Every finding on record at Select Home Health Services LLC

Standard: Initial assessment visit. CFR(s): 484.55(a) Standard: Initial assessment visit. This STANDARD is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure an initial assessment was completed within 48 hours of referral for 3 of 4 active patient records reviewed (Patient #19, #20, and #23). Findings include: 1. Policy #6.019.1, Comprehensive Assessment of Patients (OASIS), indicated a comprehensive assessment will be performed on patients within 48 hours of referral or the patient’s return to home or on the physician-ordered start of care date. 2. Patient #19’s clinical record evidenced a referral date of 12/14/23 and a hospital discharge date of 12/15/23. The clinical record included an initial assessment of Patient #19 on 12/23/23. The clinical record failed to evidence a physician order to delay the initial assessment. During an interview on 01/05/24 beginning at 2:12 PM, the Clinical Manager relayed he/she could not find a reason Patient #19’s initial assessment was performed over 48 hours after referral. 3. Patient #20’s clinical record evidenced a referral date of 11/22/23 and evidenced a discharge date from a skilled nursing facility on 11/25/23. The clinical record included an initial assessment of Patient #20 on 11/29/23. The clinical record failed to evidence a physician order to delay the initial assessment. During an interview on 01/05/24 beginning at 2:12 PM, the Clinical Manager relayed there was no documentation in the clinical record to show why the initial assessment had been performed more than 48 hours after Patient #20’s return home from the skilled nursing facility. 4. Patient #23’s clinical record evidenced a referral date of 12/01/23. The clinical record included an initial assessment on 12/05/23. The clinical record failed to evidence a physician order to delay the initial assessment. During an interview on 01/05/24 beginning at 2:12 PM, the Clinical Manager relayed there was no documentation in the clinical record to show why the initial assessment had been performed more than 48 hours after Patient #23’s referral date.

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102. Survey dates: October 24, 25, 26, 27, 30, 31, November 1, 2, 2023 Active Census: 472 At this Emergency Preparedness survey, Select Home Health Services was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 484.102. QR: A 2 11/14/23

This visit was for a Federal Recertification and State Relicensure survey of a Home Health Provider. Survey Dates: October 24, 25, 26, 27, 30, 31, November 1 and 2, 2023 Facility ID: 012550 Provider/CCN Number: 157635 Medicaid #: 201051860A 12 Month Unduplicated Skilled Admissions: 1439 This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Refer to State Form for additional State Findings. During this Federal Recertification Survey, Select Home Health Services was found to be out of compliance with Condition of Participation at 42 CFR 484.55 Comprehensive Assessment of Patients. The survey was reported to the Administrator as fully extended on 11/01/23 at 12:12 PM. Based on the Condition-level deficiencies during the November 2, 2023 survey, your HHA was subject to a partial or extended survey pursuant to section 1891(c)(2)(D) of the Social Security Act, on November 02, 2023. Therefore, and pursuant to section 1891(a)(3)(D)(iii) of the Act, your agency is precluded from operating or being the site of a home health aide training, skills competency and/or competency evaluation programs for a period of two years beginning November 2, 2023, and continuing through November 1, 2025. QR: Area 2 11/14/23

Patient rights CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient's rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This CONDITION is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure patients received all services as outlined in the plan of care (See Tag G436); failed to collaborate with the physician regarding discharge for measurable outcomes and goals being achieved (See Tag G458); failed to advise the patient and physician that a discharge for cause was being considered (See Tag G464); failed to make efforts to resolve the problem (See Tag G466); failed to provide contact information for other agencies or providers (See Tag G468); failed to document the problem and efforts made to resolve the problem (See Tag G470); and failed to document the existence and resolution of the complaint (See Tag G484). The cumulative effect of these systemic problems had the potential to impact all 472 active patients which resulted in the agency being found out of compliance with the Condition of Participation 42 CFR 484.50 Patient Rights.

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 home health agency failed to ensure patients received all services as outlined in the plan of care for 1 of 1 discharged records reviewed which evidenced the agency failed to provide Occupational Therapy services as ordered in the plan of care (Patient #13). Findings include: 1. The review of Patient #13’s closed clinical record (start of care 1/12/23, discharge date 9/1/23) included a plan of care for the certification period 7/11/23 to 9/9/23. The plan of care indicated the patient was to receive Occupational Therapy (OT) services 1 time a week for 7 weeks. The record included OT Visit notes on 7/12/23 and 7/20/23. The record failed to evidence Patient #13 received any OT visits after 7/20/23 and failed to evidence collaboration with the physician regarding a change in POC frequencies for OT services. The record included documentation of missed OT visits on 2. During an interview on 10/30/23 beginning at 11:18 AM, Other Person 3 indicated they were not contacted by the home health agency to schedule further OT visits after 7/20/23. 3. During an interview on 10/30/23 beginning at 3:58 PM, the Clinical Supervisor indicated the clinical record failed to include documentation od OT missed visits and why. During an interview on 10/31/23 beginning at 11:05 AM, the Clinical Supervisor indicated the clinical record failed to evidence that the physician was notified regarding the OT missed visits nor POC frequency changes.

Outcomes/goals have been achieved CFR(s): 484.50(d)(3) The transfer or discharge is appropriate because the physician or allowed practitioner, who is responsible for the home health plan of care and the HHA agree that the measurable outcomes and goals set forth in the plan of care in accordance with §484.60(a)(2)(xiv) have been achieved, and the HHA and the physician or allowed practitioner, who is responsible for the home health plan of care agree that the patient no longer needs the HHA's services; This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to evidence collaboration with the attending physician regarding planned discharge for measurable outcomes and goals achieved for 3 of 5 discharged patient records reviewed (Patient #13, 15 and 16). Findings include: 1. The review of Patient #13’s clinical record included a Plan of Care (POC) for the certification period 7/11/23 to 9/8/23. The clinical record failed to evidence collaboration with the patient or physician regarding the planned discharge on 9/01/23, for achieving measurable outcomes and goals and failed to evidence a written notice of planned agency discharge was given to the patient at least 15 days prior to the planned discharge. During an interview on 10/30/23 beginning at 3:58 PM, the Clinical Supervisor indicated the clinical record for Patient #13 failed to include documentation that the physician was notified agreed to the planned discharge and failed to evidence a signed notice of planned discharge. 2. The review of Patient #15’s clinical record included a Plan of Care (POC) for the certification period 3/11/23 to 5/9/23. The clinical record failed to evidence collaboration with the patient or physician regarding the planned discharge on 5/09/23, for achieving measurable outcomes and goals and failed to evidence a written notice of planned agency discharge was given to the patient at least 15 days prior to the planned discharge. During an interview on 11/01/23 beginning at 2:36 PM, the Clinical Supervisor indicated the clinical record for Patient #15 failed to include documentation that the physician was notified and agreed to the planned discharge and failed to evidence a signed notice of planned discharge. 3. The review of Patient #16’s clinical record included a Plan of Care (POC) for the certification period 6/8/23 to 8/6/293. The clinical record failed to evidence collaboration with the patient or physician regarding the planned discharge on 8/02/23, for achieving measurable outcomes and goals and failed to evidence a written notice of planned agency discharge was given to the patient at least 15 days prior to the planned discharge. During an interview on 11/01/23 beginning at 2:36 PM, the Clinical Supervisor indicated the clinical record for Patient #16 failed to include documentation that the physician was notified and agreed to the planned discharge and failed to evidence a signed notice of planned discharge.

