29/2021 - 6/27/2021, and a primary diagnosis type 2 diabetes mellitus with hypoglycemia (low blood sugar) without coma. A document titled "Home Health Certification and Plan of Care" dated 4/29/2020 - 6/27/2020 indicated the patient received SN once weekly for 1 week, then twice weekly for 3 weeks, and stated "... Discharge patient when goals are met and patient is managing care ...." The start of care comprehensive assessment completed on 4/11/2020 titled "SN Start of Care OASIS" stated "... Discharge once patient/caregiver are able to perform self care and goals are met ...." 6. Record review for patient #15 was completed on 5/20/2021, start of care date 4/30/2021, discharge date 5/16/2021 (without a home visit per patient request), certification period 4/30/2021 - 6/28/2021, and a primary diagnosis traumatic pneumothorax (collapsed lung). A document titled "Home Health Certification and Plan of Care" indicated the patient received SN once weekly for 4 weeks, OT (occupational therapy) once weekly for 2 weeks (effective 5/4/2021), and PT (physical therapy) one visit between 4/30/2021 - 5/8/2021, and stated ".... pt will be discharged from HHC when all goals have been met ...." The start of care comprehensive assessment completed on 4/30/2021 titled "SN Start of Care No- OASIS" stated "... pt will be discharged from HHC [home health care] when all goals have been met ...." 7. Record review for patient #16 was completed on 5/20/2021, start of care date 5/1/2021, certification period 5/1/2021 - 6/29/2021, and a primary diagnosis of acute kidney failure, unspecified. A document titled "Home Health Certification and Plan of Care" dated 5/1/2021 - 6/29/2021 evidenced the patient received skilled nursing, PT, OT and MSW (medical social worker) services, and stated "... discharge patient once she is able to understand oxygen, disease management and goals of care are met ...." Review of a hospital D document dated 4/30/2021 titled "Discharge Summary" stated "... her daughter ... concern that patient cannot take care of herself at home and wants placement for her but she does not want to go anywhere but home ... advised compliance especially with [diabetes] meds which could be contributing to her nausea/vomiting ...." Review of a document dated 4/30/2021 (prior to admission to home health) titled "Clinical Handoff" stated "... Reason for HHC [home health care] ... fatigue, diarrhea, respiratory failure with hypoxia ...." The start of care comprehensive assessment completed on 5/3/2021 titled "SN Start of Care OASIS" stated "... discharge patient once she is able to understand oxygen, disease management and goals of care are met ...." 8. Record review for patient #17 was completed on 5/12/2021 and 5/21/2021, start of care date 5/3/2021, certification period 5/3/2021 - 7/1/2021, and a primary diagnosis fluid overload (the condition of having too much water in your body), unspecified, other pertinent diagnoses (but not limited to) type 2 diabetes mellitus and hypertensive heart disease with heart failure. A document titled "Home Health Certification and Plan of Care" dated 5/3/2021 - 7/1/2021 indicated the patient received SN 3 times weekly for 1 week, twice weekly for 2 weeks, then once weekly for 1 week for, and stated "... Discharge Plans ... When teaching completed and condition stable ...." The record failed to evidence discharge plans were based on patient-specific needs, and discharge planning needs were addressed on an ongoing basis. 9. Record review for patient #18 was reviewed on 5/11/2021, start of care date 10/18/2020, certification period 10/18/2020 - 12/16/2020, and a primary diagnosis aftercare following surgery for neoplasm (cancer), other pertinent diagnosis (but not limited to) encounter for attention to colostomy (a surgical operation in which a piece of the bowel is diverted to an artificial opening in the abdominal wall). A document titled "Home Health Certification and Plan of Care" evidenced the patient received skilled nursing services for (not limited to) colostomy care and stated "... Patient will be discharged from HHC [home health care] when patient's strength and self-independence improve and when goals are met The start of care comprehensive assessment completed on 10/18/2020 titled "SN Start of Care OASIS" stated "... will be discharged from HHC when patient's strength and self-independence improve and when goals are met ...." 10. During an interview on 5/11/2021 at 4:05 PM, when queried if "... Patient will be discharged from home health care ... when goals are met ...." was specific and individualized. Therapy supervisor V stated "... I think it would be referring to specific goals in the plan of care ...." When queried why many visit notes indicated no discharge planning was completed, clinical and quality manager D indicated there was a specific form, and it was completed a minimum of two weeks before discharge.11. Record review for patient #1 was completed on 5/10/2021 and again on 5/12/2021, start of care date 2/17/2021, certification period 4/18/2021 - 6/16/2021, and a primary diagnosis disruption of external operation (surgical) wound, not elsewhere classified. A document titled "Home Health Certification and Plan of Care" which indicated the patient received SN twice a week for 1 week, then once weekly for 8 weeks for management of surgical wound and received PT (physical therapy) twice a week for 3 weeks and stated " ... Discharge when wound healed and goals met ...." The record failed to evidence discharge plans were based on patient specific needs. The recertification comprehensive assessment completed on 4/16/2021 titled "SN Recertification OASIS", stated "... discharge when wound healed and goals met ...." 12. Review record for patient #2 was completed on 5/11/2021, start of care date 2/24/2021, certification period 4/25/2021 - 6/23/2021, and a primary diagnosis of mild hyperemesis gravidarum. A document titled "Home Health Certification and Plan of Care" indicated the patient received SN once a week for 9 weeks for management of hydration, medication administration techniques, and stated " ... Pt [patient] will be discharged from HHC [home health care] when all goals are met ...." The recertification comprehensive assessment completed on 4/22/2021 titled "SN Recertification No-OASIS, stated "... pt will be discharged from HHC [home health care] when all goals are met ...." 13. Review record for patient #3 was completed on 5/13/2021, start of care date 4/25/2021, certification period 4/25/2021 - 6/23/2021, and a primary diagnosis malignant neoplasm of colon, unspecified. A document titled "Home Health Certification and Plan of Care" which indicated the patient received SN and PT services and stated " ... Discharge once patient/caregiver are able to perform self care and goals are met ...." The record failed to evidence discharge plans were based on patient-specific needs. Review of a document dated 4/23/2021 titled "Clinical Handoff" stated " ... Reason for HHC [home health care] ... dehydration, weakness, low electrolytes ...." The start of care comprehensive assessment completed on 4/25/2021 titled "SN Start of Care OASIS" stated "... discharge once patient/caregiver are able to perform self care and goals are met ...." 14. Record review for patient #4 was completed on 5/12/2021, start of care date 4/22/2021, certification period 4/22/2021 - 6/20/2021, and a primary diagnosis acute kidney failure, unspecified. A document titled "Home Health Certification and Plan of Care" which indicated the patient received SN and PT services and stated " ... Discharge patient when goals are met and patient is managing care ...." The start of care comprehensive assessment completed on 4/22/2021 titled "SN Start of Care OASIS" stated "... discharge patient when goals are met and patient is managing care ...." 15. Record review for patient #5 was completed on 5/17/2021, start of care date 3/18/2021, certification period 3/18/2021 - 5/16/2021, and a primary diagnosis aftercare following surgery for neoplasm. A document titled "Home Health Certification and Plan of Care" which indicated the patient received skilled nurse, OT, PT and MSW services, and stated " ... pt [patient] will be discharged from HHC [home health care] when all goals have been met ...." The start of care comprehensive assessment completed on 3/18/2021 titled "SN Start of Care OASIS" stated "... pt will be discharged from HHC when all goals have been met ...." 16. During a scheduled agency discharge home visit for patient #9 on 5/6/2021 at 12:00 PM, PT (physical therapist) BB indicated to the patient there was a change in plans, the agency would "hang out another week", he offered nursing services, and the patient accepted, indicating it would help due to her right rotator cuff (shoulder) pain and also because she was in the hospital last week because she was wheezing "real bad". Clinical record review was completed on 5/18/2021, start of care date 4/6/2021, certification period 4/6/2021 - 6/4/2021, and a primary diagnosis acute kidney failure, unspecified. A document titled "Home Health Certification and Plan of Care" which indicated the patient received SN twice weekly for 2 weeks, then once weekly for 2 weeks, PT twice weekly for 3 weeks, then once weekly for 2 weeks and stated "... discharge plans ... when goals are met and pt [patient] is independent in care ...." The start of care comprehensive assessment completed on 4/6/2021 titled "SN Start of Care OASIS" stated "... When goals are met and pt [patient] is independent in care ...." 17. Record review for patient #10 was completed on 5/18/2021, start of care date 4/27/2021, certification period 4/27/2021 - 6/25/2021, and a primary diagnosis aphasia following cerebral infarction. A document titled "Home Health Certification and Plan of Care" indicated the patient received SN, PT, SLP (speech therapy) services, and stated " ... Pt [patient] will be discharge [sic] when care plan goals are met ...." The start of care comprehensive assessment completed on 4/27/2021 titled "SN Start of Care OASIS" stated "... pt will be discharge [sic] from HHC when care plan goals are met ...." 18. Record review for patient #11 was completed on 5/13/2021, start of care date 5/4/2021, certification period 5/4/2021 - 7/2/2021, and a primary diagnosis of Acute cystitis without hematuria (urinary tract infection with no blood in urine). A document titled "Home Health Certification and Plan of Care" which indicated the patient received SN, PT, OT, MSW (medical social worker) and HHA (home health aide) services and stated "... discharge patient when goals are met and patient/caregiver is managing care ...." The start of care comprehensive assessment completed on 5/4/2021 titled "SN Start of Care OASIS" stated "... discharge patient when goals are met and patient/caregiver is managing care ...." 19. Record review for patient #12 was completed on 5/19/2021, start of care date 3/13/2021, certification period 3/13/2021 - 5/11/2021, and a primary diagnosis encounter for change or removal of surgical wound dressing. A document titled "Home Health Certification and Plan of Care" which indicated the patient received SN, PT and OT services, and stated " ... SN to discharge patient from home health care when patient/caregiver have been provided with education, self-management tools and consequences of non-adherence to POC [plan of care] and/or patient and caregiver are able to self manage the care required ...." The start of care comprehensive assessment completed on 3/13/2021 titled "SN Start of Care OASIS" stated "... SN to discharge patient from home health care when patient/caregiver have been provided with education, self-management tools and consequences of non-adherence to POC [plan of care] and/or patient and caregiver are able to self manage the care required ...." 20. Record review for patient #13 was completed on 5/19/2021, start of care date 4/28/2021, certification period 4/28/2021 - 6/26/2021, and a primary diagnosis encounter for surgical aftercare following surgery on the circulatory system. A document titled "Home Health Certification and Plan of Care" which indicated the patient received SN twice a week for 2 weeks, then once a week for 2 weeks and stated " ... Discharge Plans ... when goals are met and pt [patient] is independent in care ...." The start of care comprehensive assessment completed on 4/28/2021 titled "SN Start of Care OASIS" stated "... when goals are met and pt is independent in care ...." 17-14-1(a)(1)(B)

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on record review and interview, the registered nurse (RN) failed to ensure the comprehensive assessment contained a complete review of medications and medication lists were accurately maintained for 5 of 18 records reviewed (#7, 14, 16, 17, 18). Findings include: 1. Review of an agency policy dated 9/2020 titled "Home Care Medication Safety and Monitoring" stated "... Review all medications he patient is taking including over-the-counter medications, herbals, and dietary supplements ... Compare orders to medications in the home ... Identify any potential medication adverse effects or reactions ... Notify the physician ... Update medication profile ... review ... every visit ... the information gathered ... will be shared ... between the clinician and/or physician ...." 2. Review of an agency policy dated 8/2020 titled "Home Health Ongoing Assessment - Reassessment" stated "... includes the process of drug regimen review ... Medications drug regimen review completed every visit with changes documented in patient EHR [electronic health record] and home medication list ... The following should be charted ... by end of day of visit ... Medication changes ...." 3. Review of an agency policy dated 8/2020 titled "Home Health Initial and Comprehensive Assessment" stated "... A review of all medications the patient is currently taking in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy ... The individualized plan of care orders must include the following ... all medications ...." 4. Review on 5/21/2021 of a "Drugs.com" web reference https://www.drugs.com/international/oxygen.html titled "Oxygen" stated "... In the US, Oxygen (oxygen systemic) is a member of the drug class medical gas ...." 