Every finding on record at Scroggins Nursing and Home Services

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR §484.102. Survey Dates: 06/04/2025 - 06/06/2025 and 06/09/2025 - 06/10/2025 Active Census: 15 At this Emergency Preparedness survey, Scroggins Nursing & Home Care was not found to be in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR §484.102.

Establishment of the Emergency Program (EP) CFR(s): 484.102 §403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.542, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must establish and maintain a [comprehensive] emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements: * (Unless otherwise indicated, the general use of the terms "facility" or "facilities" in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This CONDITION is not met as evidenced by: Based on record review and interview, the agency failed to develop and maintain an individualized Emergency Preparedness Plan for 1 of 1 agency reviewed with the potential to affect all patients. Findings include: Review of a binder provided by the agency on 06/10/2025, evidenced forms related to Emergency Preparedness. Review of a document titled "Agency Profile" was filled out with basic demographic information and a document titled "Outpatients in Care" was filled out and the signature page indicated the form was last signed on 10/01/2022. The remaining forms and paperwork in the binder were not filled out or individualized to the agency. During an interview on 06/09/2025, the BOM (Business Office Manager) indicated being unsure if the agency has an Emergency Preparedness program. During an interview on 06/10/2025 at 10:03 AM, the DON (Director of Nursing) indicated being unsure of what an Emergency Preparedness plan for the agency would consist of since she recently had taken over the DON position. She provided a binder of what previous staff had started to put together and indicated she would work to correct the issues now that she is aware of them

This visit was for a Federal Recertification and State Re-Licensure survey of a Home Health Provider. Survey Dates: 06/04/2025 - 06/06/2025 and 06/09/2025 - 06/10/2025 12-Month Unduplicated Skilled Admissions: 1 Partially Extended on 06/06/2025 at 1:03 PM Fully Extended on 06/10/2025 at 11:30 AM This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Refer to State Form for additional State Findings. Abbreviations: RN Registered Nurse LPN Licensed Practice Nurse HHA Home Health Aide POC Plan of Care SOC Start of Care QAPI Quality Assurance and Performance Improvement OASIS Outcome and Assessment Information Set

HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator's name, business address, and business phone number in order to receive complaints. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to furnish the patient or patient's legal representative with contact information for the home health administrator, including: the administrator's name, business address, and business phone number for the purpose of receiving complaints for 3 of 4 home visits conducted (Patient #1, #4, #6). Findings include: 1. During a home visit with Patient #6 on 06/05/2025 at 3:25 PM, a review of the patient's folder provided by the agency, failed to evidence patient was informed of the name and contact information for the home health administrator. During an interview on 06/05/2025 at 3:25 PM, Patient #6 indicated being unsure of who the Administrator and Clinical Manager of the agency are. Patient #6 indicated being unaware of their contact information. 2. During a home visit with Patient #3 on 06/06/2025 at 7:30 AM, a review of the patient's folder provided by the agency, failed to evidence patient was informed of the name and contact information for the HHA administrator. 3. During a home visit with Patient #1 on 06/09/2025 at 9:30 AM, a review of the patient's folder provided by the agency, failed to evidence patient was informed of the name and contact information for the HHA administrator. 4. During an interview on 06/06/2025 at 3:10 PM, the DON and BOM (Business Office Manager) indicated they were unaware of the requirement for written instructions informing patients/caregivers of the HHA clinical manager name and contact information, be provided to patients by the agency. The DON indicated she was unsure if they have a policy related to the requirement.

Discharge or Transfer Summary Content CFR(s): 484.58(b)(1) Standard: Discharge or transfer summary content. The HHA must send all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure a discharge summary containing: all essential medical information concerning the patient's current condition of illness and treatment, after discharge goals of care, and treatment choices was provided to their primary care provider to guarantee the safe and effective change in care for 2 of 2 closed records reviewed (Patient #9, #10). Findings include: 1. Review of a policy titled "Completion of Discharge Summary," indicated but was not limited to: "The agency will complete a discharge summary for each client discharged from the agency. A copy of the discharge summary will be made available to the client's physician. The copy may be mailed or faxed to the physician…The top portion on the DC summary shall be completed if it was not completed at the time of admission…The completion of these forms shall be placed in the clinical record…" 2. The clinical record for Patient #9, benefit period 06/29/2024 - 08/27/224, evidenced a discharge date of 07/25/2024 and a discharge order signed by the patient's primary physician on 08/29/2024. The record failed to evidence a discharge summary was created for the patient and provided to their primary care provider. 3. The clinical record for Patient #10, benefit period 06/08/2024 - 08/06/2024, evidenced a discharge date of 07/26/2024 and a discharge order signed by the patient's primary physician on 08/09/2024. The record failed to evidence a discharge summary was created for the patient and provided to their primary care provider. 4. During an interview on 06/10/2025 at 10:20 PM, the DON and BOM (Business Office Manager) indicated the agency does not currently send discharge summaries to patients' physicians at discharge; the agency reaches out to physician to obtain an order for discharge upon patient's discharge. They indicated the majority of their patients discharge unexpectedly due to loss of payor source approval.