Advise the patient of discharge for cause CFR(s): 484.50(d)(5)(i) (i) Advise the patient, representative (if any), the physician(s) or allowed practitioner(s), issuing orders for the home health plan of care, and the patient's primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) that a discharge for cause is being considered; This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to collaborate with the physician regarding possible discharge for cause for 1 of 1 discharge for noncompliance patient records reviewed (Patient #13). Findings include: 1. A review of agency policy “Discharge / Transfer from Service” indicated the home health agency will notify appropriate agency staff, the patient, and the patient’s representative (if any) and physician(s) of intent to discharge for cause. 2. The review of Patient #13’s clinical record included a Plan of Care (POC) for the certification period 7/11/23 to 9/8/23. The clinical record failed to evidence collaboration with the patient or physician regarding a possible discharge for cause. 3. During an interview on 10/30/23 beginning at 3:58 PM, the Clinical Supervisor indicated the clinical record for Patient #13 failed to evidence documentation with the patient and/or physician regarding a possible discharge for cause.

Make efforts to resolve the problem(s) CFR(s): 484.50(d)(5)(ii) (ii) Make efforts to resolve the problem(s) presented by the patient's behavior, the behavior of other persons in the patient's home, or situation; This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to evidence efforts were made to resolve the behavior problems in Patient home for 1 of 1 discharge record reviewed for noncompliance (Patient #13). Findings include: 1. A review of agency policy “Discharge / Transfer from Service” indicated the home health agency will notify appropriate agency staff, the patient, and the patient’s representative (if any) and physician(s) of intent to discharge for cause; will make efforts to resolve the problem(s) or situation; will provide the patient and representative (if any), with contact information for other agencies or providers who may be able to provide care and will document in the patient’s clinical record the problem, efforts to resolve the problem, and resources provided to the patient or representative (if any). 2. The review of Patient #13’s clinical record included a Plan of Care (POC) for the certification period 7/11/23 to 9/8/23. The plan of care indicated Patient was to receive Occupational Therapy (OT) services 1 time a week for 7 weeks. The record included OT Visit notes on 7/12/23 and 7/20/23. The record failed to evidence Patient #13 received any OT visits after 7/20/23 and failed to evidence documentation of any problems in the household and / or home health agency staff not feeling safe in the home. 3. During an interview on 10/30/23 beginning at 3:58 PM, the Clinical Supervisor indicated the clinical record for Patient #13 failed to evidence documentation of OT staff not feeling safe in the home.

Provide contact info other services CFR(s): 484.50(d)(5)(iii) (iii) Provide the patient and representative (if any), with contact information for other agencies or providers who may be able to provide care; and This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to provide the patient and/or representative with contact information for other home health agencies who may be able to provide care for 1 of 1 discharge record reviewed for noncompliance (Patient #13). Findings include: 1. A review of agency policy “Discharge / Transfer from Service” indicated the home health agency will notify appropriate agency staff, the patient, and the patient’s representative (if any) and physician(s) of intent to discharge for cause; will make efforts to resolve the problem(s) or situation; will provide the patient and representative (if any), with contact information for other agencies or providers who may be able to provide care and will document in the patient’s clinical record the problem, efforts to resolve the problem, and resources provided to the patient or representative (if any). 2. The clinical record of Patient #13’s failed to evidence Patient was provided a list of agencies that may be able to provide services, before discharge. The record included a 37 page referral, that was sent to Entity 4 for home health services. The referral was sent on 9/1/23 after Patient #13 was discharged from the home health agency for noncompliance. 3. During an interview on 10/30/23 beginning at 3:58 PM, the Clinical Supervisor indicated the clinical record failed to evidence documentation that Patient was provided list of other agencies or providers who may be able to provide care, prior to discharge for noncompliance.

Document efforts to resolve problems CFR(s): 484.50(d)(5)(iv) (iv) Document the problem(s) and efforts made to resolve the problem(s), and enter this documentation into its clinical records; This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to document the problem and efforts made to resolve the problem in the clinical record for 1 of 1 discharge for noncompliance patient records reviewed (Patient #13). Findings include: 1. A review of agency policy “Discharge / Transfer from Service” indicated the home health agency will notify appropriate agency staff, the patient, and the patient’s representative (if any) and physician(s) of intent to discharge for cause; will make efforts to resolve the problem(s) or situation; will provide the patient and representative (if any), with contact information for other agencies or providers who may be able to provide care and will document in the patient’s clinical record the problem, efforts to resolve the problem, and resources provided to the patient or representative (if any). 2. The review of Patient #13’s clinical record included a plan of care for certification period 7/11/23 to 9/8/23. The plan of care indicated the patient was to receive Occupational Therapy (OT) services 1 time a week for 7 weeks and Physical Therapy services 1 time a week for 1 week; 2 times a week for 7 weeks and 1 time a week for 1 week. The record evidenced OT Visits were completed on 7/12/23 and 7/20/23 and PT visits were completed on 7/13/23, 7/19/23, 7/21/23, 7/24/23, 7/28/23, 7/31/23, 8/02/23, 8/07/23, 8/11/23, 8/14/23, 8/16/23, 8/21/23, 8/23/23 and 8/28/23. 3. The home health agency complaint log included a complaint filed by Patient #13’s son on 7/24/23 for OT not providing services. The clinical record for Patient #13 failed to evidence any problems identified during the 7/12/23 and 7/29/23 OT visits and failed to evidence any efforts made to resolve the complaint filed by Patient #13’s son regarding missed OT visits and evidenced Patient #13 was discharged for noncompliance effective 9/01/23. 4. During an interview on 10/30/23 beginning at 3:58 PM, the Clinical Supervisor indicated the clinical record failed to evidence documentation of the complaint filed by Patient #13’s son and failed to include any further OT visits were made after 7/20/23.

Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to document the existence of the complaint and the resolution of the complaint in the clinical record for 1 of 1 discharged clinical records reviewed with a complaint (Patient #13). Findings include: 1. A review of agency policy “Complaints and Grievances” indicated the patient or representative is notified when appropriate action has been taken or that the problem has been resolved. 2. The home health agency complaint log included a complaint filed by Patient #13’s son on 7/24/23 for OT not providing services as ordered in the plan of care. The clinical record for Patient #13 failed to evidence documentation of the complaint and any efforts made to resolve the complaint filed by Patient #13’s son regarding missed Occupational Therapy visits and evidenced Patient #13 was discharged for noncompliance effective 9/01/23. 3. During an interview on 10/30/23 beginning at 11:18 AM, Other Person 3 indicated they had not received any complaint resolution documentation from the home health agency. 4. During an interview on 10/30/23 beginning at 3:58 PM, the Clinical Supervisor indicated the clinical record failed to evidence documentation of the complaint or resolution of the complaint that was filed by Patient #13’s son. 410 IAC 17-12-3(c)(2)

Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient's eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This CONDITION 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 referral to the agency (See G514); Based on record review and interview, the home health agency failed to ensure all wounds were measured during the initial comprehensive assessment (See G528); and Based on observation, record review, and interviews, the home health agency failed to ensure a complete review of all current medications was performed (See G536). Findings include: The cumulative effect of these systemic problems had the potential to impact all 472 active patients which resulted in the agency being found out of compliance with the Condition of Participation 42 CFR 484.55 Comprehensive Assessment of Patients.