5. Clinical record for patient #7 was reviewed on 5/21/2021, start of care date 7/21/2020, certification period 7/21/2020 - 9/18/2020, and a primary diagnosis aftercare following surgery for neoplasm (cancer). A document dated 7/21/2020 and signed by RN HH on 7/22/2021 titled "Home Health Certification and Plan of Care [POC] stated "... Pain - Opioid [narcotic medication] use ... Patient ... will teach back understanding of opioid use ...." but failed to evidence any opioid medications were listed on the medication section of the plan of care Review of a document dated and signed by RN II on 7/20/2020 titled "Clinical Handoff" stated "... Medication changes ... Yes ... Start taking on ... July 21, 2020 ... senna-docusate [constipation medication] ...." The POC failed to evidence senna-docusate was listed on the medication section of the plan of care. Review of a document dated and signed by RN HH on 7/21/2020 titled "SN Start of Care OASIS [outcome and assessment information set]" stated "... Is Patient currently taking Opioids?: Yes ...." Review of a document dated and signed by RN JJ on 7/29/2020 titled "SN Routine Visit" stated "... Took her oxycodone [opioid pain medication] about 20 minutes ago ... Received approval to add the senna to the med list and take oft [sic] the dulcolax [medication] ...." The clinical record failed to evidence dulcolax was ever on the medication list. Review of a document dated and signed by LPN W on 8/4/2020 titled "SN Routine Visit" stated "... [patient] reports she has a diaper rash ... showed doctor today and he told her to use just a diaper rash cream ...." The document failed to evidence the nurse identified what specific cream the patient used or add it to the medication list. Review of a document dated and signed 8/10/2020 by RN KK titled "SN Routine Visit" stated "... [patient] spoke with ... [physician E' office] today ... they increased [sic] in lisinopril [blood pressure medication] from 10mg [milligrams] at noon to 20mg ...." The clinical record failed to evidence lisinopril on the medication list. Review of a document dated and signed 8/12/2020 by RN JJ titled "Case Communication" stated "... [patient] had gone to ... [emergency room] ... for uncontrolled pain ... blood pressure was elevated ... [physician F] increased [lisinopril] to 40 mg at her phone visit with him today ... doctor also told her she could take tylenol along with the oxycodone ...." The clinical record failed to evidence tylenol on the medication list. Review of a hospital D document dated 8/16/2020 titled "Discharge Summary" evidenced the patient's new medications included cefdinir (Omnicef) (antibiotic) for 7 days, labetalol (normodyne) (blood pressure medication) every 12 hours, hold for pulse/heart rate less than 55 BPM (beats per minute), magnesium oxide (mineral supplement), metronidazole (Flagyl) (antibiotic) for 7 days, and hydralazine (blood pressure). Review of a document dated and signed 8/20/2020 by RN LL titled "SN Routine Visit" stated "... Last day of antibiotics is Sunday ...." The clinical record failed to evidence cefdinir (Omnicef), labetalol (normodyne), metronidazole (Flagyl), or hydralazine on the medication list. Review of a document dated and signed 8/28/2020 by RN KK titled "SN Routine Visit" stated "... [blood pressure] 202/101 (with hydralazine order to take if SBP [systolic/top blood pressure number] > [greater] 180, patient took med ...." The clinical record failed to evidence hydralazine on the medication list. Review of a document dated and signed 9/4/2020 by RN MM titled "SN Routine Visit" evidenced the patient received supplemental oxygen at 2 liters per minute (LPM) while she slept. The clinical record failed to evidence oxygen on the medication list. Review of a document dated and signed 9/8/2020 by RN MM titled "SN Routine Visit" evidenced the patient started keflex (antibiotic) "yesterday" due to congested sinuses. The clinical record failed to evidence keflex on the medication list. Review of a document dated and signed 9/10/2020 by LPN W titled "SN Routine Visit" stated "... [patient] states she is on doxycycoline [sic] [antibiotic] for sinus infection ...." The clinical record failed to evidence doxycycline on the medication list. 6. Clinical record for patient #14 was reviewed on 5/19/2021, start of care date 4/29/2021, and a primary diagnosis type 2 diabetes mellitus with hypoglycemia (low blood sugar) without coma. A document dated 4/29/2021 and signed by RN RR on 5/1/2021 titled "SN Start of Care OASIS" evidenced the patient was a high nutritional risk, the patient reported she did not routinely check her blood sugar, she didn't check it today (4/29/2021), she just ate a bagel and drank 2 glasses of orange juice, patient was supposed to check her blood sugar every morning before breakfast and at bedtime, and blood sugar was checked during nursing visit before dinner with result of 422. The physician was made aware. Review of a document dated 4/30/2021 titled "Case Communication (Chartable)" evidenced the physician responded to the high blood sugar report on 4/29/2021 and indicated the patient should restart glymepiride (diabetes medication) daily. The plan of care failed to evidence glymepiride on the medication list. 7. Clinical record for patient #16 was reviewed on 5/19/2021, start of care date 5/1/2021, certification period 5/1/2021 - 6/29/2021, and a primary diagnosis acute kidney failure, unspecified. A document from hospital D document dated 4/30/2021 titled "Discharge Summary" which evidenced the discharge medication list included (but not limited to) loperamide (immodium) for diarrhea, and saccharomyces boulardii (florastor- a probiotic). Review of a document dated and signed by RN VV on 4/30/2021 titled "Clinical Handoff" evidenced immodium and florastor were new medications. Review of a document titled "Home Health Certification and Plan of Care" for certification dates 5/1/2021 - 6/29/2021 failed to evidence immodium or florastor on the medication list. During an interview on 5/20/2021 at 1:38 PM, clinical manager D indicated she didn't see immodium or florastor on the plan of care. 8. Clinical record for patient #17 was reviewed on 5/12/2021, start of care date 5/3/2021, certification period 5/3/2021 - 7/1/2021, and a primary diagnosis fluid overload (the condition of having too much water in your body), unspecified. A document dated and signed 5/3/2021 by RN XX titled "SN Start of Care OASIS" evidenced new medications included (but not limited to) furosemide (diuretic) and humalog (insulin). The record failed to evidence furosemide nor insulin on the medication list. 9. Clinical record for patient #18 (discharged record) was reviewed on 5/11/2021, start of care date 10/18/2020, certification period 10/18/2020 - 12/16/2020, and a primary diagnosis aftercare following surgery for neoplasm (cancer). A document dated and signed by RN (registered nurse) X on 10/24/2020 titled "SN [skilled nurse] Routine Visit" which evidenced medication issues were found during the home visit, but failed to evidence the issue(s), or interventions (such as a drug regimen review) to resolve them. During an interview on 5/20/2021 at 9:05 AM, clinical manager D indicated she did not see documentation in the record which identified the issue(s) or interventions to resolve them. 10. During an interview on 5/20/2021 at 1:38 PM, the clinical manager, alternate administrator/clinical director, lead RN NN, therapy supervisor V, and RN clinical supervisor U indicated they didn't want to keep going over medication concerns, and it wasn't worth re-visiting the concerns on every chart. 11. During an interview on 5/21/2021 at 1:00 PM, (clinical record review on patient #7), the following (but not limited to) was addressed: When queried about the absence of the opioid on the POC, the clinical manager indicated it looked like it was a medication bottle visualized the home, and the nurse entered an opioid goal while she waited to get clarification from the doctor, she didn't have a reason why the goal was added. Additionally, she stated "... Because we're integrated [agency and hospital D], sometimes all medications aren't on the list [agency clinical record medication list] ...." She also indicated when the nurse saw it (the opioid medication pill bottle) in the home, she added the goal, and it was not uncommon to need physician clarification. Regarding the nursing visit on 8/4/2021, the clinical manager indicated the nurse probably would have waited to add the cream until the patient got it, and indicated it was not documented if she had it or not. Regarding the nursing visit on 8/10/2021 when queried if the lisinopril dose increase was documented on the medication profile, or if order was clarified, therapy supervisor V, indicated a nurse with hospital D's cardiology department updated the medication list. When queried if the agency nurse should have clarified it, the clinical manager stated "... Well, that's part of the integrated health system. There's really no way around it because we share a medication list." 17-14-1(a)(1)(B)

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on observation, record review and interview, the home health agency failed to ensure all patients' plans of care were reviewed and signed by the certifying physician within 30 days (per agency policy) (G572); failed to ensure all patients' plans of care included all required elements (G574); failed to ensure the physician was promptly notified of changes in the patient's condition (G590); failed to provide ongoing training/education to all patients and failed to monitor the patient's comprehension and response to training/education (G610); failed to ensure that all patients received written visit schedules (G614); failed to ensure that all patients had current/updated written medication schedule/instructions prepared by agency staff in the home (G616); failed to ensure that all patients received a current/updated written plan of care (G618); and failed to ensure all patients received the name and contact information of the agency's clinical manager (G622). This practice had the potential to affect all agency patients. The cumulative effect of these systemic problems resulted in the home health agency's inability to ensure the provision of quality health care for the Condition of Participation 42 CFR 484.60 Care planning, coordination, and quality of care.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure all patients' plans of care were reviewed and signed by the certifying physician within 30 days (per the agency's own policy) for 2 of 18 records reviewed (#2, 12). Findings include: 1. Review of agency policy dated 12/2020 titled "Home Care Orders for Care" stated "... the physician certifies the need for the home health care services at the start of care ... by signing the Plan of Care within 30 days of Start of Care ...." 2. Record review of patient #2 was completed on 5/11/2021, start of care date 2/24/2021, primary diagnosis mild hyperemesis gravidarum (severe vomiting with pregnancy). The record evidenced a document titled "Home Health Certification and Plan of Care" for certification period 2/24/2021 - 4/24/2021, was electronically signed by the physician on 4/13/2021 (48 days after the start of care). During an interview on 5/12/21 at a 3:00 PM, when queried if the plan of care should be signed within 30 days of the start of care, clinical and quality manager D indicated she believed the policy was 30 days. 3. Record review of patient #12 was completed on 5/19/2021 and again on 5/21/2021, start of care date 3/13/2021, primary diagnosis aftercare following surgery for neoplasm (cancer). The record evidenced a document titled "Home Health Certification and Plan of Care" for certification period 3/13/2021 - 5/11/2021, was electronically signed by the physician on 4/24/2021(42 days after the start of care). During an interview on 5/21/21 at 1:00 PM, when queried if the plan of care should be signed within 30 days of the start of care, clinical and quality manager D indicated the timeframe was 30 days.

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: 21. Record review of patient #1 was completed on 5/10/2021, start of care date 2/17/2021, and a primary diagnosis of disruption of external operation (surgical) wound, not elsewhere classified, and other pertinent diagnoses (but not limited to) infection and inflammatory reaction due to other internal joint prothesis, and acute osteomyelitis (infection), right ankle. Review of a document titled "Home Health Certification and Plan of Care" for certification period 2/17/21- 4/17/21, evidenced (but not limited to) the patient's prescribed medication included (but not limited to) cholecalciferol (Vitamin D3) for vitamin D deficiency. The plan of care failed to evidence the diagnosis of vitamin D deficiency. During an interview on 5/12/21 at 3:00 PM, when queried if vitamin D deficiency should be listed as a diagnosis on the plan of care, clinical supervisor U indicated vitamin D3 deficiency was not a current diagnosis, so the agency's coder would not list it as a diagnosis. 22. Record review of patient #2 was completed on 5/11/2021 and again on 5/12/2021, start of care date 2/24/2021. The record evidenced documents titled "Home Health Certification and Plan of Care" for certification periods 2/24/2021 - 4/24/2021, and 4/25/2021 - 6/23/2021. The primary diagnosis for both certification periods was mild hyperemesis gravidarum (severe vomiting with pregnancy) and both documents evidenced (but not limited to) the patient's prescribed medications included (but not limited to) polyethylene glycol (laxative) for constipation. Both plans of care failed to evidence the pertinent diagnosis of constipation. During an interview on 5/12/21 at 3:00 PM, when queried if constipation should be a diagnosis on the plans of care, clinical supervisor U indicated the coders couldn't list it as a diagnosis without an actual diagnosis from the physician. 23. Record review of patient #3 was completed on 5/13/2021 and again on 5/20/2021, start of care date 4/25/2021, primary diagnosis malignant neoplasm (cancer) of colon, unspecified. The record evidenced a document titled "Home Health Certification and Plan of Care" for certification period 4/25/2021 - 6/23/2021, which evidenced the patient elected specific advance directives including a living will and healthcare power of attorney/durable power of attorney, but failed to evidence details of the patient's wishes, or if the patient was a full code (initiate life-saving/resuscitative measures if patient unresponsive) or DNR (do not resuscitate). Review of a document dated and signed by LPN DD on 4/26/21 titled "SN (skilled nurse) Routine Visit" stated "... Clinical Assessment ... Gastrointestinal ... Supplements ... Ensure [nutritional supplement] ...." Review of a document dated and signed by RN J on 4/29/21 titled "SN Routine Visit" stated "... Goal: Diet-Nutrition and Hydration ... Visit Notes ... Pt [patient] also trying to drink one ensure a day ...." Review of a document dated and signed by RN J on 5/4/21 titled "SN Routine Visit" stated "... Goal: Diet-Nutrition and Hydration ... Visit Notes ... Drinking supplement shakes ...." 24. During an interview on 5/20/21 at 9:05 AM, when queried if supplements should be included on the plan of care, clinical and quality manager D indicated supplements were not required to be entered on the plan of care. 17-13-1(a)(1)(B) 17-13-1(a)(1)(C) 17-13-1(a)(1)(D)(viii) 17-13-1(a)(1)(D)(xiii) Based on observation, record review, and interview, the agency failed to ensure all patients' plans of care included all pertinent diagnoses, the types of services, supplies, and equipment required, nutritional requirements, all medications and treatments, safety measures to protect against injury, patient-specific interventions and education, measurable outcomes and goals identified by the agency and the patient, and information related to advance directives, for 15 of 18 records reviewed (#1, 2, 3, 4, 6, 7, 8, 9, 10, 12, 14, 15, 16, 17, 18). Findings include: 1. Review of an agency policy dated 8/2020 titled "Home Health Initial and Comprehensive Assessment" stated "... The individualized plan of care orders ... must include the following: ... All pertinent diagnoses ... The primary diagnosis should be the reason the patient is receiving services ... The types of services, supplies, and equipment required ... Nutritional requirements ... All medications and treatments ... Safety measures to protect against injury ... Patient care individualized verbal orders and goals, with measurable outcome dates ... Advanced [sic] directives (if any) ... The clinician will contact the physician responsible for the plan of care, for review and confirmation of orders and diagnosis [sic] ... The Home Health Coding Specialists will code the diagnosis [sic], confirmed by the physician ... If any discrepancy between medical history and documented diagnosis [sic], the coding specialist will notify clinician and/or clinician supervisor to confirm with physician ...." 2. Review of agency policy dated 12/2020 titled "Home Care _ Orders for Care" stated " ... The individualized plan of care must specify the services necessary to meet the patient-specific needs ... all orders will be kept current and renewed or updated as appropriate to ... Changes in diagnosis, treatment (including procedures and medications), and equipment ...." 3. Review of agency policy dated 1/2021 titled "Medical Records" stated " ... integrated medical record ...medical record documentation from all approved [hospital D] Healthcare facilities contribute to the patient's integrated medical record ...enables sharing of relevant medical information including history taking, assessment, planned pattern of care, delivery of care, ongoing evaluation, goals, and outcomes. ..." 