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 POCs included personalized patient and caregiver training and education to promote an efficient discharge; patient/caregiver identified goals, measurable outcomes, interventions, and education to reach goals; and an explanation of the patient's likelihood for emergency department visits and hospital re-admission for 10 of 10 patients' records reviewed (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10). Findings include: 1. A review of a policy titled "Medical Plan of Care", indicated but was not limited to: "The medical plan of care shall be developed in consultation with the home health agency staff and shall cover all pertinent diagnoses and include the following: Any other appropriate items…" 2. The clinical record for Patient #1, benefit period 05/12/2025 - 07/10/2025, evidenced the POC failed to include personalized patient and caregiver training and education to promote an efficient discharge; patient/caregiver identified goals, measurable outcomes, interventions, and education to reach goals; and an explanation of the patient's likelihood for emergency department visits and hospital re-admission. 3. The clinical record for Patient #2, benefit period 05/13/2025 - 07/11/2025, evidenced the POC failed to include personalized patient and caregiver training and education to promote an efficient discharge; patient/caregiver identified goals, measurable outcomes, interventions, and education to reach goals; and an explanation of the patient's likelihood for emergency department visits and hospital re-admission. 4. The clinical record for Patient #3, benefit period 05/25/2025 - 07/23/2025, evidenced the POC failed to include personalized patient and caregiver training and education to promote an efficient discharge; patient/caregiver identified goals, measurable outcomes, interventions, and education to reach goals; and an explanation of the patient's likelihood for emergency department visits and hospital re-admission. 5. The clinical record for Patient #4, benefit period 05/18/2025 - 07/16/2025, evidenced the POC failed to include personalized patient and caregiver training and education to promote an efficient discharge; patient/caregiver identified goals, measurable outcomes, interventions, and education to reach goals; and an explanation of the patient's likelihood for emergency department visits and hospital re-admission. 6. The clinical record for Patient #5, benefit period 04/10/2025 - 06/08/2025, evidenced the POC failed to include personalized patient and caregiver training and education to promote an efficient discharge; patient/caregiver identified goals, measurable outcomes, interventions, and education to reach goals; and an explanation of the patient's likelihood for emergency department visits and hospital re-admission. 7. The clinical record for Patient #6, benefit period 05/24/2025 - 07/22/2025, evidenced the POC failed to include personalized patient and caregiver training and education to promote an efficient discharge; patient/caregiver identified goals, measurable outcomes, interventions, and education to reach goals; and an explanation of the patient's likelihood for emergency department visits and hospital re-admission. 8. The clinical record for Patient #7, benefit period 05/24/2025 - 07/22/2025, evidenced the POC failed to include personalized patient and caregiver training and education to promote an efficient discharge; patient/caregiver identified goals, measurable outcomes, interventions, and education to reach goals; and an explanation of the patient's likelihood for emergency department visits and hospital re-admission. 9. The clinical record for Patient #8, benefit period 04/09/2025 - 06/07/2025, evidenced the POC failed to include personalized patient and caregiver training and education to promote an efficient discharge; patient/caregiver identified goals, measurable outcomes, interventions, and education to reach goals; and an explanation of the patient's likelihood for emergency department visits and hospital re-admission. 10. The clinical record for Patient #9, benefit period 06/29/2024 - 08/27/2024, evidenced the POC failed to include personalized patient and caregiver training and education to promote an efficient discharge; patient/caregiver identified goals, measurable outcomes, interventions, and education to reach goals; and an explanation of the patient's likelihood for emergency department visits and hospital re-admission. 11. The clinical record for Patient #10, benefit period 06/08/2024 - 08/06/2024, evidenced the POC failed to include personalized patient and caregiver training and education to promote an efficient discharge; patient/caregiver identified goals, measurable outcomes, interventions, and education to reach goals; and an explanation of the patient's likelihood for emergency department visits and hospital re-admission. 12. During an interview on 06/05/2025 at 2:36 PM, the DON acknowledged the POCs for all agency patients do not contain patient/caregiver specific education and training to meet goals for discharge in relation to identified measurable goals and interventions, emergency department/re-admission risk, or patient/caregiver training/education for a timely discharge. She indicated being unaware of the requirement due to being new to her role and will work to fix the issues now that she is aware. 410 IAC 17-13-1(a)(1)(C)(xi) 410 IAC 17-13-1(a)(1)(C)(xiii)