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 referral to the agency for 1 of 4 active patients reviewed with a start of care after 10/01/23 (Patient #7). Findings include, The policy titled, “Comprehensive Assessment of Patients (OASIS)” indicated, The initial assessment must be performed within 48 hours of receiving the referral, the patient’s return home, or the start of care (SOC) date ordered by the physician. Patient #7’s clinical record included a referral date of 10/03/23 and included an initial assessment on 10/09/23. The record failed to evidence the initial assessment occurred within 48 hours of referral or the patient’s return home and failed to evidence a physician order to delay the initial assessment. During an interview on 11/01/23 at 01:00 PM, the Clinical Supervisor indicated the patient had been discharged from a facility on 10/06/23 but that the initial assessment was more than 48 hours after the discharge. The Clinical Supervisor indicated the clinical record did not include the reason for the late assessment. 410 IAC 17-14-1(a)(1)(A)

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure all wounds were measured during the initial comprehensive assessment for 1 of 6 active patients with wounds (Patient #4). The clinical record for Patient #4 included a comprehensive assessment titled, “Visit Note Report,” identified as completed on 10/19/23 at 3:12 PM. completed by Registered Nurse (RN) 3 identified four wounds and the documentation revealed wound care was provided. The comprehensive assessment failed to evidence measurements for each of the four wounds; RN 3 answered “No” to the question within the assessment, "measurements taken." The record revealed a 71 page referral document which included wound care notes dated 10/9/23 which indicated Patient had six wounds which included a Stage III left ankle wound. An interview, conducted with RN 3 on 10/31/23 at 9:22 a.m., indicated they do not remember Patient and indicated they probably did not document due to the wounds being unmeasurable. In an interview with the Clinical Supervisor on 10/31/23 at 1:16 PM, they indicated they expected wound measurements to be completed for Patient #4 at the start of care. The clinical supervisor reviewed the admission notes for Patient #4 and then indicated the documentation revealed RN 3 performed wound care and they would expect all the wounds to be measured during the assessment. The clinical record revealed Other Person 1 sent a note within the electronic medical record, on 10/26/23, inquiring about a fifth wound which was identified within the referral medical documents. The clinical record for Patient #4 revealed a skilled nurse visit note, dated 10/27/23, which indicated RN 1 assessed and provided wound care to all wounds previously identified and to wound #5 which was discovered by other Person 1 within the referral documents. The clinical record failed to evidence wound #5 was measured by the agency staff through exit date. The documentation indicated measurements were not taken due to “not due.” During an interview on 11/1/23 at 2:44 PM, the Clinical Supervisor indicated they expect a skilled nurse to measure a wound which was not previously documented and expected a SN to measure a new wound. When queried, the Clinical Supervisor indicated they did not find measurements for the newest wound, wound #5.

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 interviews, the home health agency failed to ensure a complete review of all current medications was performed for 7 of 17 patient records reviewed (Patients #1, 2, 3, 5, 11, 13, and 14). The clinical record for Patient #13 included a medication list which included but not limited to Bisacodyl (a medication used to prevent and treat constipation) 5 mg tablet two times daily as needed. The medication list failed to include indications for use of the as needed medication. During an interview on 11/01/23 beginning at 12:01 PM, the Clinical Supervisor indicated all as needed medications should have an indication for use and indicated the medication list for Patient #13 did not include indications for use for the as needed Bisacodyl. The clinical record for Patient #14 included a medication list which included but not limited to Gabapentin (a medication used to treat nerve pain) 100 mg capsule as needed. The medication list failed to include medication frequency and indication for use of the as needed medication. During an interview on 11/01/23 beginning at 12:01 PM, the Clinical Supervisor indicated all as needed medications should have a frequency and an indication for use and indicated the medication list for Patient #14 did not include indications for use for the as needed Gabapentin. 410 IAC 17-14-1(a)(1)(B) Review of the clinical record for Patient #2 evidenced a Plan of Care for the certification period of 09-13-2023 through 11-11-2023, with orders for Physical Therapy twice weekly. The list of current medications included, but was not limited to, "AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE (a combination medication used to treat certain infections caused by bacteria) 125 MG TABLET ORAL 1 tablet 2 times daily and DOXYCYCLINE HYCLATE (medication used to treat bacterial infections in many different parts of the body) 100MG CAPSULE ORAL 1 capsule 2 times daily. The record failed to evidence discontinuation dates for the medications. On 10-25-2023 at 1:45 PM at the completion of the observation visit of Physician Therapist (PT) 1, with Patient #2, the Patient’s medication list was reviewed with PT 1, who was queried as to whether the patient was actively taking two [antibiotics], the Amoxicillin and the Doxycycline as listed on the agency’s plan of care. PT 1 indicated they would need to verify before responding. During an interview with Person 1, a licensed practical nurse [LPN] for Entity 1, an assisted living facility, they indicated the facility administers Patients medications and indicated the Amoxicillin was discontinued on 05-05-2023 and the Doxycycline was discontinued on 05-08-2023. On 10-25-2023 at 1:50 PM, when queried as to when medications would be reconciled, PT 1 indicated medication reconciliations are done at recertification by checking the agency's medication list against Entity 1's medication list (as the Patient’s medications are kept secure and administered by Entity 1) and further indicated the Amoxicillin and Doxycycline should not have been present on the current plan of care list of medications. 7. On 10/26/23 beginning at 10AM, Occupational Therapist (OT) 1 was observed as they provided care for Patient #3 who resided at Entity 6. During the home visit observation, OT 1 failed to review Patient’s medication regimen with Patient #3 or their caregiver. During an interview with OT 1 on 10/26/23 at 11:15 AM, when queried, OT 1 indicated the medications are reviewed with the Patient at the start of care and with every visit. OT 1 revealed they did not review medications at this visit. Following the home visit observation, Patient #3, and their primary caregiver, who resides with Patient, provided the medications taken by Patient daily. The following medications were reported to be taken by Patient, and confirmed by caregiver, and were not included within the Patient’s plan of care or any updated plan of care. Metoprolol succinate 25 milligrams[mg.] on tablet daily, for atrial fibrillation, colchicine 0.6 mg. twice a day for gout, Preservision AREDS supplement for vision taken once per day, and Muro-128 2% eye drop one drop to the left eye, twice a day, and albuterol inhaler 2 inhalations every 6 hours as needed for obstructive airway disease. These medications were included on Entity 6’s medication list. Following the Patient’s home visit, Person 6, the Healthcare Director at Entity 6 provided Patient’s medication list which indicated current orders as of 10/26/23 at 11:30 AM Findings include: 1. Policy “Medication Profile” indicated it was the responsibility of the admitting RN [registered nurse] or therapist to obtain a list of all medications that the patient is currently taking on a routine or PRN [as needed] basis and ensure they are entered in the patient’s electronic chart. A verbal review of medications with the patient or person responsible to ensure knowledge of medication purpose, route, amount, and frequency will be compared to the written label on the medication bottle. 2. Patient #1’s clinical record included a medication list included the medication trazodone (an antidepressant medication also used to treat insomnia [inability to fall or stay asleep]) 50 milligram tablet, 1 tablet by moth at bedtime as needed. The record failed to include the indications for use of this as needed medication. During an interview on 11/01/23 at 12:14 PM, the Clinical Supervisor indicated Patient #1’s medication list did not include indications for use for trazodone. 3. During an interview on 10/26/23 at 03:30 PM, the Clinical Supervisor indicated the antibiotics discontinued in May should not have been on Patient 2’s plan of care as an active medication in October. 4. During a home visit observation of RN 2 providing care for Patient #5 on 10/27/23 beginning at 10:55 AM, RN 2 indicated Entity 2 (an assisted living facility) administered Patient #5’s medications. During the home visit observation, Person 2, an LPN at Entity 2 provided their facility’s current medication list for Patient #5 which indicated these were current orders as of 10/27/23 at 10:58 AM. The medication list included but not limited to acetaminophen (a non-opioid medication used to treat pain and fever) 325 mg, 2 tablets by mouth twice daily; docusate sodium capsules (a stool softener to prevent and treat constipation) 100 mg, 1 capsule by mouth twice daily; Ensure Clear Blueberry/Pomegranate (a nutritional supplement), 1 container by mouth twice daily; furosemide (a medication used to treat fluid retention and swelling) 40 mg tablet, 1 tablet by mouth twice daily; acetaminophen tablets 325 mg, 2 tablets by mouth every 6 hours as needed for fever greater than 101 degrees with a maximum of 4 grams of acetaminophen every 24 hours; Geri-Lanta (a medication used to treat the symptoms of too much stomach acid) suspension, 30 milliliters by mouth every hour as needed for heartburn, acid reflux, indigestion, upset stomach, or gas pain with a maximum of 6 doses in 24 hours; hydrocodone/ acetaminophen (medication used to treat pain severe enough to require opioid treatment) 5/325mg tablets, 1 tablet by mouth every 6 hours as needed with a maximum of 4 grams of acetaminophen every 24 hours; loperamide (a medication used to control and relieve the symptoms of acute diarrhea) 2 mg capsule, 2 capsules by mouth after first loose stool then 1 capsule after each loose stool as needed with a maximum of 16 mg in 24 hours; ondansetron (a medication used to treat nausea) 8 mg tablet, 1 tablet by mouth every 8 hours as needed for nausea; and senna (a medication used to treat constipation) 8.6 mg tablet, 2 tablets by mouth every day as needed for constipation. Patient #5’s clinical record included a medication list which included the medication torsemide (a medication used to treat fluid retention and swelling) 20 milligram (mg) tablet, 1.5 tablets daily by mouth. This medication was not included on Entity 2’s medication list for Patient #5. Patient #5’s clinical record failed to include acetaminophen (scheduled or as needed),docusate sodium, Ensure Clear, furosemide, polyethylene glycol powder, Geri-Lanta, hydrocodone/ acetaminophen, loperamide, ondansetron, or senna that were included on Entity 2’s medication list. During an interview on 10/27/23 at 04:06 PM, the Clinical Supervisor indicated the clinician should compare the agency medication list to the facility’s medication list at initial and recertification comprehensive assessments. 5. During an interview on 10/27/23 at 04:06 PM, the Clinical Supervisor indicated the medication list should have included indications for as needed medications and should have include the sliding scale dosing information should have been included on the medication list for the sliding scale insulin. 6. Patient #11’s clinical record included a medication list which included but not limited to Miralax oral powder (a medication used to prevent and treat constipation) 17 gram dose daily as needed; the list failed to include indications for use of the as needed medication. During an interview on 11/02/23 at 03:02 PM, the Clinical Supervisor indicated the plan of care for Patient #11 did not include indications for use for the Miralax.