4. Review of an agency job description dated 2009 titled "RN - Review of an undated job description Home Health & Hospice" stated " ... Initiates and develops of a holistic plan of care based on the diagnosis ...Values the patients' needs through the development, implementation, and evaluation of individualized plan of care. ..." 5. Review of an undated agency job description titled "Clinical Documentation Spec [specialist]" stated "... Reviews clinical documentation in the medical record to ensure the record accurately reflects the care provided. Asks for clarification from the medical staff via written/verbal communication to obtain accurate and complete physician documentation that supports the severity of illness and the intensity of service. Serves as the bridge between coding and clinical staff ...." 6. Review of an undated agency job description titled "HH [home health] Med Rec [medical record] Coding Specialist" stated "... responsible for ... coding home health records ...." 7. Review of a document from the Indiana Department of Health (IDOH) dated 11/01/2018 titled "Advance Directives Your Right to Choose" stated "... WHAT TYPES OF ADVANCE DIRECTIVES ARE RECOGNIZED IN INDIANA ... Talking directly to your physician and family ... Organ and tissue donation ... Health care representative ... Living Will Declaration or Life-Prolonging Procedures Declaration ... Psychiatric advance directives ... Out of Hospital Do Not Resuscitate Declaration and Order ... Physician Orders for Scope of Treatment (POST) ... Power of Attorney... Writing down your health care choices in an advance directive document makes your wishes clear and may be necessary to fulfill legal requirements ... Because most people have several health care providers, you should discuss your wishes with all of your providers and give each provider a copy of your advance directives ...." 8. Review on 5/21/2021 of a "Drugs.com" web reference https://www.drugs.com/international/oxygen.html titled "Oxygen" stated "... In the US, Oxygen (oxygen systemic) is a member of the drug class medical gas ...." 10. Record review for patient #6 was completed on 5/20/2021, start of care date 8/30/2020, certification period 8/30/2020 - 10/28/2020, primary diagnosis diverticulitis (infection or inflammation of pouches that can form in the intestines) of intestine, part unspecified, with perforation and abscess without bleeding. Review of a hospital D document 8/28/2020 titled "Discharge Summary" stated "... may not lift, push, pull, drag or carry over 10-15lbs until cleared by surgeon ... Shower daily, no tub baths ...." Review of an agency document dated 8/28/2020 titled "Clinical Handoff" stated "... pharmacy needed to provide supply [sic] saline flushes to RLQ [right lower quadrant] JP [Jackson-Pratt] drain ... Inpatient Code Status ... FULL ...." Review of a document titled "Home Health Certification and Plan of Care" for certification dates 8/30/2020 - 10/28/2020 which stated "... DME [durable medical equipment] and Supplies ... N/A ... Patient has executed the following advance directives ... None ...." The document failed to evidence the patient's supplies included saline flushes, failed to include safety measures to protect against injury as directed on the hospital discharge summary to not lift, push, pull, drag or carry over 10-15lbs until cleared by surgeon, shower daily, no tub baths; and failed to evidence specific advance directives/code status, or measurable outcomes and goals. 11. Record review for patient #7 was completed on 5/21/2021, start of care date 7/21/2020, certification period 7/21/2020 - 9/18/2020, and a primary diagnosis aftercare following surgery for neoplasm (cancer). A document titled "Home Health Certification and Plan of Care" for certification dates 7/21/2020 - 9/18/2020 which stated "... Patient has executed the following advance directives ... Healthcare Representative (HCR) ... Copies obtained ... No ... [goals] Patient will attain optimal activity level ... Pain ... Opioid use ... Patient ... will teach back understanding of opioid use ... Patient will report ... pain has been reduced or controlled ...." The plan of care failed to evidence an opioid medication on the medication list and failed to evidence specific advance directives/code status, oxygen use, or measurable outcomes and goals. Review of an agency document dated 7/20/2020 titled "Clinical Handoff" stated "... Do not attempt to resuscitate ... Start taking on: July 21, 2020 ... mirtazapine (REMERON SOL-TAB) ... senna-docusate (PERICOLACE) ... Inpatient Code Status: DNR ... Advance Directives: Durable Power of Attorney, Living Will ... Healthcare representative is showing as "expired" in hyperspace ...." Review of an agency document dated and signed by RN HH on 7/21/2020 titled "SN Start of Care OASIS" stated "... Is patient currently taking opioids? ... Yes ...." 12. Record review for patient #8 was completed on 5/21/2021, start of care date 4/11/2020, certification period 4/11/2020 - 6/9/2020, and a primary diagnosis malignant neoplasm (cancer) of upper-outer quadrant of left female breast. A document dated and signed by RN X on 4/11/2020 titled "SN Start of Care OASIS" stated "... Wear face mask and gloves in home per patient request ...." Review of a document titled "Home Health Certification and Plan of Care" for certification dates 4/11/2020 - 6/9/2020 stated "... Patient has executed the following advance directives ... None ... [goals] patient will attain optimal activity level ... Currently reports exhaustion related to immunosupression [sic] secondary to cancers ...." The plan of care failed to evidence the patient's code status, measurable outcomes and goals, the patient's specific request for staff to wear mask and gloves in her home, or the section titled "Safety Measures" failed to include immunosuppressant precautions. 13. Record review for patient #14 was completed on 5/20/2021, start of care date 4/29/2021, and primary diagnosis type 2 diabetes mellitus with hypoglycemia (low blood sugar) without coma. A document dated 4/29/2021 and signed by RN RR on 5/1/2021 titled "SN Start of Care OASIS" evidenced the patient was a high nutritional risk, the patient reported she did not routinely check her blood sugar, she didn't check it today (4/29/2021), she just ate a bagel and drank 2 glasses of orange juice, patient was supposed to check her blood sugar every morning before breakfast and at bedtime, and blood sugar was checked during nursing visit before dinner with result of 422. Review of a document dated 4/30/2021 titled "Case Communication (Chartable)" evidenced the physician responded to the high blood sugar report on 4/29/2021 and indicated the patient should restart glymepiride (diabetes medication) daily. The plan of care failed to evidence glymepiride on the medication list and failed to evidence an updated plan of care order. Review of a document titled "Home Health Certification and Plan of Care" for certification dates 4/29/2021 - 6/27/2021 stated "... Patient has executed the following advance directives ... Living Will and Financial Power of Attorney/Durable Power of Attorney ...." The document failed to evidence the patient was a high nutritional risk, included patient specific interventions, and failed to evidence how frequently the patient should check her blood sugar. 14. Record review for patient #15 was completed on 5/20/2021, start of care date 4/30/2021, certification period 4/30/2021 - 6/28/2021, and a primary diagnosis traumatic pneumothorax (collapsed lung), subsequent. Encounter A document dated and signed by RN SS on 4/30/2021 titled "SN Start of Care No-OASIS" evidenced, her current pain level was "8" (on a 0-10 scale, with 0 being no pain and 10 being the worst pain possible), best pain was "6", worst pain was "10", and patient's goal was "6"; and she had a poor appetite. Review of an agency document dated and signed 4/28/2021 by RN TT titled "Clinical Handoff" evidenced the patient fell from her garage attic to the floor, inpatient code status was full code, used a cane for mobility assist, and other known diagnoses included (but not limited to) chronic constipation, sleep apnea, and liposarcoma (cancer) right arm. Review of a document titled "Home Health Certification and Plan of Care" for certification dates 4/30/2021 - 6/28/2021 stated "... Assess diet management for regular diet and instruct on nutrition/diet when applicable ... Patient has executed the following advance directives ... Healthcare Representative ... Living Will ... [goals] will attain optimal activity level ... will learn self-management of orthopedic disease by implementing modified life style changes ...." The plan of care failed to evidence diagnosis of pain, chronic constipation, sleep apnea, and liposarcoma (cancer) right arm, specific advance directives/code status, specific interventions for poor appetite, or measurable outcomes and goals. 15. Record review for patient #16 was completed on 5/20/2021, start of care date 5/1/2021, certification period 5/1/2021 - 6/29/2021, and a primary diagnosis acute kidney failure, unspecified. A hospital D document dated 4/30/2021 titled "Discharge Summary" which evidenced diagnosis (but not limited to) of hypothyroidism, discharge medication list included (but not limited to) loperamide (immodium) for diarrhea, and saccharomyces boulardii (florastor- a probiotic), and the patient was a full code. Review of a document dated and signed by RN VV on 4/30/2021 titled "Clinical Handoff" evidenced the patient's last HgbA1c (a lab test showing average blood sugars over a period of time) was 9.3 (should be below 7.0), immodium and florastor were new medications, the patient was a full code, and advance directives included durable power of attorney, healthcare representative, and living will. Review of a document dated 5/1/2021 and signed by RN WW on 5/3/2021 titled "SN Start of Care OASIS" evidenced other diagnoses included (but not limited to) depression, and patient had decreased appetite, very tired and weak. Review of a document titled "Home Health Certification and Plan of Care" for certification dates 5/1/2021 - 6/29/2021 stated "... sertraline [antidepressant] ... by mouth daily ... levothyroxine [a medication to treat hypothyroidism] ... by mouth daily ... Assess diet management for diabetes and instruct on nutrition/diet when applicable ... Patient has executed the following advance directives ... Healthcare Representative ... Healthcare Power of Attorney/Durable Power of Attorney... [goals] will attain optimal activity level ... will learn self-management of diabetes disease by implementing modified life style changes ... will learn self-management of pulmonary disease by implementing modified life style changes ... will learn self-management of kidney disease by implementing modified life style changes ... will learn self-management of gastrointestinal disease by implementing modified life style changes ...." The plan of care failed to evidence diagnoses of hypothyroidism or depression, the medications immodium or florastor, specific advance directives/code status, specific interventions for poor appetite, or measurable outcomes and goals. During an interview on 5/20/2021 at 1:38 PM, clinical manager D indicated she didn't see immodium or florastor on the plan of care. 16. Record review for patient #17 was reviewed on 5/12/2021 and completed on 5/21/2021, start of care date 5/3/2021, certification period 5/3/2021 - 7/1/2021, and a primary diagnosis fluid overload (the condition of having too much water in your body), unspecified. A document dated and signed 5/3/2021 by RN XX titled "SN Start of Care OASIS" evidenced new medications included (but not limited to) furosemide (diuretic) and humalog (insulin). Review of a document titled "Home Health Certification and Plan of Care" for certification dates 5/3/2021 - 7/1/2021 stated "... Patient has executed the following advance directives ... Living Will ... notify [physician H] ... 2 to 3-pound weight gain in 24 hours or 5 pounds in a week ... [goals] will attain optimal activity level ... will report that pain has been reduced or controlled ... will learn self-management technique by weighing self daily ...." The plan of care failed to evidence furosemide or humalog on the medication list specific advance directives/code status, or measurable outcomes and goals. 17. Record review for patient #18 was reviewed on 5/11/2021 and completed on 5/21/2021, start of care date 10/18/2020, and a primary diagnosis aftercare following surgery for neoplasm (cancer). A document titled "Home Health Certification and Plan of Care" for certification dates 10/18/2020 - 12/16/2020. The document evidenced (but not limited to) the patient's medications included (but not limited to) cosopt eye drops (to treat glaucoma), levaquin (antibiotic to treat infection), flagyl (antibiotic to treat infection), and elavil (antidepressant); (nurse) to assess for depression and provide interventions as prescribed; and the patient elected specific advance directives including a living will and financial power of attorney/durable power of attorney. The section titled "Goals ..." stated "... attain optimal activity level ... will understand dietary instructions and restrictions ... fear and anxiety will be reduced to a manageable level ... [gastrointestinal, musculoskeletal, infectious, and oncological disease management goals were the same:] patient will learn self management of ... disease by implementing modified life style changes, self care needs, and verbalizing when to notify the physician ...." The Plan of Care failed to evidence diagnoses of glaucoma, infection, irritable bowel syndrome with diarrhea, or depression; the section titled "Safety Measures" failed to include immunosuppressant or fall precautions, dietary supplement of Ensure, all medications, or measurable outcomes and goals. Review of a document dated 10/18/2020 and signed by RN L on 10/19/2020 titled "SN [skilled nurse] Start of Care OASIS [Outcome and Assessment Information Set]" evidenced (but not limited to) the patient had partially impaired vision, could not see medication labels or newsprint, could see obstacles and count fingers at arm's length, currently on oral antibiotics, fiber modified diet, required assist with personal care, was a fall risk, was independent prior to this illness, had no assistive devices, required assist with feeding, and stated "... have a caregiver present for (walking, dressing, bathing, meal prep) until you are able to do these tasks safely on your own ...." Review of a hospital D document 10/17/2020 titled "Discharge Summary" stated "... Final discharge diagnosis ... Intraabdominal infection, Bacteremia [presence of bacteria in the blood] ... Updated Problem list ... Diagnosis ... Full Code Status ... Elavil ... associated diagnoses ... irritable bowel syndrome with diarrhea ... current mild episode of major depressive disorder ... Dietary nutrition supplements Ensure ... During an interview on 5/11/2021 at 4:05 PM, when queried if a patient took cosopt for glaucoma and antibiotics for infection have correlating diagnoses on the plan of care, clinical supervisor U stated "... as far as glaucoma, there's documentation that she sets up her own pills ....", and clinical manager D stated "... I'd have to look at the chart more." When queried if all current medications should have correlating diagnoses on the plans of care, the alternate administrator stated "... Some meds don't have diagnoses, like herbs ...." During this time, clinical manager D and therapy supervisor V indicated they would have to ask the coders if the diagnoses should be included, and the alternate administrator indicated were most likely not going to impact the patient's treatment, and she would argue that they were not required. During an interview on 5/20/2021 at 9:05 AM, clinical manager D indicated chemo (immunosuppressant) precautions could be included in the plan of care section/locator 15 Safety Measures, and the agency did not have a copy of the patient's living will or power of attorney. When queried about the patient's goals not being measurable, she indicated it was established on the first day of survey they (staff) had nothing to add to the topic. When queried where specific patient teaching was documented, she stated "... She said she did teach back ...." 