Every finding on record at Sj Home Care LLC

An Emergency Preparedness Survey was conducted by the Indiana Department of Health (IDOH) in accordance with Condition of Participation for Home Health Agencies (HHAs) at 42 CFR §484.102. Survey Dates: 9/25, 26, 27, 28, and 29th, 2023. Facility Number: 009403 Provider Number: 157470 Current Census: 191 QR: A 2 10/09/23

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the communication plan included a list of all employees and phone numbers in 1 of 1 agency surveyed, with the potential to affect all patients and employees. Findings include: 1. The Emergency Preparedness binder was provided for review; the binder included an employee list of names and phone numbers which terminated employees and failed to include the Alternate Administrator, identified as the Alternate disaster coordinator. The list included a phone number for licensed practical nurse (LPN) 2. 2. On 9/29/23, an attempt to reach LPN 2 was conducted using the phone number for LPN 2 listed in the Emergency Binder; the phone call failed to go through. The Business Office Manager provided a new number for LPN 2, which did reach LPN 2. 3. The Emergency Preparedness binder failed to identify contact information for equipment vendors or for Entity C, the agency’s primary referral source. 4. During an interview on 9/29/2023 at 1:45 PM, the Administrator confirmed the numbers were not current and was missing the Alternate Administrator contact information and vendor and hospital list.

This visit was a Federal and State survey of a home health provider. The survey was announced as fully extended on 9/27/2023 at 8:45 AM. Survey dates: September 25, 26, 27, 28 and 29, 2023 Unduplicated Skilled Admissions: 655 This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Refer to State Form for additional State Findings. QR: Area 2 10/09/23

Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to provide their patient's, on admission, the contact information for the Area Agency on Aging with the potential to affect all patients for 1 of 1 agency. Findings include: A review of the patient handbook failed to identify the contact address and phone number for the Area Agency on Aging, a resource for patient advocacy. During an interview on 9/25/2023 at 2:10 PM, the Administrator confirmed the contact information for the Area Agency on Aging was missing from the handbook.

Investigate complaints made by patient CFR(s): 484.50(e)(1)(i) (i) Investigate complaints made by a patient, the patient's representative (if any), and the patient's caregivers and family, including, but not limited to, the following topics: This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to investigate a complaint in 1 of 5 complaints regarding medication management, with the potential to affect any patient receiving medication management services. Findings include: 1. The agency grievance policy evidenced a timeline for the investigation of complaints; per the timeline, the employee notified of the complaint, must document the complaint within 24 hours and notify the Administrator. The Administrator is expected to investigate the complaint by interviewing the employee, involved in the complaint, the patient, and / or the person making the complaint. 2. A review of the complaint log evidenced Patient #7 filed a complaint on 4/25/2023; Patient #7 indicated the nurse did not provide their expected service which was to prefill their medications. Patient 7 relayed they called the agency on 4/21/23, and had not yet received a follow up from the agency. 3. The clinical record for Patient #7 indicated Patient declined a nurse visit on 5/12/2023; Patient indicated they did not want services any longer. 4. The complaint report indicated Person D, the previous administrator, first discussed the complaint with Patient #7 on 5/23/2023, 11 days after Patient indicated they did not want or need services. 5. A review of the agency discharge list indicated Patient #7 was discharged for noncompliance on 5/23/2023. 6. During an interview on 9/26/2023 at 2:10 PM, the Alternate Clinical Manager and Administrator indicated the agency failed to investigate the complaint per agency expectations and indicated patients would not be discharged for noncompliance for refusing one visit.

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 resolve in 1 of 5 complaints regarding a complaint filed regarding medication management, with the potential to affect all patients receiving medication management services. Findings include: 1. The agency grievance policy indicated the agency must attempt to resolve complaints, once the Administrator was notified of the complaint. The policy included a process to escalate complaints to a corporate level if needed. 2. The agency complaint log included a complaint from Patient #7, dated 4/25/2023; Patient #7 indicated the nurse never refilled their medications; the documentation failed to evidence a follow – up with Patient #7. 3. A review of the clinical record for Patient #7 indicated Patient refused a nursing visit on 5/12/23, as they did not need or want services from the agency. 4. The complaint report failed to evidence the previous Administrator contacted Patient prior to 5/23/2023, at which time, Patient discontinued services. 5. During an interview on 9/26/2023 at 2:10 PM, the Administrator and Alternate Clinical Manager indicated the complaint was not resolved per agency expectations. 410 IAC 17 - 12 - 3(c)(2)

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 an initial assessment was completed by a registered nurse [RN] within 48 hours, for 1 of 5 patient records reviewed with a referral for skilled nurse services (Patient #8). Findings include: 1. Review of Policy 2.1.001 “Admission Process” indicated admission / initial visits are made within 48 hours from referral unless there is a specific physician ordered start of care (SOC) date which would supersede the state established timeframes. 2. Review of Patient #8’s clinical record evidenced a referral for Skilled Nursing (SN) services was received on 2/27/23. The initial assessment by the Registered Nurse (RN) was performed on 3/02/23. The clinical record failed to evidence a physician order to perform the initial assessment greater than 48 hours after referral was received. 3. During an Interview on 9/29/23 beginning at 2:56 PM, the Administrator indicated that initial assessment should have occurred within 48 hours after the referral had been received and they were unsure why there was a delay in the initial assessment. 410 IAC 17-14-1(a)(1)(A)

