Every finding on record at Rhm Services LLC

An emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42CFR 484.102. Survey Dates: 04-22-204 and 04-23-2024. Active Census: 78 At this Emergency Preparedness survey, Comforcare Home Health was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 484.102. QR completed by Area 3-MG, 4-26-2024.

This visit was for a Federal Recertification and State Re-licensure survey of a Home Health Provider. Survey Dates: 04-22-2024 and 04-23-2024 12-Month Unduplicated Skilled Admissions: 0 Census: 78 This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Refer to State Form for additional State Findings. QR completed by Area 3-MG on 4-26-2024.

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 agency failed to ensure that the Alternate Clinical Manager Registered Nurse (RN), Admin 3, completed the start-of-care comprehensive assessment within 5 days after the start-of-care date in 1 of 2 patients admitted in the last 30 days. (Patient: #8) Findings Include: 1. A review of an agency policy with a review date of 02-01-2024, titled “Comprehensive Assessment” indicated but was not limited to, “ … Comprehensive Assessment, consistent with the client’s immediate needs will be completed for all clients in a timely manner, but no later than five (5) calendar days after the Start of Care … ” 2. A review of the clinical record for Patient #8 contained an initial comprehensive assessment dated 04-6-2024, timed from 12:54 PM to 2:35 PM, electronically signed by Admin 3. The initial assessment indicated the primary reason for home health was for a Home Health Aide (HHA) to assist with Activities of Daily Living (ADLs)/Instrumental Activities of Daily /Living (IADLS). The sections “Pertinent History and/or Previous Outcomes” and “Patient History and Diagnoses” were left blank. The “Primary Caregiver” section indicated the caregiver was available and willing to assist with care but failed to list the caregiver's information and what the caregiver was doing to assist with care needs. The section titled, “Functional Limitations” musculoskeletal was left blank. The “Integumentary Status” section indicated that the turgor was good but failed to assess Patient #8's Arteriovenous (AV) Dialysis fistula ( an abnormal connection between an artery and vein). The area titled “Braden Scale” (a scale used for predicting pressure sore risk) was not scored and failed to indicate a total score for Patient #8’s pressure sore risk. The two-question PHQ-2 questionnaire ( an assessment that indicates a risk of depression) indicated Patient #8 answered “Not at all” which gave total scores of 0 to both questions. Admin 3 marked “Yes” that Patient #8 indicated a risk for depression but failed to document those risks in the section titled “Mental/Psychosocial/Cognitive Status.” The sections “Durable Medical Equipment (DME)/Medical Supplies, Rehab Potential, Frequencies, Interventions, Goals, Care Planning and Coordination, and Discharging Planning” were blank. A review of a “Face to Face” document signed by Patient #8’s physician on 04-12-2024, indicated the patient’s medical condition to support home health services as “Homebound, Fall Risk, Chronic Kidney Disease, and Degenerative Disk disease. A review of a verbal physician’s order for the start of care dated 04-16-2024 at 8:00 AM, signed by the Clinical Manager, Admin 2, indicated services for Skilled Nursing for supervision of the Home Health Aide services and Home Health Aide services for ADL/IADL for safety. A review of a “Progress Note” from Entity 12, a physician group, dated 10-26-2023 at 3:52 PM, electronically signed by Person 14, the Nurse Practitioner for Person 13, the patient’s physician. The progress note indicated, “74-year-old … who has Vitamin B12 deficiency; Folic acid deficiency; arteriovenous dialysis fistula; End Stage Renal Disease (ESRD) ( kidney failure) on hemodialysis (treatment used to filter wastes, salts, and fluid from the blood); Type 2 Diabetes Mellitus (a condition of the body’s inability to regulate sugar); Hypertension; Coronary Artery Disease ( a condition of narrowing of the major vessels); Chronic Diastolic Congestive Heart Failure (a condition in which the heart’s main pumping chamber (left ventricle) becomes stiff and unable to pump effectively); Degeneration of Lumber Intervertebral Disc (a condition where one or more discs in the spine deteriorate due to age, results in neck and back pain); Anemia; Memory loss; History of Deep Vein Thrombosis (DVT) (a condition which the blood clots form in veins located deep inside the body); and Arthritis (joint pain, swelling, and stiffness) … Patient requires home care services … patient does not have the arm strength for a manual wheelchair, uses a rollator walker which is supportive, but they do not have endurance for any walking other than short distance and requires a motorized wheelchair … ” During an interview on April 23, 2024, at 1:12 PM, Admin 3 stated they were responsible for submitting the comprehensive assessment within 5 days of the start-of-care date. Admin 3 confirmed Patient #8's start-of-care date was April 16, 2024. Additionally, Admin 3 verified the initial comprehensive assessment for Patient #8 was still pending and they were still working on it by checking the computer system. 3. During an interview on 04-23-2024 at 1:22 PM, the Administrator and Clinical Manager, Admin 2, confirmed Patient #8’s initial start-of-care comprehensive assessment was incomplete. The Administrator further confirmed the comprehensive assessment should be completed within 5 days of the start-of-care date.