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 orders for treatment were received prior to staff providing services for 12 of 17 patient records reviewed (Patients # 3, 4, 8, 9, 10, 11, 12, 13, 14, 15, 16, and 17). *Patient #6’s clinical record included a POC for the certification period 09/30/23 to 11/28/23 which was returned to the agency with orders for home health aide (HHA) services 1 time per week for 8 weeks for assistance with personal care, hygiene, and activities of daily living. The clinical record failed to include verbal orders and / or physician written orders for services provided prior to 10/11/23. A HHA visit note included but not limited to the HHA performed a partial sponge bath and assisted Patient #6 with ambulation on 10/10/23. During an interview on 11/01/23 at 01:00 PM, the Clinical Supervisor indicated the RN had left a message for the physician regarding verbal orders for Patient #6 and indicated the Clinical Supervisor could not find documentation the physician provided orders for services provided, prior to 10/11/23. *Patient #8’s clinical record included a POC for certification period 10/12/23 to 12/10/23 with orders for PT 1 time per week for 1 week, 2 times per week for 4 weeks, and 1 time per week for 4 weeks to provide balance training and enhance functional mobility; occupational (OT) effective 10/15/23, 1 time per week for 1 week; and master of social work (MSW) effective 10/15/23, 1 time per week for 1 week for assess social and emotional factors and need for care. The clinical record failed to include documentation that verbal orders or physician-signed written orders were received for the skilled services included on the POC. PT visit notes indicated therapy treatment was performed for Patient #8 on 10/17/23, 10/19/23, 10/23/23, 10/26/23, and 10/30/23. An OT visit note indicated therapy treatment was performed for Patient #8 on 10/19/23. A Certified Occupational Therapy Assistant (COTA) visit note indicated therapy treatment was performed for Patient #8 on 10/26/23. A MSW visit note indicated services were provided for Patient #8 on 10/20/23. During an interview on 11/01/23 at 01:00 PM, the Clinical Supervisor indicated there were no verbal orders or physician-signed, written orders authorizing the skilled services on the POC and provided to Patient #8. *Patient #9’s clinical record included a POC for certification period 10/17/23 to 12/15/23 which included but not limited to orders for SN 1 time per week for 1 week, 2 times per week for 7 weeks, and 1 time per week for 1 week to perform wound care and speech therapy (ST) 1 time per week for 9 weeks to help improve clarity of speech and evaluate and treat a swallowing impairment. SN visit notes indicated wound care was performed for Patient # 9 on 10/17/23 and 10/24/23. A ST note indicated ST services were provided to Patient #9 on 10/18/23. The clinical record failed to evidence verbal or written orders authorizing the skilled services on the written POC. The clinical record failed to evidence physician authorized orders for ST prior to 10/20/23 and failed to evidence physician-signed written orders for SN prior to 10/25/23. During an interview on 11/02/23 at 03:02 PM, the Clinical Supervisor indicated there were no documentation that verbal or written orders for Patient #9 were received, prior to 10/25/23. *Patient #10’s clinical record included a POC for certification period 10/14/23 to 12/12/23 which included orders for SN 2 times per week for 8 weeks and 1 time per week for 1 week for wound care and PT 1 time per week for 9 weeks to restore functional mobility and provide gait training. The clinical record failed to evidence verbal orders and / or physician-signed written orders for the current plan of care, prior to 10/20/23. SN notes indicated wound care was performed for Patient #10 on 10/16/23 and 10/19/23. A Physical Therapy Assistant (PTA) visit note indicated therapy services were performed for Patient #10 on 10/18/23. During an interview on 11/02/23 at 03:02 PM, the Clinical Supervisor indicated there were no verbal or physician-signed written orders for the current certification period for Patient #10’s services prior to 10/20/23. *Patient #11’s clinical record included a POC for certification period 10/11/23 to 12/09/23 included orders for PT 1 time per week for 2 weeks, 2 times per week for 4 weeks, and 1 time per week for 3 weeks for included but not limited to restore functional strength and range of motion and provide balance training. The clinical record failed to evidence documentation of verbal orders and /or physician-signed written orders for PT services. A PT visit note indicated therapy services were provided for Patient #11 on 10/13/23. During an interview on 11/02/23 at 03:02 PM, the Clinical Supervisor indicated there were no verbal orders or physician-signed written orders for PT services provided to Patient #11 on 10/13/23. *Patient #12’s clinical record included a POC for certification period 09/14/23 to 11/12/23 which included orders for SN, effective 09/17/23, 1 time per week for 5 weeks for included for wound care and PT 1 time per week for 9 weeks to restore functional strength and ROM and provide balance and gait training. SN visit notes indicated wound care was performed for Patient #10 on 09/22/23, 09/29/23, 10/05/23, and 10/13/23. PT visit notes indicated therapy services were performed for Patient #10 on 09/14/23, 10/15/23, 10/27/23, and 10/31/23. A PTA visit note indicated therapy services were provided for Patient #12 on 09/25/23. The clinical record failed to evidence documentation that verbal and / or physician-signed written orders for skilled services were obtained, for the current certification period prior to 11/01/23. During an interview on 11/02/23 at 03:02 PM, the Clinical Supervisor indicated there were no verbal or physician-signed orders for treatment for the current certification period for Patient #12 prior 11/01/23. During an interview on 10/26/23 at 03:30 PM, the Clinical Supervisor indicated verbal orders should be documented in the individual orders that are incorporated into the POC. *The Policy titled, “Physician Orders/Plan of Care/Medical Supervision” revealed the physician establishes and reviews a plan of treatment for the patient, the following staff / discipline may receive Verbal orders RN [registered nurse], LPN [licensed practical nurse], PT [physical therapist], OT [occupational therapist], ST [speech therapist], and MSW [Master of Social Work]. Verbal orders are to be placed into writing, signed, timed, and dated by the person receiving the order and incorporated into the Patient’s record, and indicated Verbal Orders must be signed by the physician. *The clinical record for Patient #3 failed to include documentary evidence that the clinician obtained verbal nor that they received written physician orders to provide skilled care. SN visit notes dated 10/03/23 and 10/17/23 revealed ostomy care was performed for Patient #3 during each visit. The PT visit notes indicated services were provided 10/5/23, 10/11/23, 10/13/23 and 10/18/23. The OT visit notes indicated therapy treatment was performed on 10/4/23, 10/6/23, 10/10/23, 10/13/23 and 10/17/23. During an interview with the Clinical Supervisor on 11/1/23 at 12:14 PM, when asked, the Clinical Supervisor referenced the POC signed 10/19/23 and the referral for OT dated 10/03/23. *The clinical record for Patient #4 revealed an order from the attending to evaluate and treatment for appropriate disciplines, effective 10/12/23. The clinical record failed to evidence further orders were received from the attending physician or their surrogate. SN visit notes indicated wound care was performed for Patient on 10/23/23 and 10/27/23. A PT visit note indicated therapy treatment was performed for Patient on 10/23/23. The clinical record failed to evidence physician orders for the skilled services provided as of exit date 11/02/23. *The review of Patient #13’s clinical record included a POC for certification period 7/11/23 to 9/08/23 with orders for OT services 1 time a week for 9 weeks. The record evidenced OT visits were performed on 7/12/23 and 7/20/23. The record failed to evidence documentation of a verbal order or a signed written order was obtained prior to the above visits performed. During an interview on 11/02/23 at 03:02 PM, the Clinical Supervisor indicated the clinical record of Patient 13, failed to evidence documentation that verbal or physician-signed orders for the skilled care services were obtained from the attending physician, prior to the provision of said services. *The review of Patient #14’s clinical record included a POC for certification period 6/29/23 to 8/27/23 with orders for SN services 1 time a week for 1 week; 2 times a week for 7 weeks and 3 times a week for 1 week. The record evidenced SN visits were performed on 6/29/23, 7/03/23, 7/05/23, 7/10/23 and 7/12/23. The record failed to evidence documentation of a verbal order or a signed written order was obtained prior to the above visits performed. During an interview on 11/02/23 beginning at 03:02 PM, the Clinical Supervisor indicated the clinical record of Patient 14, failed to evidence documentation that verbal or physician-signed orders for the skilled care services were obtained from the attending physician, prior to the provision of services. *The review of Patient #15’s clinical record included a POC for certification period 3/11/23 to 5/09/23 with orders for PT services 1 time a week for 9 weeks and OT services 1 time a week for 8 weeks. The record evidenced PT visits were performed on 3/14/23, 3/22/23 and 3/28/23 and OT visits were performed on 3/16/23 and 3/28/23. The record failed to evidence documentation of a verbal order or a signed written order was obtained prior to the above visits performed. During an interview on 11/02/23 beginning at 03:02 PM, the Clinical Supervisor indicated the clinical record of Patient 15, failed to evidence documentation that verbal or physician-signed orders for the skilled care services provided were obtained from the attending physician, prior to the provision of services. *The review of Patient #16’s clinical record included a POC for certification period 6/08/23 to 8/06/23 with orders for PT and OT services 1 time a week for 9 weeks. The record evidenced PT visits were performed on 6/09/23 and 6/15/233 and OT visits were performed on 6/08/23 and 6/14/23. The record failed to evidence documentation of a verbal order or a signed written order was obtained prior to the above visits performed. During an interview on 11/02/23 beginning at 03:02 PM, the Clinical Supervisor indicated the clinical record of Patient 16, failed to evidence documentation that verbal or physician-signed orders for the skilled care services were obtained from the attending physician, prior to the provision of services. *The review of Patient #17’s clinical record included a POC for certification period 4/19/21 to 6/17/23 with orders for SN services 1 time a week for 2 weeks and PT services 1 time a week for 1 week; 2 times a week for 5 weeks and 1 time a week for 3 weeks. The record evidenced SN visits were performed on 4/21/23 and 4/25/23 and a PT visit was performed on 4/19/23. The record failed to evidence documentation of a verbal order or a signed written order was obtained prior to the above visits performed. During an interview on 11/02/23 beginning at 03:02 PM, the Clinical Supervisor indicated the clinical record of Patient 17, failed to evidence documentation that verbal or physician-signed orders for the skilled care services were obtained from the attending physician, prior to the provision of services.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to notify the attending physician involved in the patient’s care regarding a change in Therapy visit frequencies for 2 of 5 discharged records reviewed with Therapy services (Patient’s #13 and #17). Findings include: 1. The review of agency policy “Care Planning” indicated the is revised as frequently as deemed necessary by the RN/Therapist and the qualified professional based on the ongoing assessments of the patient / client’s needs and the clinician will inform the patient’s physician of any changes that suggest the need to alter the plan of care. 2. The review of Patient #13’s clinical record included a plan of care (POC) for certification period 7/11/23 to 9/8/23. The POC indicated the patient was to receive Occupational Therapy (OT) services 1 time a week for 7 weeks and Physical Therapy (PT) services 1 time a week for 1 week; 2 times a week for 7 weeks and 1 time a week for 1 week. The record evidenced OT Visits were completed on 7/12/23 and 7/20/23. The record failed to evidence OT visits were performed 1 time a week after the 7/20/23 visit and failed to include documentation that the physician was made aware of the missed OT visits and POC frequencies not being achieved. During an interview on 10/30/23 beginning at 11:18 AM, Other Person 3 indicated they had not been contacted by the home health agency to schedule further OT visits after 7/20/23. During an interview on 10/30/23 beginning at 3:58 PM, the Clinical Supervisor indicated the clinical record failed to include OT missed visit documentation and during an interview on 10/31/23 beginning at 11:05 AM, the Clinical Supervisor indicated the clinical record failed to include evidence that the physician was notified regarding the OT missed visits or POC frequency changes. 3. The review of Patient #17’s clinical record included a Physical Therapy (PT) Start of Care (SOC) on 4/19/23 with a Plan of Care (POC) for the certification period 4/19/23 to 6/17/23. The POC indicated the patient was to receive Physical Therapy (PT) services 1 time a week for 1 week; 2 times a week for 5 weeks and 1 time a week for 3 weeks. The record failed to evidence any PT visits were completed after the SOC for 5 weeks and failed to evidence the attending physician was notified regarding the missed PT visits and POC frequencies not being achieved. During an interview on 11/01/23 beginning at 10:38 AM, the Alternate Administrator indicated the clinical record failed to include PT missed visit documentation and failed to include evidence that the physician was notified regarding the PT missed visits or POC frequency changes. 410 IAC 17-13-1(a)(2)