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure all doctor's orders were included on the POC for 1 of 2 skilled home visits conducted (Patient # 3). Findings include: Review of a policy titled "Medical Plan of Care," indicated but was not limited to: "The medical plan of care shall be developed in consultation with the home health agency staff and shall cover all pertinent diagnoses and include the following: Nutritional requirements…Medications and treatments…" The clinical record for Patient #3, benefit period 05/25/2025 - 07/23/2025, evidenced a POC with a section listed as "16. Nutritional Req: GT 30 mL Q 4hr Infinity Pump," an incomplete treatment/nutrition order. The order failed to indicate the type, amount, and rate to administer for the feeding. During a home visit on 06/06/2025 at 7:30 AM, RN 2 was prepared to administer the G-tube (short for gastrostomy tube that is essentially a soft, flexible tube inserted through the skin of your abdomen directly into your stomach for feedings when unable to eat by mouth) feeding for Patient #3 with an Infinity Pump. RN 2 indicated the patient received four (4) feedings daily of Nourish Peptide formula (complete) that comes in a 32 fluid ounce bag and is divided up into bottles with 6 ounces each combined with two (2) ounces of water and is run on the Infinity pump at a rate of 250 milliliters (mL) an hour with 30 mL of water to flush when the feed was complete. RN 2's administration failed to match the order on the POC for the nutritional requirement. During an interview on 06/06/2025 at 7:30 AM, RN 2 indicated not being aware the complete order was not on the POC and what the patient was supposed to be given and what was administered. During an interview on 06/06/2025 at 3:20 PM, the DON indicated the order for nutritional requirement treatment was not complete on Patient #3's POC. She indicated the order was missing the formula type and the rate of administration for the formula were not included as they should be in order for the order to be complete.

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 record review and interview, the agency failed to ensure all patients received a schedule with frequency of visits and by what service type for 3 of 4 home visits conducted (Patients #1, #3, and #6). Findings include: 410 IAC 17-12-3(b)(2)(D)(i) 1. During a home visit with Patient #6 on 06/05/2025 at 3:25 PM, a review of the patient's folder provided by the agency, failed to evidence a visit schedule of services to be provided by the agency and who would be providing the services. 2. During a home visit with Patient #3 on 06/06/2025 at 7:30 AM, a review of the patient's folder provided by the agency, failed to evidence a visit schedule of services to be provided by the agency and who would be providing the services. 3. During a home visit with Patient #1 on 06/09/2025 at 9:30 AM, a review of the patient's folder provided by the agency, failed to evidence a visit schedule of services to be provided by the agency and who would be providing the services. 4. During an interview on 06/05/2025 at 3:40 PM, HHA 1 indicated the DON just brought a new folder to the home and told her to put it somewhere they could easily locate it. She indicated there is no aide plan of care, schedule of visits patient should receive, medication list present in the folder. 5. During an interview on 06/06/2025 at 3:10 PM, the DON and BOM indicated they were unaware of the requirement for a written visit schedule to be provided to patients by the agency. The DON indicated she was unsure if they have a policy related to the requirement. 410 IAC 17-12-3(b)(2)(D)(i)

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 record review and interview, the agency failed to ensure all patients received a current written medication list for 4 of 4 home visits conducted (Patients #1, #3, #4, and #6). Findings include: 1. During a home visit with Patient #6 on 06/05/2025 at 3:25 PM, a review of the patient's folder provided by the agency, failed to evidence a complete list of current medications prescribed. 2. During a home visit with Patient #3 on 06/06/2025 at 7:30 AM, a review of the patient's folder provided by the agency, failed to evidence a complete list of current medications prescribed. 3. During a home visit with Patient #4 on 06/06/2025 at 12:17 PM, a review of the patient's folder provided by the agency, failed to evidence a complete list of current medications prescribed. 4. During a home visit with Patient #1 on 06/09/2025 at 9:30 AM, a review of the patient's folder provided by the agency, failed to evidence a complete list of current medications prescribed. 5. During an interview on 06/05/2025 at 3:40 PM, HHA 1 indicated the DON recently brought a new folder to the home and told her to put it somewhere they could easily locate it. She indicated there is no aide plan of care, schedule of visits patient should receive, medication list present in the folder. 6. During an interview on 06/06/2025 at 3:10 PM, the DON indicated being unaware of the requirement for a written medication list to be provided to patients by the agency. She was unsure if they have a policy related to the requirement.

Treatments and therapy services CFR(s): 484.60(e)(3) Any treatments to be administered by HHA personnel and personnel acting on behalf of the HHA, including therapy services. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure all patients received a list of all current treatments to be administered by personnel for 1 of 2 skilled home visits conducted (Patient #3). Findings include: During a home visit with Patient #3 on 06/06/2025 at 7:30 AM, the nurse surveyor reviewed the patient's folder from the agency. The folder failed to evidence a written list of all treatments, including G-tube (short for gastrostomy tube that is essentially a soft, flexible tube inserted through the skin of your abdomen directly into your stomach for feedings when unable to eat by mouth) feeding for nutrition, to be administered for the patient by RN 2. During an interview on 06/06/2025 at 3:10 PM, the DON indicated being unaware of the requirement for a written list of all current treatments to be provided to patients by the agency. She was unsure if they have a policy related to the requirement.