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the individualized plan of care included all elements: pertinent diagnosis and their onset date, all supplies and equipment, specific frequency and duration of visits, nutritional requirements, requirements, all accurate medications, allergies, treatments, all necessary interventions to address the underlying risk factors, all safety measures, infection control precautions, a description of the patient’s risk for emergency department visits and hospital readmissions, services being provided by outside agencies/facilities, measurable outcomes, prognosis, goals identified by the home health agency and patient, rehab potential, discharge planning, and orders may be received/accepted by outside physicians for 2 of 6 active records reviewed. (Patients: #3, and 8) Findings Include: 4. A review of Patient #3’s clinical record evidenced a Plan of Care (POC) with a start of care date of 06-15-2023 and a recertification period of 4-10-2024 to 06-08-2024, electronically signed by the Alternate Clinical Manager (Admin 3), indicated but was not limited to the diagnoses, Parkinson's (a condition of the brain causing issues with movement, pain, and mental health) Fibromyalgia (a chronic disorder causing pain, fatigue, and stiffness), Neurocognitive disorder with Lewy Bodies (protein deposits in the brain on the cells causing issues with memory and thinking), orthostatic hypotension (a drop in blood pressure when a person stands or sits-up suddenly), and Gastroesophageal reflux disease (when stomach acid rises into the esophagus). The POC evidenced a section titled “Allergies” was blank. The POC failed to include the patient’s allergies. During an interview with Admin 3 on 04-23-2024 at 02:55 PM, they confirmed Patient #3’s allergies were not listed on the POC and indicated the allergies were supposed to be listed on the POC. 410 IAC 17-13-1(a)(1)(D)(i, ii, iii, iv, v, vi, vii, viii, ix, x, xi, xii, xiii) 1. A review of an agency policy revision dated 01-01-2021, titled “Plan of Care” indicated but was not limited to, “ … The plan of care is based on a Comprehensive Assessment and information provided by the client/family and health team … An individualized Plan of Care signed by a Physician shall be required for each client …The Plan of Care shall be completed in full, and include: a. Start of Care date b. Certification period … d. Orders for specific clinical services and treatments (frequency/duration), e. All pertinent diagnosis (es), principal and secondary, including dates of onset f. Medical history … h. Allergies i. Mental status j. Treatment goals k. Prognosis l. Rehabilitation potential m. Functional limitations and precautions n. Activities permitted or restrictions o. Specific dietary or nutritional requirements p. Medications: dose/frequency/route q. Medical supplies and equipment required r. Any safety measures to protect against injury s. Caregiver needs; instructions to client/caregiver, as applicable t. Instructions for timely discharge or referral u. Discharge plans … ” 2. A review of the clinical record for Patient #8 revealed an initial comprehensive assessment dated 04-6-2024, electronically signed by the Registered Nurse (RN)/Alternate Clinical Manager, Admin 3. However, the clinical record failed to contain a plan of care. A review of a “Face to Face” document signed by Patient #8’s physician on 04-12-2024, indicated the patient’s medical condition to support home health services as “Homebound, Fall Risk, Chronic Kidney Disease, and Degenerative Disk disease. A review of a verbal physician’s order for the start of care dated 04-16-2024 at 8:00 AM, signed by the Clinical Manager, Admin 2, indicated services for Skilled Nursing for supervision of the Home Health Aide services and Home Health Aide services for ADL/IADL for safety. A review of a “Progress Note” from Entity 12, a physician group, dated 10-26-2023 at 3:52 PM, electronically signed by Person 14, the Nurse Practitioner for Person 13, the patient’s physician. The progress note indicated, “74-year-old … who has Vitamin B12 deficiency; Folic acid deficiency; arteriovenous dialysis fistula; End Stage Renal Disease (ESRD) ( kidney failure) on hemodialysis (treatment used to filter wastes, salts, and fluid from the blood); Type 2 Diabetes Mellitus (a condition of the body’s inability to regulate sugar); Hypertension; Coronary Artery Disease ( a condition of narrowing of the major vessels); Chronic Diastolic Congestive Heart Failure (a condition in which the heart’s main pumping chamber (left ventricle) becomes stiff and unable to pump effectively); Degeneration of Lumber Intervertebral Disc (a condition where one or more discs in the spine deteriorate due to age, results in neck and back pain); Anemia; Memory loss; History of Deep Vein Thrombosis (DVT) (a condition which the blood clots form in veins located deep inside the body); and Arthritis (joint pain, swelling, and stiffness) … Patient requires home care services … patient does not have the arm strength for a manual wheelchair, uses a rollator walker which is supportive, but they do not have endurance for any walking other than short distance and requires a motorized wheelchair … ” During an interview on 04-23-2024 at 1:12 PM, Admin 3 indicated that the plan of care for Patient #8 was in pending status and that they were still working on it. 3. During an interview on 04-23-2024 at 1:22 PM, the Clinical Manager, Admin 2, confirmed Patient #8’s plan of care had not been completed.