18. During an interview on 5/11/2021 at 4:05 PM, clinical supervisor U indicated a measurable outcome was parameters that would show when a goal was met, specific, like blood sugar parameters, and therapy supervisor V indicated "attain optimal activity level" was not a measurable goal. 19. During an interview on 5/20/2021 at 9:05 AM, when queried to define a "manageable level" regarding a plan of care goal "Fear and anxiety will be reduced to a manageable level" (patient #3 discharge record), clinical manager D stated "... I think it's patient specific ... might differ day to day, especially with a new ostomy ... I think we're meeting the intent of the reg [regulation] ...." Additionally, she stated "... I don't think every goal will have a measure ... level of detail you are looking for is not in the chart ...." 20. During an interview and record review on 5/20/2021 at 1:38 PM, clinical manager D stated "... If it's about measurable goals on the plan of care, we don't want to keep going over it. It's not worth re-visiting it on every chart. If it's about patient response/comprehension to teaching, we don't want to keep going over it ...." Also, clinical manager D, therapy supervisor V, lead RN NN, clinical supervisor U, and the alternate administrator indicated if it was documented that the patient taught back, that was an acceptable form of comprehension, and all indicated they had no further questions or concerns about findings discussed, they also didn't want to keep going over additional concerns about medications, diagnoses on plans of care, and it was not worth re-visiting.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on observation and record review the skilled nurse failed to ensure the physician was notified of changes in condition for 1 of 18 records reviewed (#9). Findings include: Review of a policy dated 12/2020 titled "Home Care_Orders for Care" stated "... All orders will be kept current and renewed or updated as appropriate to ... Changes in patient's condition ...." Record review for patient #9 was completed on 5/18/2021, start of care date 4/6/2021, certification period 4/6/2021 - 6/4/2021, and a primary diagnosis acute kidney failure, unspecified, other pertinent diagnoses included (but not limited to) hypertensive heart and chronic kidney disease with heart failure. A document titled "Home Health Certification and Plan of Care" which evidenced the patient received skilled nursing twice a week for 2 weeks, then once a week for 2 weeks, and stated " ... Medications ... torsemide (demadex) (diuretic used to decrease swelling) ... take 0.5 tablets (10 mg total) by mouth daily ... Orders for Discipline and Treatments ... Notify physician M if patient has a 2 to 3-pound weight gain in 24 hours or 5 pounds in a week ...." The skilled nurse failed to notify the physician of weight gain per orders as evidenced by: Review of a document dated 5/7/2021 titled "Visit Frequency" stated " ... updated visits for skilled nursing ... 1 visit every 2 weeks for 2 weeks [5/7/2021 - 5/15/2021] Review of a document dated 4/6/2021 titled "SN Start of Care OASIS" stated " ... M1060 ... Weight (in pounds) ... 281 ...." Review of a document dated 4/9/2021 titled "SN Routine Visit" stated " ... Vitals ... Weight ... 290 lb 6.4 oz [ounce] ...." Review of a document dated 4/12/2021 titled "SN Routine Visit" stated " ... Vitals ... Weight ... 290 lb 6.4 oz ... Actions Performed ... pt [patient] weights stable ...." Review of a document dated 4/21/2021 titled "SN Routine Visit" stated " ... Vitals ... Weight ... 294 lb ... Actions Performed ... Edema unchanged ... Pt doing telehealth ...." Review of a document dated 4/29/2021 titled "SN Only DC Alive" stated " ... Vitals ... Weight ... 297 lb ... Discharge Summary ... Reason for Discharge: All goals met ...." Review of a document dated 5/1/2021 titled "Case Communication" stated " ... SN received a call from pt caregiver stating .... Received a call from pt and she was having wheezing and coughing ... SN called pt ... advised that pt go to the ER to be evaluated ...." Review of a hospital D document dated 5/1/2021 titled "ED (emergency department) Provider Notes" evidenced the patient went to the ED with a cough, wheezing and possible fluid overload, and stated " ... medication changes ... changed: torsemide ... take 1 tablet (20 mg total) by mouth daily for 5 days ...." During an interview on 5/20/21 at 9:05 AM, (clinical record review on patient #9), the following (but not limited to) was addressed: When queried should the skilled nurse contact the physician according to the plan of care regarding a weight increase, clinical and quality manager D indicated the skilled nurse would contact the physician if telehealth was not involved, telehealth is part of the integrated record but not part of the home health record. Additionally, she stated, " ... If telehealth is involved, telehealth would manage the weight ...." Clinical supervisor U indicated home health turns care over to telehealth when patient takes diuretics (water pills). When queried what intervention(s) the skilled nurse performed related to the patient's weight gain, clinical and quality manager D indicated the best intervention was to order telehealth. Regarding the nursing call to patient on 5/1/2021 when queried if the nurse should have made a visit to check on patient condition, clinical and quality manager D indicated the nurse made a clinical judgement based on the assessment of patient over the phone. When queried if a hospital emergency room visit could have been avoided, the clinical and quality manager D indicated she could not answer that because she wasn't the nurse taking the call and thought the nurse made a "good clinical choice". On 5/20/2021 at 4:00 PM, VP and administrator A entered room and told surveyors she had oversight of the Telehealth program, Telehealth was not part of the Home Health program and that Telehealth was not surveyable. 17-13-1(a)(2)

Patients receive education and training CFR(s): 484.60(d)(5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge. This ELEMENT is not met as evidenced by: Based on observation, record review and interview, the agency failed to ensure all patients and/or caregivers received ongoing education and training regarding the needs of the patient as identified in the plans of care and failed to evidence patient and/or caregiver responses and comprehension of all training provided for 8 of 18 records reviewed (#6, 7, 8, 14, 15, 16, 17, 18). Findings include: 1. Review of agency policy dated 8/2020 titled "Home Health Ongoing Assessment-Reassessment" stated " ... requirements of care during ongoing assessments/reassessment and updates to the Plan of Care ... includes information that may be used to demonstrate ... progress toward achievement of desired outcomes ... During each home visit, the clinician will monitor the patient's response to care against the established goals including but not limited to ... ongoing patient and/or caregiver education/teaching ...." 2. Clinical record review for patient #6 was completed on 5/19/2021, start of care date 8/30/202, and a primary diagnosis diverticulitis (infection or inflammation of pouches that can form in the intestines) of intestine, part unspecified, with perforation and abscess without bleeding. A document titled "Home Health Certification and Plan of Care" for certification period 8/30/2020 - 10/28/2020, which stated (but not limited to) "... RLQ [right lower abdominal quadrant] JP [Jackson-Pratt] drain site [a drain from the inside of the body to the outside to drain fluids] ... SN/Caregiver/patient to flush drain with 5ml normal saline twice daily ... SN/Caregiver/patient to empty drainage container twice daily or when half full ... teach patient/caregiver wound care procedure ... Educate on complications to report ....", and evidenced additional nursing orders (but not limited to) to educate on cardiopulmonary system, GI system, signs and symptoms of infection, pain management, and improvement of functional ability. Review of a hospital D document 8/28/2020 titled "Discharge Summary" stated "... may not lift, push, pull, drag or carry over 10-15lbs until cleared by surgeon ... Shower daily, no tub baths ...." The medical record failed to evidence the patient or caregiver was educated on post-surgical instructions. Review of a document dated 8/30/2020 titled "SN Start Of Care No-OASIS" stated "... Pt was educated on pain control ...." The document failed to evidence what was taught specific to this patient, or the patient/caregiver's response to the teaching, and indicated the patient was not receptive to further teaching or drain care by the nurse, and another nurse would visit later the same day to provide drain care. Review of an additional document dated 8/30/2020 titled "SN Per Required Need Visit" which stated "... SN had pt demonstrate JP [drain] flushing, milking line, emptying drain, and re-applying pressure ... able to complete without issue ... educated pt and wife on s/s infection and when to call HHC ...." The document failed to evidence the nurse educated post-surgical instructions, how often to flush the drain, when to empty the drain, or the patient/caregiver response to infection control teaching. Review of a document dated 9/3/2020 titled "SN Routine Visit" stated "... [patient] states he ate a large meal yesterday and then had pain 1 hour after that for several hours ... states he was flushing [drain] and then not getting anything in return and was sore ...." The document failed to evidence the nurse educated the patient/caregiver on specific gastrointestinal system management such as consumption of smaller, more frequent meals to help prevent potential abdominal distention/pressure/pain, or interventions for non-draining drain such as when to contact physician or call agency nurse. Review of a document dated 9/10/2020 titled "SN Agency DC [discharge] Alive No-OASIS" stated "... Patient will attain optimal activity level ... Goal Met ... will teach back methods to decrease episodes of fatigue and shortness of breath ... Goal Met ... learn self management of cardiopulmonary status by teaching back ... Goal Met ... [agency] to provide treatment and education to maintain and/or improve patients [sic] current level of functionality ... Goal Met ...." The clinical record failed to evidence the nurse provided patient specific education related to attainment of optimal activity level, methods to decrease episodes of fatigue and shortness of breath, management of cardiopulmonary status, or education to maintain and/or improve the patient's current level of functionality. 3. Clinical record review for patient #7 was completed on 5/21/2021, start of care date 7/21/2020, and a primary diagnosis aftercare following surgery for neoplasm (cancer). A document titled "Home Health Certification and Plan of Care" for certification period 7/21/2020 - 9/18/2020, which stated (but not limited to) "... Aspira drain [a drain from the lung to the outside of the body to drain fluid] ... SN to drain every other day prn [as needed] for shortness of breath or discomfort ... May drain up to 1000 ml of fluid in one sitting ... May teach patient/caregiver draining procedure ... Educate on complications to report ... Instruct patient/caregiver in [sic] management of pain ... instruct ... on pain scale ... Patient and/or caregiver will teach back understanding of pain relief therapy/intervention ... teach back understanding of opioid [narcotic pain medicine] use ...." The document also evidenced the patient took coumadin (a blood thinner medication), and the patient's safety measures included (but not limited to) bleeding precautions. Review of a document dated 7/21/2020 titled "SN Start of Care OASIS" stated "... [patient's] current pain rating (0 = No Pain, 10 = WORST Pain): 8 ... Pain interferes with ... ADLs [activities of daily living], Rest ... What makes it better ... Heat ... Education given on ... Medication side effects, PRN medication schedule, Patient tolerance, when to contact MD ... Patient/caregiver will teach back ...signs and symptoms to monitor for, for ... coumadin ... Progressing ... will teach back understanding of pain relief therapy/interventions ...." The document failed to evidence the patient was instructed on directions for use and precautions for heat therapy/modality, or other non-medicinal methods to mitigate pain. Review of a document dated 7/23/2020 titled "SN Routine Visit" evidenced the patient's spouse requested education on how to change the patient's sterile dressing on the aspira insertion site next visit, and the patient was in "quite a bit of pain". The document failed to evidence instruction was provided on pain management. Review of a document dated 7/25/2020 titled "SN Routine Visit" evidenced the patient's husband observed both drainage procedure and dressing change, current pain level was "6", pain interfered with mobility, rest, sleep, activity made pain worse, and medications and rest made it better; and education was provided about use, storage and disposal of opioid medications, medication side effects, PRN medication schedule and when to contact physician. The document failed to evidence education was provided for non-medicinal methods to mitigate pain such as types of activity to avoid that might potentiate pain and failed to evidence patient/caregiver response to education, and comprehension/response to observation of dressing change and drain procedure. Review of a document dated and signed by on-call RN Y on 7/28/2020 titled "Patient Telephone Encounter" stated "... [per patient and caregiver] Pt had a fever last night and has been sweating today. Dressing has come loose and there is redness and itching around stitches. The [sic] are concerned about a possible infection ... [Spouse] ... feels comfortable changing dressing tonight ... nurse come to evaluate the wound tomorrow ...." The document failed to evidence the nurse educated the patient/spouse, such as signs and symptoms of infection or worsening of wound, or when to contact agency and/or physician. Review of a document dated 8/4/2020 titled "SN Routine Visit" stated "... pt reports she has a diaper rash up the crack of her buttock ... [physician] told her to use just a diaper rash cream, he also educated patient to leave brief off for awhile to get air ...." The document failed to evidence any other instruction was provided to support physician's instructions such as incontinence care, how long to leave brief off, how often to change brief, or frequent skin inspections to identify new or worsening skin breakdown. Review of a document dated 8/7/2020 titled "SN Routine Visit" stated "... [patient] reports her weight was 182.2 [pounds] at her appointment this week. Was listed at 191 on admission [8.8 pound weight loss in 17 days] ... Reports she is starting to eat better ... diaper rash is pretty much gone ... had diarrhea 3 times yesterday ... not had a bm [bowel movement] so far today ... [patient] held her senokot [laxative/stool softener] a day ...." The document failed to evidence the nurse provided education such as ways to improve appetite, small frequent meals and snacks, prevention of new or worsening skin breakdown, incontinence care, foods to avoid with diarrhea, or when to contact agency for unrelieved signs or symptoms. During an interview on 5/21/2021 at 1:00 PM, when queried about the patient's weight loss, clinical and quality manager D stated "I don't see any interventions related to diet [in the patient's clinical record] ...." Regarding pain management, she indicated since admission (for home health), the patient was touched by other providers, had telehealth visits very often, they provided pain management, and the agency did its part. 4. Clinical record for patient #8 was reviewed on 5/21/2021, start of care date 4/11/2020, primary diagnosis malignant neoplasm (cancer) of upper-outer quadrant of left female breast, other pertinent diagnoses (but not limited to) personal history of other venous thrombosis and embolism (thrombus is a blood clot that forms in a vein, embolus is anything that moves through the blood vessels until it reaches a vessel that is too small to let it pass), and personal history of pulmonary (lung) embolism (PE). A document titled "Home Health Certification and Plan of Care" for certification period 4/11/2020 - 6/9/2020 which stated (but not limited to) "... Instruct patient/caregiver on signs and symptoms of altered cardiopulmonary status to report ... signs of UTI (urinary tract infection) ... signs/symptoms of infection ... immunosuppression [compromised immune system] secondary to cancers ...." Review of a document dated 4/11/2021 titled "SN Start of Care OASIS" stated "... patient has a history of PE and 1 month ago her xarelto [anticoagulant medication] dose was cut in half and she is concerned about blood clots ... she self caths [tube inserted into bladder to drain urine] twice daily ... Reviewed COVID-19 binder insert. Thoroughly explained homecare ... Patient does not want to go to the hospital for port [a small, implantable reservoir under the skin for direct intravenous access] flush due to COVID-19 ... Wear face mask and gloves in home per patient request ...." The document failed to evidence cardiopulmonary education was provided (regarding the patient's history and stated concern for blood clots), instruction on infection prevention (related to the patient straight cath, signs/symptoms of UTI, agency policy on use of facemasks, and immunosuppression precautions); and failed to evidence the patient's response to instruction that was provided. 