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 record review and interview, the agency failed to supply the patient and caregiver written instructions communicating the name and contact information for the home health agency's clinical manager for 3 of 4 home visits conducted (Patient #1, #3, #6). Findings include: 1. During a home visit with Patient #6 on 06/05/2025 at 3:20 PM, a review of the patient's folder provided by the agency, failed to evidence written instructions informing of the name and contact information for the HHA clinical manager. During an interview on 06/05/2025 at 3:25 PM, Patient #6 indicated being unsure of who the Administrator and Clinical Manager of the agency are. Patient #6 indicated being unaware of their contact information. 2. During a home visit with Patient #3 on 06/06/2025 at 7:30 AM, a review of the patient's folder provided by the agency, failed to evidence written instructions informing of the name and contact information for the HHA clinical manager. 3. During a home visit with Patient #1 on 06/09/2025 at 9:30 AM, a review of the patient's folder provided by the agency, failed to evidence written instructions informing of the name and contact information for the HHA clinical manager. 4. During an interview on 06/06/2025 at 3:10 PM, the DON and BOM indicated they were unaware of the requirement for written instructions informing patients/caregivers of the HHA clinical manager name and contact information, be provided to patients by the agency. The DON indicated she was unsure if they have a policy related to the requirement.

Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA's governing body. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to show documentation of OASIS data being incorporated into the QAPI program for 1 of 1 agency reviewed. Findings include: Review of the agency's QAPI program on 06/10/202, failed to evidence OASIS data being incorporated into the improvement program. During an interview on 06/10/2025 at 12:00 PM, the DON indicated the agency does not incorporate OASIS data into the QAPI program. She indicated she is new to the DON role and will work to correct the issue now that she is aware of the requirement. 410 IAC 17-12-2(a)

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to develop, improve, or complete a performance improvement project for 1 of 1 agency reviewed. Findings include: Review of a policy dated 05/05/2010 and titled "Quality Assurance Program," indicated but was not limited to: "SNHS will have an ongoing Quality Assurance Program which will be the responsibility of the Administrator and/or Administrator of Nursing…The agency will develop, implement, maintain, and evaluate a quality assessment and performance improvement program…" Review of the agency's QAPI program binder on 06/10/2025, failed to evidence current or past performance improvement projects had been implemented. During an interview on 06/10/2025 at 12:00 PM, the DON indicated the agency not currently have any performance improvement projects and was unaware of the requirement due to being new to the role. She indicated she will work to get the requirement into place now that she is aware.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure discharge summaries were sent to patients' primary care provider within the specified timeframe after the patient's discharge for 2 of 2 closed records reviewed (Patient #9, #10). Findings include: 1. Review of a policy titled "Completion of Discharge Summary," indicated but was not limited to: "The agency will complete a discharge summary for each client discharged from the agency. A copy of the discharge summary will be made available to the client's physician. The copy may be mailed or faxed to the physician…The top portion on the DC summary shall be completed if it was not completed at the time of admission…The completion of these forms shall be placed in the clinical record…" 2. The clinical record for Patient #9, benefit period 06/29/2024 - 08/27/224, evidenced a discharge date of 07/25/2024 and a discharge order received by the patient's primary physician on 08/29/2024. 3. The clinical record for Patient #10, benefit period 06/08/2024 - 08/06/2024, evidenced a discharge date of 07/26/2024 and a discharge order received by the patient's primary physician on 08/09/2024. 4. During an interview on 06/10/2025 at 10:20 PM, the DON and BOM (Business Office Manager) indicated the agency does not currently send discharge summaries to patient's physician at discharge; the agency reaches out to physician to obtain an order for discharge upon discharge need. They indicated a majority of their patients discharge unexpectedly due to loss of payor source approval. They indicated being unaware of a timeframe required for sending discharge summaries to the primary care provider. 410 IAC 17-15-1(a)(6)

This visit was for a Federal and State Re-licensure Survey of a Home Health Agency. Survey Dates: 9/26/2022-10/03/2022 Facility ID: IN010088 Active census: 23 The Survey was Partially Extended on 9/29/2022 at 3:00 p.m. These deficiencies reflect State Findings cited in accordance with 410 IAC 17. Refer to state form for additional state findings. QR Completed 10/19/2022 A4