Discharge plans communication CFR(s): 484.60(c)(3)(ii) (ii) Any revisions related to plans for the patient's discharge must be communicated to the patient, representative, caregiver, all physicians or allowed practitioner's issuing orders for the HHA plan of care, and the patient's primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any). This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to document collaboration with the patient, caregiver and physician regarding discharge and failed to provide notification to the patient at least 15 days prior to discharge for 3 of 5 discharged patient records reviewed (Patient’s #13, 15, and 16). Findings include: 1. The review of Patient #13’s clinical record included a Plan of Care (POC) for the certification period 7/11/23 to 9/8/23. The clinical record failed to evidence collaboration with the patient or physician regarding the discharge for noncompliance and failed to evidence a written notice of planned agency discharge was given to the patient at least 15 days prior to the planned discharge. During an interview on 10/30/23 beginning at 3:58 PM, the Clinical Supervisor indicated the clinical record for Patient #13 failed to include documentation that the physician was notified and agreed to the discharge and failed to evidence a signed notice of planned discharge was given to the patient. 2. The review of Patient #15’s clinical record included a Plan of Care (POC) for the certification period 3/11/23 to 5/9/23. The clinical record failed to evidence collaboration with the patient or physician regarding the planned discharge and failed to evidence a written notice of planned agency discharge was given to the patient at least 15 days prior to the planned discharge. During an interview on 11/01/23 beginning at 2:36 PM, the Clinical Supervisor indicated the clinical record for Patient #15 failed to include documentation that the physician was notified and agreed to the planned discharge and failed to evidence a signed notice of planned discharge. 3. The review of Patient #16’s clinical record included a Plan of Care (POC) for the certification period 6/8/23 to 8/6/23. The clinical record failed to evidence collaboration with the patient or physician regarding the planned discharge and failed to evidence a written notice of planned agency discharge was given to the patient at least 15 days prior to the planned discharge. During an interview on 11/01/23 beginning at 2:36 PM, the Clinical Supervisor indicated the clinical record for Patient #16 failed to include documentation that the physician was notified and agreed to the planned discharge and failed to evidence a signed notice of planned discharge.