5. Clinical record for patient #14 was completed on 5/20/2021, start of care date 4/29/2021, primary diagnosis type 2 diabetes mellitus with hypoglycemia (low blood sugar) without coma. A document titled "Home Health Certification and Plan of Care" for certification period 4/29/2021 - 6/27/2021 which stated (but not limited to) "... diabetic diet ... instruct patient/caregiver ... diabetes management ... instruct on nutrition/diet when applicable ...." Review of a document dated 4/29/2021, 3:25 PM - 4:30 PM visit, titled "SN Start of Care OASIS" evidenced the patient was a high nutritional risk, unable to take medications unless administered by another person, her goal was to take her medications like her doctor wanted without help from another person, she required home health care for disease education, medication education, she lived at home with her spouse, she didn't routinely check her blood sugars, she didn't check it today (5/1/2021), she reported she just ate a bagel and 2 glasses of orange juice, and ate nothing else today (5/1/2021), she was supposed to check her blood sugar every morning before breakfast, and before bed every night, and her blood sugar reading during the nursing visit was 422. The document failed to evidence dietary instruction was provided, such as sugar levels in orange juice can cause a significant spike in blood sugar levels, increasing the risk of hyperglycemia (too high blood sugar levels); bagels are low in nutrients but high in carbohydrates, offer little nutritional benefit and could trigger a blood glucose spike; importance of eating regularly scheduled meals are beneficial for people with diabetes, and the importance of checking her blood sugar as indicated. Review of a document dated 4/30/2021 titled "Case Communication (Chartable)" evidenced the agency was notified by the patient's physician to restart taking glymepiride (diabetic medication) daily, and patient would need reinforcement of education regarding this at next scheduled nursing visit. Review of a document dated 5/6/2021 (next nursing visit) titled "SN Routine Visit Note" indicated the nurse reviewed the following with the patient (but not limited to): long term effects of uncontrolled blood sugars, reviewed meds, glimepiride was not in pill planner, provided educations sheets of signs and symptoms of high and low blood sugars and how to treat, importance of following a diabetic diet, and reviewed meds added in pill planner. The document failed to evidence patient comprehension and response to individualized instruction. 6. Record review for patient #15 was completed on 5/20/2021, start of care date 4/30/2021, certification period 4/30/2021 - 6/28/2021, primary diagnosis traumatic pneumothorax (collapsed lung), subsequent. A document titled "Home Health Certification and Plan of Care" for certification period 4/29/2021 - 6/27/2021 evidenced the patient's medications included (but not limited to) xanax daily as needed (anti-anxiety), and oxycodone every four hours as needed (narcotic pain relief), and stated (but not limited to) "... Instruct ... medication management, including purpose ... educate on anxiety ... instruct on nutrition/diet when applicable ... Instruct ... management of pain ... instruct on use of medication ... Educate on wound care ...." Review of a document dated 4/30/2021 titled "SN Start of Care No-OASIS" evidenced the patient's current pain level was "8" (on a 0-10 scale, with 0 being no pain and 10 being the worst pain possible), best pain was "6", worst pain was "10", and patient's goal was "6", she had a poor appetite, and stated "... [patient] able to teach back ... disease process ... diet/nutrition ... medication schedule ... SN reviewed medications with patient ... assessed wounds and provided wound care ... discussed care plan ...." The document failed to evidence instruction was provided such as when the "as needed" use of xanax and oxycodone should be taken, methods to increase appetite, wound care procedure(s), or patient specific disease process, and failed to evidence patient comprehension or what she taught back. Review of a document dated 5/3/2021 titled "SN Routine Visit" stated "... Personal goal: heal wounds, pain control ... Progressing ... provide ... education to maintain and/or improve patients [sic] current level of functionality ... Progressing ... most of her pain is in her back, using heating pad ...." The document failed to evidence education/instruction was provided such as wound care/management, methods to mitigate pain, methods to maintain and/or improve current level of functionality, directions for use of a heating pad, or patient comprehension/response to education that was provided. Review of a document dated 5/4/2021 titled "PT [physical therapy] Evaluation" stated "... Education Topics Addressed: home safety, fall prevention ... Collaboration with client [patient] ... Clinical impression discussed with client ....'' The document failed to evidence patient specific home safety or fall prevention education provided, or the patient's comprehension and response to education. Review of an agency document dated 5/10/2021 titled "SN Routine Visit" stated "... [patient] reports using incentive spirometer [handheld equipment/device that helps the lungs recover after a surgery or lung illness] five times a day ...." The document failed to evidence education was provided such as the proper use of the incentive spirometer. During an interview on 5/20/2021 at 1:38 PM, the alternate administrator stated "... We can't control what they [patients] do ...." regarding the incentive spirometer. When queried about patient education/precautions for the use of the heating pad, clinical manager D indicated she didn't see any, and it would depend on the level of education of the patient if teaching was needed, and clinical supervisor U indicated the patient was not diabetic, so there was no concern with decreased sensation. Clinical manager M also indicated a lot of times, patients brought home incentive spirometers from the hospital, the patient was younger, and she seemed very motivated, and she would not expect to see it on the plan of care unless the physician ordered it, she would not expect a nurse to get an order for a heating pad, and she didn't see education was provided. 7. Record review for patient #16 was completed on 5/20/2021, start of care date 5/1/2021, certification period 5/1/2021 - 6/29/2021, primary diagnosis acute kidney failure, unspecified. A document titled "Home Health Certification and Plan of Care" for certification dates 5/1/2021 - 6/29/2021 which stated "... Bleeding precautions, Oxygen precautions, educate and implement needle precautions ... Educate correct use of support devices ... Patient to wear oxygen ... instruct ... diabetes management ... nutrition/diet ... educate ... GI status ... [patient] will teach back methods to decrease episodes of fatigue ... teach back oxygen safety measures ...." Review of a document dated 4/30/2021 titled "Clinical Handoff" stated "... Reason for HHC [home health care] ... fatigue, diarrhea, respiratory failure with hypoxia ... NEW meds ... Immodium [anti-diarrheal] ...." and evidenced the patient's last HgbA1c (a lab test showing average blood sugars over a period of time) was 9.3 (should be below 7.0). Review of a document dated 5/1/2021 titled "SN Start of Care OASIS" stated "... pt did not have o2 [sic- oxygen] on during visit pt [sic] stated she has been wearing 2 L [2 liters per minute] when needed and at night ... she does not check her blood sugar but wants to start, SN provided education ... has chronic back pain and takes norco [narcotic pain medicine] ... pt has feel [sic-fell] 4 times in the last 4 months with transfers onto bed ... has decreased appetite ... feels very tired and weak ...." The document failed to evidence education was provided such as oxygen precautions, importance of regular blood glucose monitoring and risks associated with non-compliance, use of non-narcotic medications for mild/moderate pain, fall precautions, methods to increase appetite, and energy conservation techniques. 8. Clinical record for patient #17 was completed on 5/12/2021 and 5/21/2021, start of care date 5/3/2021, primary diagnosis fluid overload (the condition of having too much water in your body), unspecified. A document titled "Home Health Certification and Plan of Care" for certification period 5/3/2021 - 7/1/2021 which stated "... Instruct ... signs/symptoms of altered cardiopulmonary status to report ... diabetes management ... nutrition/diet ... care of lower extremities including diabetic foot care ... signs/symptoms of infection ... management of pain ... non-opioids, Position changes, Relaxation and rest ... instruct on pain scale ...." Review of an agency document dated 5/5/2021 titled "SN Routine Visit" stated "... Problem ... Activity level Goal ... Patient/caregiver will teach back methods to decrease episodes of fatigue and shortness of breath ... Progressing ... sn [sic] provided education to pt ... pt to learn self management of cardiopulmonary status by teaching back ... Goal Met ... pt able to teach back ... High Risk Medication ...,,. Progressing ... sn provided education ... Active pain ... Progressing ... sn provided education ... Home Safety ... Progressing ... sn provided education ...." The record failed to evidence specific education provided to the patient, what the patient taught back, patient comprehension/response to teaching, and failed to evidence education was provided such as care of lower extremities including diabetic foot care, diabetes management, or high risk medications. Review of a document dated 5/7/2021 titled "New Intervention" stated "... Order ... Disciplines: SN ... apply ACE wraps to bilat lwr [both lower] extremities daily, remove at night - may teach caregivers to perform ...." Review of an agency document dated 5/7/2021 titled "SN Routine Visit" stated "... [patient] did have office visit yesterday with cardiologist who ordered her legs to be wrapped to help with edema ... see care plan for details ... sn wrapped legs and provided education to pt who v/u [verbalized understanding] ... unable to wrap them herself ...." The document failed to evidence specific instruction was provided for use of the ace wraps, such as to remove them at night, elevation of lower extremities to help in decreasing edema, or signs/symptoms to report to nurse/physician. During a home visit on 5/12/2021 at 1:00 PM, the patient indicated she felt like her swelling was worse, she didn't currently wear the ace wraps, they were put on in the hospital for the first time, they seemed to be okay, the (home care) nurse put on smaller ones and they wouldn't stay up, and they also made creases. When queried how often she was supposed to wear them, the patient stated "... I thought the PA [physician assistant] said three days ... I honestly don't know ...." During this time, RN Z confirmed the ace wraps were supposed to be removed at night. When queried about the instruction/education she received from the nurse, the patient indicated she received education on (but not limited to) home safety, diet, and fall prevention, and indicated she did not receive education on lasix or humalog (medications), self-management of cardiopulmonary disease, COVID-19, or Infection prevention. She also indicated the nurse answered questions if she had them regarding diabetes and pain. 9. Clinical record review for patient #18 was reviewed on 5/11/2021, start of care date 10/18/2020, primary diagnosis aftercare following surgery for neoplasm (cancer). A document titled "Home Health Certification and Plan of Care" for certification period 10/18/2020 - 12/16/2020 stated (but not limited to) "... teach patient/caregiver ostomy [a surgical opening from the small intestine to the outside of the body for removal of waste] changing procedure ... diet management for (low fiber) and instruct on nutrition/diet ... educate GI [gastrointestinal] status ... instruct patient on use of Heat therapy ... educate on wound care [midline and left abdominal wounds] ... GOALS ... Fear / Anxiety Goal ... patients [sic] fear and anxiety will be reduced to a manageable level by ...." The document failed to evidence interventions to mitigate fear/anxiety. Review of a document dated 10/18/2020 titled "SN Start of Care OASIS" stated "... SN performed wound care with husband watching. He is hoping to be able to learn and perform wound care, but is not confident about the packing step ... Patient is very emotional about [ostomy] and new diagnosis [cancer] ... Review of a document dated 10/19/2020 titled "SN Routine Visit" stated "... Needs daily dressing changes and husband is not comfortable performing at this time ... Problem: Diet-Instructions Goal ... Patient/caregiver will understand dietary instructions and restrictions ... Patient able to teach back dietary instructions ... Patient will learn self-management of GI disease ... Progressing ... Patient and/or caregiver will return demonstrate procedure of changing ostomy appliance ... Progressing ...." The document failed to evidence what specific instruction was provided related to diet, what was taught back, patient or caregiver's comprehension, or specific responses to any instruction provided, and failed to evidence any instruction was provided related to self-management of GI disease or procedure for changing ostomy appliance. Review of a document dated 10/20/2020 titled "SN Routine Visit" stated "... Patient will learn self-management of GI disease by implementing modified lifestyle changes, self-care needs, and verbalizing when to notify the physician ... Progressing ... reviewed with patient ... Patient/caregiver will return demonstration [sic] of midline abdominal incision wound care procedure ... Goal Met ... Spouse not willing/able to perform wound care ... Spouse informed Sn [sic] that he cannot do the dressing changes ... Sn [sic] reviewed with patient as well and she is not able to perform either ...." The document failed to evidence specific instruction was provided related to self-management of GI disease, patient or caregiver's comprehension or specific responses, and failed to evidence how the patient/caregiver inability to perform wound care resulted in the goal being met. Review of a document dated 10/21/2020 titled "SN Routine Visit" stated "... Patient will learn self-management of GI disease by implementing modified lifestyle changes, self-care needs, and