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 encode and transmit completed OASIS (Outcome and Assessment Information Set) assessment data on 4 of 4 skilled patient records reviewed (Patient #1, #2, #3, & #5), which had the potential to affect all patients. Findings include: A policy titled "Comprehensive Assessment of Client Discharge" was provided by the Director of Nursing on 09/26/2022 at 11:30 a.m. The policy indicated but was not limited to; "Discharge OASIS Data will be collected at the time of discharge...the collected data will be encoded/locked within 7 calendar days from the date of the collection...collected data will be transferred to the state monthly...validation reports to verify transmission will be maintained in the client's record." During an interview on 9/26/2022 at 1:30 p.m. the Director of Nursing (DON) was asked for a copy of their validation reports showing the agency was submitting OASIS data on all skilled patients over the age of 18 utilizing Medicaid or Medicare. On 9/29/2022 at 10:30 a.m. the Director of Nursing stated they went to pull their validation reports and were unsuccessful. They contacted the help desk and were working with the state to fix the issue. The DON believes they are using an outdated program to submit the data which is why it was unsuccessful but are now working with the state to get it updated and corrected.

Transfer and discharge CFR(s): 484.50(d) Standard: Transfer and discharge. The patient and representative (if any), have a right to be informed of the HHA's policies for transfer and discharge. The HHA may only transfer or discharge the patient from the HHA if: This STANDARD is not met as evidenced by: Based on record review, and interview the agency failed to provide all patients with a written policy informing them of their discharge rights prior to discharge for 7 of 7 clinical records reviewed. (Patient #1, #2, #3, #4, #5, #6, & #7). Findings include: 1. An undated policy was provided by the Director of Nursing (DON) on 9/26/2022 at 11:36 a.m. The policy indicated but was not limited to; "Clients or their legal representative will be notified of their discharge from the agency (5) calendar days before services are stopped." 2. The agency's admission packet was provided by the DON on 9/26/2022 at 11:36 a.m. and failed to evidence of a copy of the agency's transfer or discharge policy. 3. The complete clinical record for patient #1 was reviewed on 9/26/2022 and failed to evidence documentation that patient #1 received a copy of the agency's discharge/transfer policy. 4. The complete clinical record for patient #2 was reviewed on 9/26/2022 and failed to evidence documentation that patient #2 received a copy of the agency's discharge/transfer policy. 5. The complete clinical record for patient #6 was reviewed on 9/29/2022 and failed to evidence documentation that patient #6 received a copy of the agency's discharge/transfer policy. 6. The complete clinical record for patient #7 was reviewed on 9/29/2022 and failed to evidence documentation that patient #7 received a copy of the agency's discharge/transfer policy. 8. During a home visit on 9/27/2022 for patient #5, patient #5 did not have an agency admission packet or documentation for review. 9. During a home visit on 9/28/2022 for patient #4 at 9:00 a.m., patient #4 stated they did not have an admission packet or documents to review. 10. During a home visit on 9/28/2022 for patient #3 at 11:40 a.m., patient #3 did not have a written discharge/transfer policy in the home. 11. During an interview on 9/27/2022 at 3:50 p.m. the Director of Nursing stated, "We do need to update our policies. I actually like the survey process because it helps us recognize what we may in have missed in regulation changes."