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on observation, record review and interview, the home health agency failed to ensure collaboration between home health agency staff and Assisted Living Facility (ALF) staff for 3 of 8 ALF patient records reviewed (Patient’s #14, 15 and 16). Findings include: 1. A review of agency policy “Coordination of Client Care” indicated that all service providers involved in the care of a client, including contracted healthcare professionals or another Agency, will be engaged in an effective interchange, reporting and coordination of care regarding the client. All such coordination of care will be documented in the client record. 2. The review of Patient #14’s clinical record included a plan of care (POC) for certification period 6/29/23 to 8/27/23 and skilled nurse (SN) visit notes for 6/29/23, 7/03/23, 7/05/23, 7/10/23 and 7/12/23. The POC failed to mention collaboration with the Assisted Living Facility (ALF) and the SN visit notes failed to include collaboration documentation with the ALF. During an interview on 11/01/23 beginning at 2:36 PM, the Clinical Supervisor indicated the POC failed to include the ALF information and the SN visit notes failed to include clinician documentation with the ALF. 3. The review of Patient #15’s clinical record included a plan of care (POC) for certification period 3/11/23 to 5/09/23 and and Occupational Therapy (OT) visit notes for 3/16/23, 3/28/23, 4/03/23, 4/13/23, 4/22/23, 4/26/23 and 5/01/23 and Physical Therapy (PT) visit notes for 3/14/23, 3/22/23, 3/28/23, 4/04/34, 4/10/23, 4/18/23, 4/28/23, 5/01/23, and 5/09/23. The POC failed to mention collaboration with the Assisted Living Facility (ALF) and the OT and PT visit notes failed to include collaboration documentation with the ALF. During an interview on 11/01/23 beginning at 2:36 PM, the Clinical Supervisor indicated the POC failed to include the ALF information and the OT and PT visit notes failed to include clinician documentation with the ALF. 4. The review of Patient #16’s clinical record included a plan of care (POC) for certification period 6/08/23 to 8/06/23 and Occupational Therapy (OT) visit notes for 6/08/23, 6/14/23, 6/20/23, 6/26/23, 7/08/23, 7/12/23, 7/19/23 and 7/26/23 and Physical Therapy (PT) visit notes for 6/09/23, 6/15/23, 6/22/23, 7/07/23, 7/13/23, 7/18/23, 7/27/23 and 8/02/23. The POC failed to mention collaboration with the Assisted Living Facility (ALF) and the OT and PT visit notes failed to include collaboration documentation with the ALF. During an interview on 11/01/23 beginning at 2:36 PM, the Clinical Supervisor indicated the POC failed to include the ALF information and the OT and PT visit notes failed to include clinician documentation with the ALF. 410 IAC 17-12-2(g)