verbalizing when to notify the physician ... Goal Met ...." The document failed to evidence what specific instruction was provided related to self-management of GI disease, patient or caregiver's comprehension, or specific responses that resulted in the goal being met. Review of a document dated 10/22/2020 titled "SN Routine Visit" stated "... Problem: Fear / Anxiety ... Progressing ... Pt [patient] somewhat anxious about meeting with oncologist next week ... Patient did have multiple questions today and was somewhat anxious ... SN provided active listening and emotional support ...." The document failed to evidence the nurse provided intervention/instruction to mitigate fear or anxiety, or patient response to emotional support. Review of a document dated 10/23/2020 titled "SN Routine Visit" stated "... Problem: Fear / Anxiety ... Progressing ... Pt does have some anxiety as ostomy bag began leaking this morning ...." The document failed to evidence the nurse provided intervention/instruction to mitigate fear or anxiety. Review of a document dated 10/24/2020 titled "SN Routine Visit" stated "... Problem: Fear / Anxiety ... Not Progressing ... Patient does verbalize feeling very anxious about managing the ostomy and also about chemo. Provided encouragement and emotional support ... [patient] does ... experience pain with sneezing, activity and/or coughing ...." The document failed to evidence instruction to mitigate fear or anxiety and failed to evidence non-medicinal instruction to mitigate pain with sneezing, activity and/or coughing such as slow position change, frequent rest periods, or guarding of abdomen while sneezing or coughing by holding a pillow gently against abdomen. Review of an additional document dated 10/24/2020 titled "SN Per Required Need [PRN] Visit" stated "... SN in home for PRN visit to assess ostomy appliance due to it leaking ... bag found to have a hole in it ... appliance changed ...." The document failed to evidence instruction provided for ostomy management. Review of a document dated 10/25/2020 titled "SN Routine Visit" stated "... Problem: Fear / Anxiety ... Not Progressing ... Reports she is struggling with lack of control related to diagnosis. SN empathized with patient and provided education related to empowerment. Encouraged to accept support of her family and friends ...." The document failed to evidence the patient's comprehension or response to instruction, or evidence instruction was provided on ostomy management. Review of a document dated 10/26/2020 titled "SN Routine Visit" failed to evidence instruction was provided to the patient or caregiver regarding ostomy management. Review of a document dated 10/27/2020 titled "SN Routine Visit" stated "... Problem: Cardio/Resp [cardiac/respiratory] Goal ... Starting 10/18/2020 ... Patient to learn self-management of cardiopulmonary disease by teaching back when to notify home care nurse or physician of symptoms ... Pt does have low B/P [blood pressure] but denies any dizziness or lightheadedness ... Patient will learn self-management of oncological disease by implementing modified life style changes, self care needs, and verbalizing when to notify the physician ... Goal Met ... Pt able to teach back ... Patient had an appointment with [physician B] with oncology. Patient somewhat upset ... informed she has stage 4 ... cancer and that is not curable [sic] ...." The document failed to evidence the nurse provided instruction related to signs or symptoms of low blood pressure that should be reported to the nurse or physician, or provided instruction for anxiety/fear, such as coping mechanisms, distraction, meditation; and failed to evidence what instruction was provided related to self-management of oncological disease, or what the patient was able to teach back to result in the goal being met. Review of a document dated 10/31/2020 titled "SN Routine Visit" stated "... Pt is still hesitant about learning ostomy appliance changes ... Patient Goal ... Personal Goal ... Patient would like to be able to regain [sic] strength and confidence in her self-care ... Progressing ... Goal : Treatment and education ... Pt states she does feel like she is urinating less ... denied any s/s [signs/symptoms] of UTI [urinary tract infection] ... encouraged pt to drink more fluids ...." The document failed to evidence instruction was provided related to the patient's personal goal to increase strength and confidence, signs and symptoms of UTI and when to report to nurse or physician; and failed to evidence the patient's current fluid intake or instruction regarding how much additional fluids the patient should drink. Review of a document dated 11/1/2020 titled "SN Routine Visit" stated "... B/P still low. Pt complains of being weak and fatigued ... decided not to take her [blood pressure medication] this morning due to continued low b/p [blood pressure] ... Sn assisted pt with changing [sic] ostomy appliance ... Pt still very anxious about doing this herself ...." The document failed to evidence the nurse provided education such as signs or symptoms of low blood pressure that should be reported to the nurse or physician, importance of taking all medications as ordered by the physician, or risks associated with non-compliance with physicians' orders. Review of a document dated 11/2/2020 at 4:45 PM titled "Case Communication (Chartable)" stated "... Patient called ... having leakage from ostomy bag and needs a nurse to come and change it for her ... I asked pt is [sic] she had been shown how to change her own bag. She said she is very elderly. Explained to patient that we will not be there for her all the time and she will be discharged from HHC [home health care], and she needs to learn to do this ...." Review of an additional document dated 11/2/2020 titled "SN Per Required Need [PRN] Visit" stated "... SN in home for PRN visit due to ostomy leaking ...." The document failed to evidence the nurse provided any instruction related to ostomy management. Review of a document dated 11/6/2020 titled "SN Routine Visit" stated "... Hr [heart rate] still elevated. Pt still fatigued, weak and tired. Pt also has some SOB [shortness of breath] with slight activity ... Pt tearful and very upset. States multiple times she does not want to go back to the hospital ... also has SOB with exertion and walking short distances ...." The document failed to evidence the nurse instructed the patient/caregiver such as methods to mitigate fear/anxiety, energy conservation techniques, or to call "911" for unrelieved SOB. Review of a hospital D document dated 11/8/2020 titled "Discharge Summary" evidenced the patient was subsequently hospitalized 11/6/2020 - 11/8/2020 for (not limited to) hypovolemic hyponatremia (fluid loss and low sodium) due to reduced oral intake. 10. During an interview on 5/11/2021 at 4:05 PM, the alternate administrator/clinical director and clinical and quality manager indicated there was no specific number associated with teach back, such as five ways to decrease shortness of breath, therapy supervisor V indicated there was no evidence patient was instructed on use of heat therapy in clinical record, and clinical and quality manager D also indicated she did not see the level of detail that was queried during in the interview evidenced in the clinical record.

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on observation, record review and interview, the agency failed to ensure all patients received a home visit schedule which included discipline frequencies, written in plain language, and was consistent with the patient's most current plan of care for 6 of 7 patients with observed home visits (#1, 2, 3, 4, 11, 17). Findings include: 1. Review of a policy dated 9/2020 titled "Rights-Responsibilities" stated "... Information is provided to patients in plain language ... The Agency will provide the patient and caregiver with a copy of written instructions outlining the following ... Visit schedule and frequency for each discipline acting on behalf of the agency ...." 2. Record review was completed for patient #17, start of care 5/3/2021, certification dates 5/3/2021 - 7/1/2021. A document titled "Home Health Certification and Plan of Care" evidenced the patient received skilled nursing 3 times per week for 1 week, then twice weekly for 2 weeks, then once weekly for 2 weeks, beginning 5/3/2021. During a home visit for patient #17 on 5/12/2021 at 1:00 PM, the patient's home folder was reviewed, which evidenced an undated document titled "Care Plan Summary." The document stated "...This is your plan for home health ....", and evidenced a section titled "Planned home health team members visit frequency" which stated "... nurse ... 3x week x/week [3 times weekly for 1 week], 2/week x 2 weeks [2 times weekly for 2 weeks] ... 1xwx2 [1 time weekly for 2 weeks] ...." The document failed to evidence start date for visit frequencies and failed to ensure the discipline frequencies were written in plain language.3. Record review was completed for patient #1, start of care 2/17/2021. During a home visit for patient #1 on 5/7/2021 at 10:30 AM, the patient ' s home folder was reviewed, which evidenced untitled calendars dated April 2021 and May 2021, with the following reference acronyms at the top of the documents: RN= Nursing, SLP=Speech Therapy, PT=Physical Therapy, and MSW= Social Worker. Both calendars failed to evidence any scheduled visits were entered by agency staff. Review of an undated document titled "Care Plan Summary" stated "... This is your plan for home health ..." The document evidenced a section titled "Planned home health team members visit frequency" which stated "... Physical Therapist ... 1w1, 2w3, 1w2 [once weekly for 1 week, twice weekly for 3 weeks, once weekly for 2 weeks] ... Occupational Therapist ... 1w1 [1 visit only], DC [discharge] on 4/16/2021. ..." The document failed to evidence a start date for visit frequencies, the discipline frequencies were written in plain language, any nurse visit frequencies, an order for occupational therapy. Review of a document titled "Home Health Certification and Plan of Care" certification dates 2/17/2021 - 4/17/2021 evidenced the patient received skilled nursing twice weekly for 1 week, then 3 visits every week for 5 weeks; PT visits 1 visit every 2 weeks for 2 weeks, twice weekly for 1 week, then 1 visit every week for 2 weeks. The plan of care and updated plan of care orders failed to evidence an order for occupational therapy. Review of a document titled "Home Health Certification and Plan of Care" certification dates 4/18/2021 - 6/16/2021 evidenced the patient received skilled nursing twice weekly for 1 week, then 1 visit every week for 8 weeks; PT visits twice weekly for 3 weeks, and an evaluation/interim order for PT to start 4/13/2021. The plan of care and updated plan of care orders failed to evidence an order for occupational therapy. 4. Record review was completed for patient #2, start of care 2/24/2021. During a home visit for patient #2 on 5/6/2021 at 9:30 AM, the patient's home folder was reviewed, which evidenced an undated document titled "Care Plan Summary" stated "... This is your plan for home health ..." The document evidenced a section titled "Planned home health team members visit frequency" which stated "... Nurse ... 2x per week for 3 weeks [two times weekly for 3 weeks], 1x per week for 3 weeks [once weekly for 3 weeks] ...." The document failed to evidence a start date for visit frequencies and the discipline frequencies were written in plain language. Review of a document titled "Home Health Certification and Plan of Care," certification dates 2/24/2021 - 4/24/2021 evidenced the patient received skilled nursing 3 visits weekly for 2 weeks, then 1 visit every week for 2 weeks. Review of a document titled "Home Health Certification and Plan of Care," certification dates 4/25/2021 - 6/23/2021 evidenced the patient received skilled nursing once weekly for 9 weeks. 5. Record review was completed for patient #3, start of care 4/25/2021. During a home visit with patient #3 on 5/13/2021 at 10:00 AM, review of an undated document titled "Care Plan Summary" stated "... This is your plan for home health ..." The document evidenced a section titled "Planned home health team members visit frequency" which stated "... Nurse ... 2 visits a week 2-3 wks, then weekly visit 4 wks [2 visits each week for 2 to 3 weeks, then once a week for 4 weeks] ... Physical Therapist ... 1x 1 week for 4 weeks [once weekly for 4 weeks]. ..." The document failed to evidence a start date for visit frequencies and the discipline frequencies were written in plain language. Review of a document titled "Home Health Certification and Plan of Care," certification dates 4/25/2021 - 6/23/2021 evidenced the patient received skilled nursing 3 visits every week for 1 week, 2 visits every week for 1 week, then 1 visit every week for 3 weeks; PT once every 2 weeks for 2 weeks, then 1 visit every week for 4 weeks. 6. Record review was completed for patient #4, start of care 4/22/2021. During a home visit for patient #4 on 5/7/2021 at 1:00 PM, the patient ' s home folder was reviewed. The folder evidenced an untitled calendar dated May 2021, which evidenced the following reference acronyms: RN= Nursing, SLP=Speech Therapy, PT=Physical Therapy, and MSW= Social Worker. The calendar failed to evidence any scheduled visits were entered by agency staff. Review of an undated document titled "Care Plan Summary" stated "... This is your plan for home health ...." The document evidenced a section titled "Planned home health team members visit frequency" which stated "... Nurse ... 1x/wk for 4wks [once weekly for 4 weeks] ... Physical Therapist ... 1x/wk for 1wk [once weekly for 1 week], then 2x/wk for 2wks [twice weekly for 2 weeks] ... Occupational Therapist ... not needed ... Home Health Aide ... 1x/wk for 3wks [once weekly for 3 weeks] ...." The document failed to evidence start date for visit frequencies, failed to ensure the discipline frequencies were written in plain language, and failed to include the OT visit frequency for the evaluation visit made on 4/26/2021. Review of a document titled "Home Health Certification and Plan of Care," certification dates 4/22/2021 - 6/20/2021 evidenced the patient received skilled nursing once weekly for 4 weeks, home health aide (HHA) once weekly for 3 weeks, occupational therapy (OT) once every 2 weeks for 2 weeks, physical therapy (PT) 1 visit between 4/22/2021 - 5/1/2021, 1 visit between 4/28/2021 - 5/1/2021, and then 2 visits every week for 2 weeks. Review of a document dated 4/26/2021 titled "OT Evaluation" stated "... Pt [patient] reports no further need of OT services after evaluation [today] ...." 7. Record review was completed for patient #11, start of care 5/4/2021. During a home visit for patient #11 on 5/13/2021 at 9:00 AM, the patient ' s home folder was reviewed, which evidenced an undated document titled "Care Plan Summary" stated "... This is your plan for home health ..." The document evidenced a section titled "Planned home health team members visit frequency" which stated "... Physical Therapist ... 1w1, 2w2 [once weekly for 1 week, 2 times every week for 2 weeks] ... Occupational Therapist ... 2wk2, 1wk2 [twice a week for 2 weeks, once a week for 2 weeks]" The document failed to evidence a start date for visit frequencies, the discipline frequencies were written in plain language, any home health aide frequencies, any nurse frequencies and any social worker frequencies. Review of a document titled "Home Health Certification and Plan of Care," certification dates 5/4/2021 - 7/2/2021 evidenced the patient received home health aide (HHA) once weekly for 1 week, 2 visits a week for 3 week; social worker (MSW) 1 visit every 2 weeks for 2 weeks; occupational therapy (OT) 1 visit every 2 weeks for 2 weeks, 2 visits every week for 2 weeks, and then once a week for 1 week; physical therapy (PT) 1 visit every 2 weeks for 2 weeks, 1 visit every week for 2 weeks, and then 2 visits every week for 2 weeks; skilled nursing 2 visits every week for 1 week and then once weekly for 3 weeks.