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 include the patients' risk for hospitalization and failed to include patient-specific education, outcomes, and measurable goals identified by the patient and the agency for 7 of 7 clinical records reviewed. (Patient #1, #2, #3, #4, #5, #6, & #7). 1. An undated policy titled "Certification and Plan of Treatment" was provided by the Director of Nursing (DON) on 9/26/2022 at 11:30 a.m. The document indicated, but was not limited to; "The goals should be measurable ..." 2. The complete clinical record for the certification period of 01/20/2022-3/20/2022 for patient #1 was reviewed on 9/26/2022 and included the following: A document titled Certification and Plan of Treatment dated 2/08/2022 for patient #1 indicated but was not limited to; "Goals ... client will be clean and free from odor (ongoing)." The plan of care failed to include patient #1's risk for an emergency room visit or rehospitalization. 3. The complete clinical record for the certification period of 6/20/2022-8/18/2022 for patient #2 was reviewed on 9/26/2022 and included the following: A document titled Certification and Plan of Treatment dated 6/20/2022 for patient #2 indicated but was not limited to; "Goals ... client will be clean and free from odor (ongoing)." The plan of care failed to include patient #2's risk for an emergency room visit or rehospitalization. 4. The complete clinical record for the certification period of 08/01/2022-09/29/2022 for patient #3 was reviewed on 9/27/2022 and included the following: A document titled Certification and Plan of Treatment dated 8/11/2022 for patient #3 indicated, but was not limited to; "Goals ... client will have necessary care while the primary caregiver is absent from the home (ongoing)." The plan of care failed to include patient #3's risk for an emergency room visit or rehospitalization. 5. The complete clinical record for the certification period of 06/10/2022-08/08/2022 for patient #4 was reviewed on 9/27/2022 and included the following: A document titled Certification and Plan of Treatment dated 6/10/2022 for patient #4 indicated, but was not limited to; "Goals ... client will maintain adequate nutrition, and skin integrity." The plan of care failed to include patient #4's risk for an emergency room visit or rehospitalization. 6. The complete clinical record for the certification period of 08/31/2022-10/29/2022 for patient #5 was reviewed on 9/27/2022 and included the following: A document titled Certification and Plan of Treatment dated 6/10/2022 for patient #5 indicated, but was not limited to; "Goals ...client will be able to meet/perform all aspects of care." The plan of care failed to include patient #5's risk for an emergency room visit or rehospitalization. 7. The complete clinical record for the certification period of 08/31/2022-10/29/2022 for patient #6 was reviewed on 9/27/2022 and included the following: A document titled Certification and Plan of Treatment dated 8/23/2022 for patient #6 indicated, but was not limited to; "Goals ...client will be clean and free from odor (ongoing)." The plan of care failed to include patient #6's risk for an emergency room visit or rehospitalization. 8. The complete clinical record for the certification period of 07/21/2022-09/18/2022 for patient #7 was reviewed on 9/29/2022 and included the following: A document titled Certification and Plan of Treatment dated 7/24/2022 for patient #7 indicated, but was not limited to; "Goals ...client will be clean and free of odor." The plan of care failed to include patient #5's risk for an emergency room visit or rehospitalization. 9. During an interview on 10/03/2022 the Director of Nursing stated she agreed the patient's goals were not measurable, did not include the patient's personal goals, and did not include interventions for achieving those goals. The DON was unable to identify the patient's risk for an emergency room visit or hospitalization risk on the plans of care. 410 IAC 17-13-1(a)(1)(D)(xiii)

Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA's governing body. This STANDARD is not met as evidenced by: Based on record review, and interview, the agency failed to show documented evidence of OASIS (Outcome and Assessment Information Set) data being incorporated into the quality assurance improvement program for 1 of 1 agency reviewed. Findings Include: Review of patient #? lacked evidence of OASIS submission. Review of patient #? lacked evidence of OASIS submission. Review of patient #? lacked evidence of OASIS submission. Findings include: On 10/03/2022 the agency's Quality Assurance Program was reviewed and failed to incorporate OASIS data into the improvement program. During an interview with the Director of Nursing on 10/03/2022 at 10:42 a.m., they stated they do not incorporate OASIS data but will address this at the next Governing Body Meeting. They stated they do complete an OASIS for each patient when required so they have the data it is just not in the binder.

Track adverse patient events CFR(s): 484.65(c)(2) Performance improvement activities must track adverse patient events, analyze their causes, and implement preventive actions. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to track adverse patient events in their quality assurance and improvement program for 1 of 1 agency reviewed. Findings include: A Quality Assurance Program policy was provided by the Director of Nursing (DON) on 9/29/2022. The document indicated the Quality Assurance program is designed to systematically and objectively monitor the quality of patient care. On 10/03/2022 the agency's Quality Assurance Program was reviewed and failed to evidence the tracking of patient adverse events. During an interview on 10/03/2022 at 10:40 a.m., the DON stated they do not currently track adverse events such as falls or infections in their Quality Assurance program but they do audit charts quarterly. The DON stated they are a small agency so they usually are aware of any falls or infections but it is not tracked in the program. 410 IAC 17-12-2(a)

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to develop, improve, or complete a performance improvement project for 1 of 1 agency reviewed. Findings Include: Quarterly medical record reviews completed for 10% of census or minimum of 5 records did not include the incorporation of OASIS data to identify and mitigate risk factors. Quality indicators based on patient satisfaction surveys reviewed with monthly governing body meetings where satisfaction was equivalent to high quality care by skilled staff, rather than use of OASIS report data identifying significant events or trends. Interview with Director of Nursing (DON) on 10/03/2022 at 10:40am revealed current Quality Assurance Performance Improvement (QAPI) Program was lacking necessary details for improvement plans discussed in governing body meetings. DON expressed understanding and plans to incorporate this detail in future meetings. Policy revised date of 01/04/2017 labeled Quality Assurance Program states SNHS (Scroggins Nursing and Homecare Services) will have an ongoing Quality Assurance Program ... designed to objectively and systematically monitor ... Findings include: A Quality Assurance Program policy was provided by the DON on 9/29/2022. The policy indicated, but was not limited to: the program is designed to systematically monitor and evaluate the quality and appropriateness of patient care, resolve unidentified problems, and improve the quality of care. On 10/03/2022 the agency's Quality Assurance Program was reviewed and failed to evidence a current or past performance improvement project in place. During an interview on 10/03/2022 at 10:40 a.m., the Director of Nursing stated they do not currently have any performance improvement projects but plan to incorporate this detail in the future.