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 clinicians followed the manufacture's' directions for use when disinfecting reusable devices and tools taken into and used for patient care for 1 of 1 occupational therapist [OT] observed (OT1). The findings include: During a home visit observation, during the provision of care by OT #1 for Patient #3 on 10/26/23 at 10:00 AM, observed OT #1 to use a Clorox Disinfecting Wipe, obtained from a flex pack, and wiped their electronic blood pressure device and immediately placed the electronic blood pressure device into their visit supply bag. OT #1 then used the wipe on their computer, then placed the computer onto the soiled barrier and picked up her/ his porous clipboard from the barrier. After they wiped the clipboard, they immediately picked up their computer from the soiled barrier, and their travel bag. With their other hand, they picked up the soiled barrier and disposed of inside the home, then exited the residence. The Direction For Use at the Clorox web site, https://shop.clorox.com/products/clorox-disinfecting-wipes-flex-pack, revealed these wipes require the user to utilize a sufficient number of wipes to non–porous surface to remain wet for 4 minutes to disinfect. During an interview with OT #1 on 10/26/23 at 11:15 AM when queried, OT #1 indicated they believed the product required 4 full minutes to disinfect. During an interview with the Clinical Supervisor and Administrator, on 11/2/23 at 3:40 PM, when queried, they indicated the product required 4 minutes to disinfect.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(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 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 §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure supervisory visits for home health aides (HHAs) were performed every 14 days for 1 of 1 patient record reviewed where the patient received HHA services (Patient #6.) Findings include: Policy “Nurse Supervision” included but not limited to “Home Health Aides will be supervised at least every 14 days by a licensed RN [registered nurse] …” Patient #6’s clinical record included but not limited to a plan of care for certification period 09/30/23 to 11/28/23 with orders for HHA services 1 time per week for 8 weeks to assist with hygiene and activities of daily living as well as orders for included but not limited to skilled nursing, physical therapy, and occupational therapy. The clinical record included HHA visits on 10/10/23 and 10/26/23. The clinical record included an aide supervisory visit performed by an RN on 09/27/23 but failed to include any more aide supervisory visits as of 11/01/23, 35 days later. During an interview on 11/01/23 at 01:00 PM, the Clinical Supervisor indicated HHA supervisory visits should have been conducted every 14 days for a patient receiving skilled services. The Clinical Supervisor indicated there were no aide supervisory visits after 09/27/23 in Patient #6’s clinical record.

Administrator appointed by governing body CFR(s): 484.105(b)(1)(i) (i) Be appointed by and report to the governing body; This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the governing body appointed a qualified administrator for 1 of 1 agency. Findings include: 1. A review of agency policy “Administrative Control” indicated the governing body appoints and dismisses the Administrator and alternate who meets the qualifications of an Administrator to act in the absence of an Administrator. 2. The review of the home health agency governing body minutes failed to evidence the appointment of the administrator documentation. 3. During an interview on 11/02/23 beginning at 2:11 PM, Corporate Employee 1 indicated the home health agency governing body held a meeting to appoint a new administrator and failed to document this meeting naming the current administrator in writing. 410 IAC 17-12-1(b)(1)

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 home health agency failed to submit the discharge summary to the attending physician who will be responsible for providing care within 5 days of discharge for 2 of 5 discharged clinical records reviewed (Patient’s #13 and 15). Findings include: 1. A review of agency policy “Discharge / Transfer of Service” indicated the physician(s) involved in the patient’s plan of care are sent a homecare summary, medication list, post discharge goals, and patient preferences within 5 days of discharge, within 2 days of a transfer, or within 2 days of when the agency is made aware of the transfer. 2. The review of Patient #13’s clinical record evidenced a discharge date of 9/01/23. The record failed to evidence the discharge summary was sent to the attending physician within 5 days after the discharge. During an interview on 11/01/23 beginning at 12:01 PM, the Administrator indicated the discharge summary was faxed to Patient #13’s physician on 9/29/23, twenty-eight days after the discharge. 3. The review of Patient #15’s clinical record evidenced a discharge date of 5/09/23. The record failed to evidence the discharge summary was faxed to the attending physician within 5 days after the discharge. During an interview on 11/01/23 beginning at 12:01 PM, the Administrator indicated the discharge summary was faxed to Patient #15’s physician on 6/05/23, twenty-seven days after the discharge. 410 IAC 17-15-1(c)(6)

This visit was for a Federal and State complaint investigation survey of a deemed Home Health Provider. Survey Dates: 07-24, 07-25, and 07-26-2023 Complaint #: 99255. This complaint was investigated and unrelated Federal and State deficiencies were cited. 12 Month Unduplicated Skilled Admissions: 1523 These deficiencies reflect State findings in accordance with 410 IAC 17 et seq. QR by Area 3 on 7-31-2023