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on observation, record review and interview, the agency failed to ensure that all patients received a medication schedule with instructions for use for 2 of 7 home visits observed (#1, 9). Findings include: 1. Review of a policy dated 9/2020 titled "Rights-Responsibilities" stated "... information is provided to patients in plain language ... the agency will provide the patient and caregiver with a copy of written instructions outlining the following ... patient medication list including medication name, dosage, frequency, and which medications will be administered by Agency staff ...." 2. Review of a policy dated 9/2020 titled "Home Care Medication Safety and Monitoring" stated "... ongoing visits ... update medication list in the home ...." 3. Review of a policy dated 8/2020 titled "Home Health Ongoing Assessment-Reassessment" stated "... home medication list will include schedule/instructions, including medication name, dosage and frequency ...." 4. During a home visit with patient #1 (start of care 2/17/2021) on 5/7/2021 at 10:30 AM, the patient's home folder was reviewed, and failed to evidence a written medication list. During this time, RN T indicated the patient used "My Chart" (a corporate/organizational web-based patient medical information system) to check on medications. 5. During a home visit with patient #9 (start of care 4/6/2021) on 5/6/2021 at 12:00 PM, the patient's home folder was reviewed, and failed to evidence a written medication list. 6. During an interview on 5/21/2021 at 4:25 PM, clinical and quality manager D indicated the regulations (state and federal regulations for operation of home health care agencies) didn't match up to the organization's advanced technology, and it was unfair.

Treatments and therapy services CFR(s): 484.60(e)(3) Any treatments to be administered by HHA personnel and personnel acting on behalf of the HHA, including therapy services. This ELEMENT is not met as evidenced by: 6. During a home visit with patient #1 (start of care 2/17/2021) on 5/7/2021 at 10:30 AM, the patient ' s home folder was reviewed, which evidenced an undated document titled "Care Plan Summary" which stated "... This is your plan for home health ...." The document evidenced a section titled "Treatment/Education to be done by your home health team", which failed to evidence patient specific written information was provided to the patient about wound care treatment or lab draw. Review of a document titled "Home Health Certification and Plan of Care," certification dates 4/18/2021 - 6/16/2021 stated "... SN [skilled nurse] to draw next PT/INR [blood test to check therapeutic drug levels] on Wednesday 4/21/2021. May use finger stick via Home monitoring system ... Wound order ... Remove old dressing ... cleanse wound with mild soap & water or saline ... place [specialized dressing compound] into the wound bed ... cover with ... pad ...." 7. During a home visit for patient #2 (start of care 2/24/2021) on 5/6/2021 at 9:30 AM, the patient ' s home folder was reviewed, which evidenced an undated document titled "Care Plan Summary" which stated "... This is your plan for home health ...." The document evidenced a section titled "Treatment/Education to be done by your home health team", which failed to evidence patient specific written information was provided to the patient about management of nausea and vomiting or management of intravenous hydration. Review of a document titled "Home Health Certification and Plan of Care," certification dates 2/24/2021 - 4/24/2021 stated "... SN [skilled nurse] to instruct patient ... management of dehydration, nausea/vomiting episodes ... keeping a daily log number of emesis [vomiting] episodes ... medication effectiveness ... assess number of IV [intravenous] bags that have been administered ... patient/caregiver flushing and med [medication] administration techniques and protocols .... " Review of a document titled "Home Health Certification and Plan of Care" start of care 2/24/2021, certification dates 4/25/2021 - 6/23/2021 stated "... SN [skilled nurse] instruct patient ... flushing and hydration medication administration techniques and protocols .... " 8. During a home visit for patient #3 (start of care 4/25/2021) on 5/13/2021 at 10:00 AM, the patient indicated a one pound weight gain ... prepares simple foods ... eats and eats ... the skin on bottom is no longer pink ..." Review of the patient ' s home folder evidenced an undated document titled "Care Plan Summary" which stated "... This is your plan for home health ...." The document evidenced a section titled "Treatment/Education to be done by your home health team", which failed to evidence patient specific written information was provided to the patient about measures for gaining weight or measure to prevent skin breakdown. Review of a document titled "Home Health Certification and Plan of Care," certification dates 4/25/2021 - 6/23/2021 stated "... SN [skilled nurse] ... Educate on prevention of skin breakdown ... educate GI [gastrointestinal] status ...." 9. During a home visit for patient #4 (start of care 4/22/2021) on 5/7/2021 at 1:00 PM the patient's home folder was reviewed, which evidenced an undated document titled "Care Plan Summary" which stated "... This is your plan for home health ...." The document evidenced a section titled "Treatment/Education to be done by your home health team", which failed to evidence patient specific written information was provided to the patient about diabetic foot care or wound care. Review of a document titled "Home Health Certification and Plan of Care" certification dates 4/22/2021 - 6/20/2021 stated "... SN [skilled nurse] ... to instruct patient/caregiver in care of lower extremities including diabetic foot care ... left flank puncture wound ... educate on wound care ... daily cleanse ... soap and water ... pat dry and leave open to air ...." 10. During a home visit for patient #9 on 5/6/2021 (start of care 4/6/2021) at 12:00 PM, the patient ' s home folder was reviewed which evidenced an undated document titled "Care Plan Summary" which included no written information. The document failed to evidence patient specific written information was provided to the patient about daily weight monitoring and fall prevention. Review of a document titled "Home Health Certification and Plan of Care," certification dates 4/6/2021 - 6/4/2021 stated "... SN [skilled nurse] ... instruct patient ... signs/symptoms of altered cardiopulmonary status to report ... check weight every day at the same time and record findings ... falls ... preventative measures to decrease risk ...." 11. During a home visit for patient #11 on 5/13/2021 (start of care 5/4/2021) at 9:00 AM, the patient ' s home folder was reviewed which evidenced an undated document titled "Care Plan Summary" which stated "... This is your plan for home health ...." The document evidenced a section titled "Treatment/Education to be done by your home health team", which failed to evidence patient specific written information was provided to the patient about urinary infection or fall prevention. Review of a document titled "Home Health Certification and Plan of Care," certification dates 5/4/2021 - 7/2/2021 stated "... SN [skilled nurse] ... Instruct patient ... signs/symptoms of altered cardiopulmonary status to report ... edema management ... GU [urinary] status ... falls ... preventative measures to decrease risk ...." Based on observation, record review and interview, the agency failed to ensure all patients received written information regarding treatments to be administered by home health agency staff (found on the agencies plan of care) for 7 of 7 patients with home visits. Findings include: 1. Review of a policy dated 9/2020 titled "Rights-Responsibilities" stated " ... the agency will provide the patient and caregiver with a copy of written instructions outlining ...any treatments to be administer by Agency staff including therapy services ...any other pertinent instruction related to the patient's care and treatments that the Agency will provide, specific to the patient's care needs ..." 2. Review of a policy dated 8/2020 titled "Home Health Initial and Comprehensive Assessment" stated " ... The individualized plan of care orders must include ... treatments ... Patient care individualized verbal orders ...." 3. Review of a policy dated 8/2020 titled "Home Health Ongoing Assessment-Reassessment" stated " ...during each home visit ... update care plans and treatments . ..." 4. During a home visit for patient #17 (start of care 5/3/2021) on 5/12/2021 at 1:00 PM, the patient indicated her pain was severe when she ambulated, she felt like her edema was worse, she didn't know how long she was supposed to wear the ace wraps, and stated "... I thought the PA said three days ... honestly, don't know ...." Review of the patient's home folder evidenced an undated document titled "Care Plan Summary" which stated "...This is your plan for home health ...." The document evidenced a section titled "Treatment/Education to be done by your home health team", which failed to evidence patient specific written information was provided to the patient about lab draws or application of ace wraps to both lower extremities. Review of a document titled "Home Health Certification and Plan of Care," certification dates 5/3/2021 - 7/1/2021 stated "... SN to obtain the following labs on 5-5-21 ... SN to obtain the following labs on 5-27-21 ...." Review of a document dated 5/7/2021 and signed by nurse practitioner (NP) J on 5/14/2021 titled "Intervention" stated "... New Intervention ... Order ... SN ... apply ace wraps to bilat lwr [bilateral lower] extremities daily, remove at night ...." 5. During an interview on 5/21/2021 at 2:25 PM, clinical and quality manager D indicated the agency looked into the regulation and consulted with NAHC (national association for homecare & hospice), and indicated it was not a requirement to provide a copy of the plan of care in the patient's home, and there was a summary in the home folder.

Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure all patients and/or caregivers received written information of the name and contact information of the home health agency's clinical manager for 7 of 7 records reviewed for patients with home visits. Findings include: 1. Review of an agency policy dated 9/2020 titled "Home Care Complaint-Grievance Process" stated " ...upon admission, the patient is provided with an Agency Handbook ...it includes the contact information for the Clinical Supervisor (manager) ..." 2. Review of an agency policy dated 9/2020 titled "Rights-Responsibilities" stated " ...the agency will provide the patient and caregiver with a copy of written instructions outlining the following ...name and contact information for the Agency's clinical supervisor ..." 3. Review of agency handbook dated 2/2021 titled "Home Health Care Patient Handbook" which is left in the patient home at time of admission failed to evidence the name and contact information of the clinical manager. 4. Review of an organizational chart dated 1/6/2021 evidenced the agency had a clinical manager (clinical and quality manager D) and clinical director (alternate clinical manager/alternate administrator B). 5. Review of an organizational chart updated 3/25/2021 evidenced (but not limited to) the agency had three nursing clinical supervisors (for central, north and west regions). 6. During a home visit with patient #17 (start of care 5/3/2021) on 5/12/2021 at 1:00 PM, review of the Home Health Care Patient Handbook failed to evidence the name and contact information of the clinical manager.7. During a home visit with patient #1 (start of care 2/17/2021) on 5/7/2021 at 10:30 AM, review of the home folder failed to evidence the name and contact information of the clinical manager. 8. During a home visit with patient #2 (start of care 2/24/2021) on 5/6/2021 at 9:30 AM, review of the home folder failed to evidence the name and contact information of the clinical manager. 9. During a home visit with patient #3 (start of care 4/25/2021) on 5/13/2021 at 10:00 AM, review of the home folder failed to evidence the name and contact information of the clinical manager. 10. During a home visit with patient #4 (start of care 4/22/2021) on 5/7/2021 at 1:00 PM, review of the home folder failed to evidence the name and contact information of the clinical manager. 11. During a home visit with patient #9 (start of care 4/6/2021) on 5/6/2021 at 12:00 PM, review of the home folder failed to evidence the name and contact information of the clinical manager. When queried, the patient indicated she did not know who the clinical manager was. 12. During a home visit with patient #11 (start of care 5/4/2021) on 5/13/2021 at 9:00 AM, review of the home folder failed to evidence the name and contact information of the clinical manager. 13. During an interview on 5/4/2021 at 3:30 PM, the alternate administrator/clinical director indicated agency clinical supervisors are the equivalent of CMS (Centers for Medicare and Medicaid services) role of clinical manager, and the agency had several staff members in this role. The clinical manager assigned to all home visits performed was clinical supervisor F. 14. During an interview on 5/5/2021 at 11:17 AM, the alternate administrator/clinical director indicated she wanted to review agency titles again. She indicated the administrator was also the VP (vice president) of the organization (not limited to Home Health, Hospice), she was the administrator, and represented the nursing supervisor for IDOH state licensure, she (alternate administrator) indicated she was tasked to daily operations, and per the CMS clinical manager role definition, she stated "... those things are handled by our [clinical] supervisors ...." She also stated "... [administrator] and I have been in those roles a long time. We wanted to let you know ...." During this time, the administrator stated "... If you [surveyors] see something out in the field, I'm not that person. There are other managers for that. [clinical and quality manager D] is the clinical manager in title per [hospital D] ... focuses on quality ... it's a newer role for her ... we do a lot of shifting in duties ...."