COVID-19 Vaccination of Home Health Agency staff CFR(s): 484.70 (d)-(d)(3)(i-x) § 484.70 Condition of Participation: Infection Prevention and Control. (d) Standard: COVID-19 Vaccination of Home Health Agency staff. The home health agency (HHA) must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. For purposes of this section, staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for COVID-19 is defined here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine. (1) Regardless of clinical responsibility or patient contact, the policies and procedures must apply to the following HHA staff, who provide any care, treatment, or other services for the HHA and/or its patients: (i) HHA employees; (ii) Licensed practitioners; (iii) Students, trainees, and volunteers; and (iv) Individuals who provide care, treatment, or other services for the HHA and/or its patients, under contract or by other arrangement. (2) The policies and procedures of this section do not apply to the following HHA staff: (i) Staff who exclusively provide telehealth or telemedicine services outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section; and (ii) Staff who provide support services for the HHA that are performed exclusively outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section. (3) The policies and procedures must include, at a minimum, the following components: (i) A process for ensuring all staff specified in paragraph (d)(1) of this section (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the HHA and/or its patients; (ii) A process for ensuring that all staff specified in paragraph (d)(1) of this section are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations; (iii) A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19; (iv) A process for tracking and securely documenting the COVID-19 vaccination status of all staff specified in paragraph (d)(1) of this section; (v) A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC; (vi) A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law; (vii) A process for tracking and securely documenting information provided by those staff who have requested, and for whom the HHA has granted, an exemption from the staff COVID-19 vaccination requirements; (viii) A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws, and for further ensuring that such documentation contains (A) All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and (B) A statement by the authenticating practitioner recommending that the staff member be exempted from the HHA's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications; (ix) A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and (x) Contingency plans for staff who are not fully vaccinated for COVID-19. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to maintain a 100% compliance rate for the federal COVID-19 vaccination requirement for 5 of 29 personnel records reviewed. (Employee J, K, L, M & N) Findings include: A document titled "COVID-19 Vaccination Policy" was provided by the Director of Nursing on 10/03/2022 at 9:35 a.m. The document indicated, but was not limited to; "Purpose: The policy is to ensure that all staff is either fully vaccinated for COVID-19 or has an exemption on file ... Employees will be required to have their vaccination card on file no more than five (5) days after their vaccination series complete ... Tracking employees who receive a medical/religious exemption ... This must be filed to the agency by the employee no more than five (5) days after completion." The agency COVID-19 Vaccination binder was provided by the Director of Nursing on 10/03/2022 at 9:35 a.m. The binder failed to evidence a vaccination card, medical exemption, or religious exemption for employees J, K, L, M, and N. During an interview on 10/03/2022 at 9:37 a.m. the Director of Nursing stated they had reached out to employees J, K, L, M, and N to provide copies of their vaccination cards for the employees' files.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure the clinical record contained clinical notes recording clinical progress, interventions and response to those interventions, and goals including progress towards those goals for 2 of 4 skilled nursing clinical records reviewed. (Patient #1, & #3) Findings include: 1. A policy titled "Certification and Plan of Treatment" was provided by the Director of Nursing (DON) on 9/26/2022 at 11:30 a.m. The document indicated, but was not limited to; "Remember that what you the discipline should be doing, will be monitored on the care note of that discipline ... if items are not documented as ordered, it then appears the discipline is not following physician orders." 2. The complete clinical record for patient #3 for the certification period of 8/01/2022 through 9/29/2022 was reviewed on 9/26/2022. The record included the following: A document titled "Certification and Plan of Treatment" that indicated, but was not limited to; " Principal Diagnosis: Cerebral Palsy ... Other Pertinent Diagnosis: Seizure Activity ... Orders for Discipline and Treatments ... 9-11 hours x [time] 5 days per week ... Assess for s/s [signs/symptoms] of disease process exacerbation ... physical assessment ... 60 Day Summary ... CP [Cerebral Palsy]/Seizure Activity, cannot stay alone ... has only had focal seizures." Clinical Notes dated from 8/01/2022 through 9/23/2022 were reviewed on 9/26/2022 and failed to evidence documentation of seizure status, failed to evidence documentation of focal seizures, exacerbation, and/or remission of seizure activity. Clinical notes indicate "6A Received [sic] care, 8A Breakfast, 12P Lunch, 5P Returned Care. The clinical documents failed properly to describe the patient's clinical status, the necessity for skilled nursing care, clinical progress, and improvement/decline in clinical status. 3. During an interview on 9/26/2022 employee H, a Licensed Practical Nurse, stated that patient #3 experienced a seizure the night before the visit that did not require medication. 4. The complete clinical record for patient #1 was reviewed on 9/26/2022 and included the following: Patient #1 had a start-of-care date of 9-10-2021 and an end-of-care date of 7/21/2022. Only 1 comprehensive assessment, the discharge comprehensive assessment, was included in the clinical record out of the required 6 comprehensive assessments for the period of care received. The record failed to include 5 of 6 plans of care, and 3 of 5 60-day summaries. 5. During an interview on 9/27/2022 at 1:00 p.m. the Director of Nursing stated she was unsuccessful in locating the missing documents and the backup copies of the files were located on a disk that is now corrupted and unable to be read. 410 IAC 17-15-1(a)(1)-(7)