This visit was for a Federal Recertification and State Re-licensure survey in conjunction with a Federal Focused Infection Control in relation to the COVID-19 pandemic. Survey Dates: 2-22, 2-23, 2-24, and 2-25-2021 Facility #: 013284 These deficiencies reflect State Findings cited in accordance with 410 IAC 17. Refer to State Form for additional State Findings. Quality Review completed on 3/8/2021 A4

Before discharge for cause HHA must: CFR(s): 484.50(d)(5) The HHA determines, under a policy set by the HHA for the purpose of addressing discharge for cause that meets the requirements of paragraphs (d)(5)(i) through (d)(5)(iii) of this section, that the patient's (or other persons in the patient's home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the HHA to operate effectively is seriously impaired. The HHA must do the following before it discharges a patient for cause: This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to document in the patient's clinical record the behaviors and circumstances that warranted patient discharge for cause as well as their efforts to resolve the problem for 1 of 2 discharged patients reviewed . (Patient #5) Findings include: A review of the Comforcare Home Health Discharge policy, C440, last revision 1/1/2019, indicated, " Clients will receive a 15 (fifteen) day notice of discharge unless the health, safety, or welfare of our staff are in immediate or significant risk if we were to continue to provide services to the patient." During the clinical record review for patient #5, reviewed 02/23/2021, failed to document the circumstance that warranted patient discharge for cause without a 15-day notice on 9/21/20. During an interview with the administrator and alternate administrator, they agreed that an incidence report should have been documented regarding patient #5 cause for discharge. The administrator stated patient #5 sent a text to a drug dealer to deliver drugs to the home while a staff member of their other entity was there. The administrator acknowledge Comforcare staff member was not in the home at the time of the incident. The agency failed to show documentation of the investigation and interviews with patient #5 caregivers. 17-12-3(b)(2)(D)(iii)

Discharge or Transfer Summary Content CFR(s): 484.58(b)(1) Standard: Discharge or transfer summary content. The HHA must send all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to evidence all necessary medical information pertaining the patient's current course of illness and treatment, post discharge goals of care, and treatments to the receiving facility or health care practitioner to ensure safe and effective transition of care for 2 or 2 discharged patients reviewed. (Patients #5 and #6) Findings include: 1. A review of the Comforcare Home Health policy, C440, last revision 1/1/2019, indicated, " ...To ensure continuity of care, treatment and services need....A discharge plan shall be developed that is documented in writing and includes all written / verbal instruction regarding the clients ongoing care needs and available resources provided to the client and family." 2. The clinical record for patient #5 reviewed 02/23/2021 failed to document that the discharge summary was sent to receiving facility or health care practitioner. The discharge summary dated 9/21/2021 failed to evidence patient #5's post discharge goals of care and treatments. 3. The discharge summary dated 11/24/2021 failed to evidence patient #6's post discharge goals of care and treatments. The agency failed to evidence that patient #6's discharge summary was sent to physician. 4. During an interview with the administrator and alternate administrator, they agreed patient's #5 and #6 progress to goals and treatments and documented that it was sent to transferring facility on the discharge summary.