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation, record review and interview, agency staff failed to follow infection control policies and procedures for 5 of 7 records reviewed with home visits. (#1, 3, 4, 11, 17). Findings include: 1. Review of an undated agency policy received 5/6/2021 at 11:20 AM, titled "Bag Techniques" stated "... bag technique ... in patient's home: bag is to be placed on a barrier ...." 2. Review of a policy updated 5/13/2021 by clinical and quality manager D, submitted 5/21/2021 at 4:55 PM "Bag Technique/Hand Hygiene Procedure" stated "... bag technique ... in patient's home ... backpack style ... may hook on chairback or door knob ... must place bag on a barrier when placed on floor or furniture ... rolling bag ... may stay on floor without a barrier ...." 3. Review of agency letter to patients with date of 4/1/2020 found in the patients' home folders stated "... Our infection prevention efforts include the following ... we will use barrier pads ... to prevent the spread of infection ...." 4. Review of an undated agency binder of documents titled "Home Health Care Patient Handbook" (patient's home folder) evidenced (but not limited to) a document titled "Indiana Universal Precautions Rule". The document contained a section titled "Infection Prevention" which in the stated "... Parkview Home Health & Hospice complies with the infection control practices required by the Indiana State Department of Health [IDOH] ... Indiana Occupational Safety and Health Administration [IOSHA] Standards ...Centers for Disease Control and Prevention [CDC] ... The following infection control practices include ... Appropriate use of protective barriers ...." 5. Review of the pubmed.gov web page reference, https://pubmed.ncbi.nlm.nih.gov/24326473/ stated "... To prevent the transmission of pathogenic microorganisms, a practice called "bag technique" is implemented by home care and hospice clinicians, and the methods used will vary depending on the home care and hospice organization's policies ... when the bag is placed directly on surfaces in the home without the use of a surface barrier under the bag, there is a risk that the bag will become contaminated with potentially pathogenic microorganisms which could then be transferred to the staff's vehicle and to the next patient's home ...." 6. During a home visit with patient #1 on 5/7/2021 at 10:30 AM, RN T placed rolling bag directly on the floor without a barrier. RN T failed to place a barrier on the floor for the rolling bag per the agency's own policy. 7. During a home visit with patient #3 on 5/13/2021 at 10:00 AM, RN J placed bag directly on the floor without a barrier. RN J failed to place a barrier on the floor for the bag per the agency's own policy. 8. During a home visit with patient #4 on 5/7/2021 at 1:00 PM, PT E placed rolling bag directly on the floor without a barrier. PT E failed to place a barrier on the floor for the rolling bag per the agency's own policy. 9. During a home visit with patient #11 on 5/13/2021 at 9:00 AM, OT AA placed rolling bag directly on the floor without a barrier. OT AA failed to place a barrier on the floor for the rolling bag per the agency's own policy. 10. During a home visit with patient #17 on 5/12/2021 at 1:00 PM, RN Z placed rolling bag directly on the floor without a barrier. RN Z failed to place a barrier on the floor for the rolling bag per the agency's own policy. 11. During an interview on 5/6/2021 at 3:00 PM, when queried if a barrier should be placed under staff bags in patient homes, clinical and quality manager D indicated the policy said bag could stay on the floor. 12. During an interview 5/20/2021 at 9:05 AM, when queried again if a barrier should be placed under staff bag in patient homes, clinical and quality manager D indicated the bag technique policy submitted on 5/6/2021 needed clarification, changes were made to the policy (which was dated 5/13/2021 and renamed "Bag Technique/Hand Hygiene Procedure"), and the updated policy was sent to all leadership who complete tracer (supervisory) visits. All home visit observations were completed prior to the agency ' s submission of the updated policy. 17-12-1(m)

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on observation, record review and interview agency staff failed to follow infection control policies and procedures for 1 of 7 records reviewed with home visits. (#3). Findings include: Review of an undated agency policy received 5/6/2021 at 11:20 AM, titled "Bag Techniques" stated "... bag technique ... in patient's home: bag is to be placed on a barrier ...." Review of a policy updated 5/13/2021 by clinical and quality manager D, submitted 5/21/2021 at 4:55 PM "Bag Technique/Hand Hygiene Procedure" stated "... bag technique ... in patient's home ... backpack style ... may hook on chairback or door knob ... must place bag on a barrier when placed on floor or furniture ... rolling bag ... may stay on floor without a barrier ...." Review of agency letter to patients with date of 4/1/2020 found in the patients' home folders stated "... Our infection prevention efforts include the following ... we will use barrier pads ... to prevent the spread of infection ...." Review of an undated agency binder of documents titled "Home Health Care Patient Handbook" (patient's home folder) evidenced (but not limited to) a document titled "Indiana Universal Precautions Rule". The document contained a section titled "Infection Prevention" which in the stated "... Parkview Home Health & Hospice complies with the infection control practices required by the Indiana State Department of Health [IDOH] ... Indiana Occupational Safety and Health Administration [IOSHA] Standards ...Centers for Disease Control and Prevention [CDC] ... The following infection control practices include ... Appropriate use of protective barriers ...." Review of the pubmed.gov web page reference, https://pubmed.ncbi.nlm.nih.gov/24326473/ stated "... To prevent the transmission of pathogenic microorganisms, a practice called "bag technique" is implemented by home care and hospice clinicians, and the methods used will vary depending on the home care and hospice organization's policies ... when the bag is placed directly on surfaces in the home without the use of a surface barrier under the bag, there is a risk that the bag will become contaminated with potentially pathogenic microorganisms which could then be transferred to the staff's vehicle and to the next patient's home ...." During a home visit with patient #3 (start of care 4/25/2021) on 5/13/2021 at 10:00 AM, RN J placed bag directly on the floor without a barrier. RN J failed to place a barrier on the floor for the bag per the agency's own policy. During an interview on 5/6/2021 at 3:00 PM, when queried if a barrier should be placed under staff bags in patient homes, clinical and quality manager D indicated the policy said bag could stay on the floor. During an interview 5/20/2021 at 9:05 AM, when queried again if a barrier should be placed under staff bag in patient homes, clinical and quality manager D indicated the bag technique policy submitted on 5/6/2021 needed clarification, changes were made to the policy (which was dated 5/13/2021 and renamed "Bag Technique/Hand Hygiene Procedure"), and the updated policy was sent to all leadership who complete tracer (supervisory) visits. All home visit observations were completed prior to the agency's submission of the updated policy. 17-12-1(m)

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: 6. Clinical record for patient #3 was reviewed on 5/13/2021, start of care date 4/25/2021, certification period 4/25/2021 - 6/23/2021, malignant neoplasm (cancer) of colon, unspecified, evidenced a document dated and signed by RN (registered nurse) J titled "SN [skilled nurse] Routine Visit" evidenced the evaluation was completed on 4/29/2021 and vitals signs were assessed by the RN at 10:24 AM, and another evaluation completed on 5/4/2021 and vitals signs were assessed by the RN at 11:06 AM. Review of the document dated and signed 4/29/2021 at 4:15 PM by PT (physical therapist) S titled "PT Evaluation" evidenced the evaluation was completed on 4/29/2021, failed to evidence assessment of vital signs was performed by the PT, and stated " ... Vitals taken by RN prior to this visit . ..." Review of the document dated and signed 5/4/2021 at 2:09 PM by PT (physical therapist) S titled "PT Routine Visit" evidenced the evaluation was completed on 5/4/2021, failed to evidence assessment of vital signs was performed by the PT, and stated " ... Vitals taken by RN prior to this visit . ..." 7. Clinical record for patient #4 was reviewed on 5/12/2021, start of care date 4/22/2021, certification period 4/22/2021 - 6/20/2021, primary diagnosis acute kidney failure, unspecified, evidenced a document dated and signed by RN CC titled "SN Routine Visit" evidenced the evaluation was completed on 4/27/2021 and vital signs were assessed by the RN at 12:04 PM. Review of the document dated and signed 4/28/2021 at 2:40 PM by PT Q titled "PT Evaluation" evidenced the evaluation was completed on 4/27/2021, failed to evidence assessment of vital signs was performed by the PT, and stated " ... SN visit prior to PT eval, vitals taken then . ..." 8. Clinical record for patient #5 was reviewed on 5/17/2021 and again on 5/20/2021, start of care date 3/18/2021, certification period 3/18/2021 - 5/16/2021, aftercare following surgery for neoplasm (cancer), evidenced a document dated and signed by OT (occupational therapist) R titled "OT Re-Evaluation" evidenced the evaluation was completed on 5/5/2021 and vitals signs were assessed by the OT at 11:02 AM. Review of the document dated and signed 5/5/2021 at 1:33 PM by PT S titled "PT Re-Evaluation" evidenced the evaluation was completed on 5/5/2021, failed to evidence assessment of vital signs was performed by the PT, and stated " ... vitals taken by OT prior to this visit . ..." 9. Clinical record for patient #9 was reviewed on 5/18/2021 and again on 5/20/2021, start of care date 4/6/2021, certification period 4/6/2021 - 6/4/2021, acute kidney failure, unspecified, evidenced a document dated and signed by PT BB titled "PT Evaluation" evidenced the evaluation was completed on 4/8/2021 and vital signs were assessed by the PT at 9:18 AM. Review of the document dated and signed 4/8/2021 at 3:43 PM by OT R titled "OT Evaluation" evidenced the evaluation was completed on 4/8/2021, failed to evidence assessment of vital signs was performed by the OT, and stated " ... OT does not need to take vitals since PT took vitals earlier . ..." 10. Clinical record for patient #10 was reviewed on 5/18/2021 and again on 5/20/2021, start of care date 4/27/2021, certification period 4/27/2021 - 6/25/2021, aphasia (difficulty communicating) following cerebral infarction (stroke), evidenced a document dated and signed by RN EE titled "SN Routine Visit" evidenced the evaluation was completed on 4/29/2021 and vital signs were assessed by the RN at 12:43 PM. Review of the document dated and signed 4/29/2021 at 5:09 PM by PT S titled "PT Evaluation" evidenced the evaluation was completed on 4/29/2021, failed to evidence assessment of vital signs was performed by the PT, and stated " ... vitals taken by RN prior to this visit . ..." 11.Clinical record for patient #12 was reviewed on 5/19/2021 and again on 5/21/2021, start of care date 3/13/2021, certification period 3/13/2021 - 5/11/2021, encounter for change or removal of surgical wound dressing, evidenced a document dated and signed by RN FF titled "SN Routine Visit" evidenced the evaluation was completed on 3/15/2021 and vital signs were assessed by the RN at 11:50 AM. Review of the document dated and signed 3/15/2021 at 4:44 PM by OT GG titled "OT Evaluation" evidenced the evaluation was completed on 3/15/2021, failed to evidence assessment of vital signs was performed by the OT, and stated " ... RN made a visit before OT visit, RN took vitals . ..." 12. During an interview on 5/20/21 at 9:05 AM when queried if a clinician should have taken patient vital signs if taken by another clinician the same day, Therapy Supervisor V indicated vital signs would be taken again the same day by the other clinician if there was a clinical reason. Based on record review and interview, the clinician failed to assess the patient's vital signs for 8 of 18 records reviewed (#3, 4, 5, 7, 9, 10, 12, 15). Findings include: 1. Review on 5/21/2021 of an "American Physical Therapy Association (APTA)" website article, https://www.apta.org/patient-care/interventions/patient-screenings, titled "Patient Screenings" dated 4/8/2020, stated "... Taking vital signs and obtaining simple clinical measures provide valuable information about your patients that in many cases are important to evaluating and managing care appropriately. Many of these measures also can be important in screening for undiagnosed problems or identifying risk. If you don't take these measures, significant information is lost ...." 2. Review on 5/21/2021 of a "McGraw Hill Medical" website article, https://accessphysiotherapy.mhmedical.com/book.aspx?bookid=1472, titled "Chapter 9: Monitoring Vital Signs" (Introduction to Physical Therapy and Patient Skills) stated "... The triad of pulse, respiration rate, and blood pressure is often considered as a baseline indicator of a patient's health status ... which is why each is called a vital or cardinal sign ... include the measurement of pulse, blood pressure, and respiration as a routine part of any physiologic examination ... Additional measurements of physiologic status, which are not universally considered vital signs, include the assessment of perceived exertion ratings, pain, and pulse oximetry ... The measurement of vital signs can be used to establish goals and to assess a patient's response to activity...." 3. Review on 5/21/2021 of a "National Center for BiotechnologyInformation (NCBI)" website article, https://www.ncbi.nlm.nih.gov/books/NBK493211/, dated 9/2/2020, titled "Nursing Admission Assessment and Examination" stated "... Part of the assessment includes data collection by obtaining vital signs such as temperature, respiratory rate, heart rate, blood pressure, and pain level using an age or condition appropriate pain scale. The assessment identifies current and future care needs of the patient by allowing the formation of a nursing diagnosis. The nurse recognizes normal and abnormal patient physiology and helps prioritize interventions and care ...." 4. Clinical record for patient #7 was reviewed on 5/21/2021, start of care date 7/21/2020, certification period 7/1/2020 - 9/18/2020, primary diagnosis aftercare following surgery for neoplasm (cancer), evidenced a document dated and signed by LPN (licensed practical nurse) W on 7/23/2020 titled "SN [skilled nurse] Routine Visit" which failed to evidence the nurse assessed the patient's vital signs. Review of a document dated and signed by LPN W on 8/11/2020 titled "SN Routine Visit" failed to evidence the nurse assessed the patient's vital signs. During an interview on 5/21/2021 at 1:00 PM, when queried if vital signs were documented on the SN visit note dated 8/11/2021, RN Clinical Supervisor (North area) stated "I do not see them." During this time, Clinical Manager D indicated she didn't know why the nurse failed to assess the patient's vital signs. During an interview on 5/21/2021 at 1:38 PM, Clinical Manager D indicated there were no vitals charted for the 7/23/2020 and 8/11/2020 SN routine visit. 5. Clinical record for patient #15 was reviewed on 5/19/2021, start of care date 4/30/2021, certification period 4/30/2021 - 6/28/2021, primary diagnosis traumatic pneumothorax (collapsed lung), subsequent encounter, other pertinent diagnoses included (but not limited to) multiple fractures of ribs (left side), fracture of left clavicle (collarbone), and unspecified fracture of first thoracic vertebrae (spine). Review of a document dated 4/28/2021 titled "Clinical Handoff" stated "... [patient] went to ER [emergency room] on 4/25 after falling from her attic space ... [to] garage floor ...." Review of a document dated and signed 5/5/2021 by OT (occupational therapist) R titled "OT Evaluation" evidenced the evaluation was completed on 5/4/2021 and vital signs were assessed by the OT at 10:34 AM. Review of a document dated and signed 5/4/2021 at 5:23 PM by PT (physical therapist) S titled "PT Evaluation" evidenced the evaluation was completed on 5/4/2021, failed to evidence assessment of vital signs was performed by the PT, and stated "... Vitals taken by OT prior to this visit. ...." During an interview on 5/20/2021 at 1:38 PM, Therapy Supervisor V indicated the patient had no significant issues, no significant diagnoses, she really didn't expect therapists to check patients' vital signs unless there was a change, the OT visit on 5/4/2021 was at 10:20 AM, and the PT visit was at 3:57 PM.