Retention of records CFR(s): 484.110(c)(1)(2) Standard: Retention of records. (1) Clinical records must be retained for 5 years after the discharge of the patient, unless state law stipulates a longer period of time. (2) The HHA's policies must provide for retention of clinical records even if it discontinues operation. When an HHA discontinues operation, it must inform the state agency where clinical records will be maintained. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to ensure all items in the clinical record were retained for a period of 5 years for 1 of 2 closed records reviewed. (Patient #1). Findings include: The complete clinical record for patient #1 was reviewed on 9/26/2022 for the period of 9/01/2021 (Start of Care) through 5/20/2022 (End of Care) and included: A plan of care for the certification period 1/20/2022 through 3/20/2022 indicating patient #1 received a home health aide 1-2 hours/day 1-3 days/week and attendant care services 1-4 hours/day 1-5 days/week. Aide Daily Visit Notes for the month of July 2022. A completed OASIS discharge assessment. The clinical record failed to include 5 of 6 required comprehensive assessments, 4 of 5 plans of care, 4 of 5 aide plans of care, and all home health aide visit notes for 2021 and January through June of 2022. During an interview on 9/27/2022 at 1:00 p.m. the Director of Nursing stated she was unsuccessful in locating the missing documents and the backup copies of the files were located on a disk that is now corrupted and unable to be read. IAC 410 17-15-1(b)

This visit was for a complaint investigation in conjunction with a Focused Infection Control COVID-19 Emergency Preparedness Survey. Survey Date: February 4th, 2021 At this Focused Infection Control Emergency Preparedness survey, in regards to staffing and implementation of staffing Scroggins Nursing and Home Services Inc. was found to be in compliance with 42 CFR 484.102 Emergency Preparedness Requirements for Medicare Participating Providers and Suppliers for Home Health Agencies.

This survey was for a federal and state complaint in conjunction with an infection control focused COVID-19 survey. Complaint IN00328301 - unsubstantiated due to lack of evidence. Survey Date: February 4th of 2021. Census: 22 Partially Extended Survey Announced 02/04/2021 at 3:30 p.m. These deficiencies reflect State Findings cited in accordance with 410 IAC 17. Refer to state form for additional state findings. Quality Review completed on 2/11/2021 A4

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 record review and interview, the agency failed to ensure staff were following acceptable standards of practice by actively screening patients prior to performing home visits and actively taking their own temperatures and documenting absence of illness or signs/symptoms of COVID-19 for 1 of 1 agency reviewed. Findings include: 1. A 3/23/2020 CMS Infection Control Covid-19 questionnaire tool indicated, but was not limited to, "Is the facility screening all staff at the beginning of their shift for fever and signs/symptoms of illness? Is the facility actively taking their temperature and documenting absence of illness (or signs/symptoms of COVID-19 as more information becomes available)?" Ref: QSO 20-20-All 2. A 3/10/2020 CMS Guidance for Infection Control and Prevention Concerning Coronavirus Disease 2019 (COVID-19) in Home Health Agencies (HHAs) indicated, but was not limited to, "How should HHAs screen patients for COVID-19? When making a home visit, HHAs should identify patients at risk for having COVID-19 infection before or immediately upon arrival to the home. They should ask patients about the following: 1. International travel within the last 14 days to countries with sustained community transmission ... 2. Signs or symptoms of a respiratory infection, such as a fever, cough, and sore throat. 3. In the last 14 days, has had contact with someone with or under investigation for COVID-19, or are ill with respiratory illness. 4. Residing in a community where community-based spread of COVID-19 is occurring." 3. A 3/16/2020 dated document titled Policy on COVID-19 was provided by the alternate administrator on 2/4/2021 at 3:28 p.m. The document failed to evidence a requirement to self screen prior to patient care and failed to evidence a policy on screening patients for potential COVID-19 infections prior to or at the beginning of scheduled home visits. 4. During an interview on 2/4/2021 at 3:30 p.m. the alternate administrator stated the agency staff did not self-screen or document absence of signs or symptoms of COVID-19 prior to each shift and they were not actively screening patients prior to or at the beginning of each home visit. She stated she was not aware that was something that they needed to do but would work on correcting it. 17-12-1(m)