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 implement its policy that required the plan of care to be individualized to include all supplies and equipment necessary to meet the patients' needs for 5 of 6 active records patients whose clinical record was reviewed. (Patients: #1, 3, 4, 5, and 6) Findings Include: 1. A review of an undated Select Home Health Services policy titled, "Physician Orders/Plan of Care/Medical Supervision," Policy No. 4.004.1, was provided by the Administrator on 07-26-2023 at 9:42 AM. The policy revealed, but was not limited to, " … a plan of care, which includes: the diagnosis, prognosis, goals to be accomplished, an order for each service, and list of drugs and equipment … " 2. During a home visit at Patient #1's residence on 07-25-2023 at 12:02 PM, observed the Registered Nurse (RN), RN 2, perform wound care to Patient #1's lower left leg. Patient #1 was sitting on a washable pad and a disposable pad in their recliner. Patient #1 had a life alert necklace around their neck, a walker in front of their chair with reachers across the top of the walker, and a motorized chair at their side. Patient #1 confirmed they received deliveries of pads and briefs due to not being able to get to the bathroom in time. RN 2 pointed out the lymphedema pumps that Patient #1 used on the side table. Observed in Patient #1's bathroom contained safety rails by the toilet and shower and a shower chair and elevated toilet seat. A review on 07-24-2023 at 2:08 PM, of the clinical record for Patient #1, with a start of care date of 05-31-2023, contained a plan of care for the initial certification period of 05-31-2023 to 07-29-2023. The plan of care revealed, but was not limited to, the following diagnoses: Lymphedema (swelling in an arm or leg caused by a lymphatic system blockage), Peripheral Vascular Diseases (a condition which narrowed blood vessels reduce blood flow to the limbs), Non-Pressure Chronic Ulcer other part Left Lower Leg with Fat Layer Exposed (a wound on the left lower leg with subcutaneous tissue showing), and Chronic Kidney Disease Stage 3 (a condition that the kidneys have mild to moderate damage making it difficult to filter waste out of the blood). The orders indicated Skilled Nursing (SN) 2 times a week for 9 weeks to teach and perform wound care to Left Lower Lateral Left Stasis Ulcer. The SN order was to cleanse with normal saline wound wash, apply a Vaseline gauze to the wound bed, and cover it with a border bandage. The section titled, "Durable Medical Equipment (DME) and Supplies," listed "NONE." The plan of care failed to list a walker, a motorized wheelchair, reachers, bathroom handrails, an elevated toilet seat, and shower chair, depends, disposable pads, washable pads, lymphedema pumps, gauze dressings, Vaseline dressings, normal saline wound wash, and safety alert necklace. A review of the OASIS initial comprehensive assessment dated 05-31-2023, in the section titled, "Equipment/Supplies," indicated a rolling walker, a power wheelchair, a tub chair, and an elevated toilet seat. The section titled, "Wound Assessment" indicated the SN cleansed the wound with normal saline wound wash, applied a Vaseline gauze to the wound bed, then covered it with a border bandage. During an interview on 07-25-2023 at 12:35 PM, RN 2, confirmed Patient #1's DME and Supplies were not listed on their plan of care and further indicated that all the DME and Supplies should be listed on the patient's plan of care. 3. A review on 07-26-2023 at 9:49 AM, of the clinical record for Patient #3, with a start of care date of 10-19-2022, contained a plan of care for the recertification period of 06-16-2023 to 08-14-2023. The plan of care revealed, but was not limited to, the following diagnoses: Pressure Ulcer of Left Buttock, Stage 2 (an open wound with damage to the top layer of skin), Pressure Ulcer to of the Right Buttock Stage 2, History of Falling, Reduced Mobility, Old Myocardial Infarction (a condition caused by lack of oxygen to the heart muscle causing damage over 4 weeks old), and Congestive Heart Failure (a chronic condition where the heart does not pump adequately). The orders indicated Skilled Nursing (SN) 2 times a week for 8 weeks, then 1 time a week for 1 week, to perform/teach pressure ulcer care to stage 2 pressure ulcer right medial buttock cleanse with wound cleanser apply Adaptec touch, cover with border dressing. The section titled, "Durable Medical Equipment (DME) and Supplies," listed a hospital bed, tub/shower equipment, walker, wheelchair, wound care dressings, wound care cleanser, and wound care supplies, but failed to list a Hoyer lift, trapeze, Xeroform dressing with border foam dressing, and iodine. A review of the OASIS recertification comprehensive assessment dated 06-15-2023, indicated in the section titled, "Equipment/Supplies," standard walker, wheelchair, tub chair, hospital bed, trapeze, and Hoyer lift. The section titled, "Wound Assessment" indicated wound care provided by the SN -- cleansed the right and left medial buttock with iodine, applied xeroform, and covered with a border dressing. During an interview on 07-26-2023 at 10:24 PM, the caregiver for Patient #3, Person 2, confirmed they used a Hoyer lift when they transferred Patient #3. 4. A review on 07-26-2023 at 11:30 AM, of the clinical record for Patient #4, with a start of care date of 01-27-2023, contained a plan of care for the recertification period of 05-27-2023 to 07-25-2023. The plan of care revealed, but was not limited to, the following diagnoses: Pressure Ulcer Left Heel Unstageable (a wound that is covered by a layer of dead tissue), Type 2 Diabetes Mellitus (a chronic condition that affects the way the body processes sugar), Chronic Obstructive Pulmonary Disease (damage to the lungs that blocks airflow and makes it difficult to breathe) and Congestive Heart Failure (a chronic condition where the heart does not pump adequately). The orders indicated Skilled Nursing (SN) 2 times a week for 8 weeks, then 1 time a week for 1 week, to perform/teach pressure ulcer care to left lower leg and heel. Cleanse with normal saline wound wash, apply betadine, and cover with border bandage. The section titled, "Durable Medical Equipment (DME) and Supplies," listed cane, hospital bed, lift, oxygen supplies, walker, walker-rolling, and wheelchair, but failed to list their Dex scan (a blood sugar monitoring device,) blood sugar testing supplies, insulin pen needles, nebulizer, and nebulizer masks, tubing, normal saline wound wash, border dressing, and betadine. A review of the OASIS recertification comprehensive assessment dated 05-23-2023, in the section titled, "Equipment/Supplies," indicated a wheelchair, hospital bed, and Hoyer lift. The section titled, "Wound Assessment," indicated wound care provided the SN cleansed lower leg pressure ulcer with normal saline wound wash, patted dry, applied betadine, and covered the wound with a border bandage. During an interview on 07-26-2023 at 12:35 PM, Patient #4, confirmed they used a nebulizer with mask twice a day for their breathing treatments, insulin pen needles when they administered their insulin and uses a Dex scan monitor for their blood sugars 3 times a day. 5. During a home visit at Patient #5's residence on 07-25-2023 at 1:30 PM, observed the Registered Nurse (RN), RN 1, perform wound care to Patient #5's left heel. Patient #5 wore a special boot on their left foot to relieve pressure. Patient #5 confirmed they check their blood sugar every morning and log it on their phone and administered their insulin using insulin pens. Patient #5 further confirmed they use a nebulizer via mask. A review on 07-26-2023 at 1:35 PM, of the clinical record for Patient #5 with a start of care date of 05-17-2023, contained a plan of care for the recertification period of 07-16-2023 to 09-13-2023. The plan of care revealed, but was not limited to, the following diagnoses: Pneumonia (an infection that inflames the air sacs in one or both lungs which may fill with fluid), Pressure Ulcer Right heel, Stage 1 (superficial localized redness of the skin usually over a boney prominence), Type 2 Diabetes (a chronic condition that affects the way the body processes sugar) Chronic Obstructive Sleep Apnea (intermittent airflow blockage during sleep). The orders indicated SN 2 times a week for 8 weeks then 1 time a week for 1 week, to perform/teach pressure ulcer care to Patient #5's right foot cleanse with normal saline apply betadine, and cover with kerlix. The section titled, "Durable Medical Equipment (DME) and Supplies" listed "NONE." The plan of care failed to list insulin pen needles, glucometer, glucometer strips, lancets, low weight bearing boot, wheelchair, walker, tub chair, cane, nebulizer, nebulizer masks, betadine, normal saline, and kerlix cling gauze dressing. A review of the OASIS recertification comprehensive assessment dated 07-12-2023, indicated in the section titled, "Equipment/Supplies," indicated, a cane, rolling walker, wheelchair, and tub chair. During an interview on 07-25-2023 at 2:25 PM, RN 1 confirmed there was no DME or supplies listed on the plan of care, and all DME and supplies that Patient #5 used should be listed on the plan of care. 6. During a home visit at Patient #6's residence, observed the Physical Therapist (PT), PT 1, complete soft tissue mobilization and stretching with Patient #6. Observed an orthopedic memory foam cushion (a cushion that relieves back pain and diminishes pressure) on the chair Patient #6 was sitting on. Patient #6 indicated they do not go anywhere without that cushion as it helps their back pain. A review on 07-26-2023 at 12:32 PM, of the clinical record for Patient #6, with a start of care date of 05-04-2023, contained a plan of care for the recertification period of 07-03-2023 to 08-31-2023. The plan of care revealed, but was not limited to, the following diagnoses: Low Back Pain, Essential Hypertension (high blood pressure), Weakness, and Atherosclerosis Heart Disease of the Native Coronary Artery (the buildup of cholesterol plaque in the wall of the artery obstructing blood flow). The orders indicated PT 2 times a week for 9 weeks, Occupational Therapy (OT), 1 time a week for 9 weeks, and a Home Health Aide (HHA), 1 time a week for 9 weeks. The section titled, "DME and Supplies," indicate shower/tub equipment and a walker but failed to list the orthopedic cushion. During an interview on 07-26-2023 at 2:15 PM, the Administrator indicated they were aware of the DME/Supplies not flowing to the plan of care from the comprehensive assessments. IAC 410 17-13-1(a)(1)(D)(ii)