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure that the plan of care (POC) was signed by the provider, per agency policy, for 4 of 12 active clinical records reviewed (Patient # 4, 5, 7, and 8). 5. Review of Patient #8’s clinical record failed to evidence a signed and returned pages 1 and 2 of the POC for certification period 8/29/23- 10/27/23. Page 1 of this POC contained the patient diagnoses, type and frequency of services, and orders for interventions and Page 2 contained orders for disciplines and treatments, goals, rehabilitation potential, discharge plans, DME and supplies, prognosis, functional limitations, safety measures and activities permitted. During an interview on 9/28/23 beginning at 2:56 PM, the Administrator indicated they could not provide a provider-signed 4 page POC for certification period 8/29/23 – 10/27/23 in Patient #8’s clinical record. 410 IAC 17-13-1(a) A review of Patient #7’s clinical record evidenced a plan of care (POC) for certification period 4/16/2023 – 5/23/2023. The POC failed to evidence a physician signature. During an interview on 9/26/2023, at 2:10 PM, the Administrator and Alternate Clinical Manager confirmed the physician never signed the POC. The Administrator and Alternate Clinical Manager indicated they have issues getting physician signed POCs back from Entity C physicians. Findings include: 1. Review of Policy 2.1.007 “Plan of Care (POC),” revised 12/01/21, included but not limited to “… the plan of care is then reviewed… and sent to the physician or authorized practitioner for review and approval / signature…” 2. Review of Patient #4’s clinical record failed to evidence a provider-signed POC for certification period 08/13/23 – 10/11/23. During an interview on 09/27/23 at 03:30 PM, asked the Administrator where the provider-signed POC was for Patient #4, and they said they would look for it. During an interview on 09/28/23 at 03:10 PM, asked the Administrator where the provider-signed POC was for Patient #4, and they again said they would look for it. The Administrator failed to provide the requested provider-signed POC. 3. Review of Patient #5’s clinical record failed to evidence a signed and returned page 1 of the POC for certification period 8/18/23- 10/16/23. Page 1 of this POC contained the patient diagnoses, type and frequency of services, and orders for interventions. During an interview on 09/28/23 at 03:10 PM, the Alternate Clinical Manager indicated they could not find a provider-signed and returned page 1 of the POC for certification period 08/18/23 – 10/16/23 in Patient #5’s clinical record. The Administrator indicated the page 1 probably didn’t get faxed or something happened in the system and it didn’t go through.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the home health agency failed to ensure all required information was included in the plan of care (POC) for 7 of 14 patient records reviewed (Patient #1, 3, 4, 5, 8, 9, 13). During an observation of wound care at a home visit, licensed practical nurse (LPN) 2 asked Patient #1 about wearing lymphedema boots (uses air compression to help reduce fluid buildup). Patient #1 confirmed they wore them every night. A review of Patient #1’s clinical record evidenced a plan of care (POC) for certification period 9/9/2023 – 11/7/2023 failed to identify lymphedema boots as equipment used for the treatment of lymphedema. On 09/27/2023, the clinical record review for Patient #6 evidenced an agency document titled “Visit Note Report”. The report was completed and signed by physical therapist (PT) 4 on 08/17/2023. The report indicated Patient #6 had an adjustable bed and a trapeze (hangs over the bed to function as a grab bar, providing leverage for patients with upper body strength to position). Review of the plan of care (POC) for the period 08/16/2023 through 10/14/2023 evidenced a diagnosis, but not limited to, hemiplegia following cerebral infarction of the right side (paralysis of right side of body after a stroke). The POC failed to evidence inclusion of an adjustable bed or trapeze. During an interview on 09/28/2023 at 3:50 PM, the alternate clinical manager indicated the adjustable bed and trapeze were not in the plan of care. On 09/27/2023, the clinical record review for Patient #9 evidenced a POC for the period 08/19/2023 through 10/17/202. The POC evidenced a diagnosis, but not limited to, essential hypertension (abnormally high blood pressure that is often due to obesity, family history and an unhealthy diet). The POC failed to evidence the nutritional requirements for Patient #9. During an interview on 09/28/2023 at 11:35 AM, registered nurse (RN) 3 indicated documented NA (not applicable) in the plan of care because did not know where to find the diet for Patient #9. During an interview on 09/28/2023 at 2:56 PM, the administrator indicated the type of diet should have been entered into the POC. During a home visit observation of PT 1 providing care for Patient #3 on 9/25/23 beginning at 3:25 PM, Patient #3 reported his last glucometer blood sugar they checked at home was 129. Patient #3 reported they check their blood sugar at home weekly on Wednesdays. Review of Patient #3’s clinical record evidenced a POC for certification period 8/02/23 – 9/30/23 which failed to include the patient’s glucometer and other home blood sugar testing supplies. During an interview on 9/28/23 beginning at 2:56 PM, the Administrator indicated glucometer blood sugar orders should have been on the POC. #8-Review of Patient #8’s clinical record evidenced a Skilled Nurse (SN) visit on 8/14/23 which indicated a Stage 2 wound on the left buttock had healed and was inactivated as of 8/14/23 and POC for certification period 8/29/23 – 10/27/23 with orders for Skilled Nurse to perform procedure of wound care to right and left buttocks weekly and prn. The clinical record failed to evidence documentation of a left buttock wound. During an interview on 9/27/23 beginning at 11:11 AM, Patient #8 indicated he only had 1 wound to the right buttock. During an interview on 9/29/23 beginning at 11:20 AM, LPN 2 indicated Patient #8 does not have a wound to his left buttock. During an interview on 9/29/23 beginning at 1:31 PM, RN 3 indicated Patient #8 does not have a wound to his left buttock. During an interview on 9/27/23 beginning at 3:15 PM, the Administrator indicated they were not sure why the POC listed orders for right and left buttocks wound care. #13- Review of Patient #13’s clinical record evidenced a Physical Therapist (PT) Start of Care (SOC) assessment visit on 4/22/23 which indicated two surgical wounds on the mid-sternal, inferior and left Medial Proximal pretibial areas and a Stage II Pressure Ulcer to the mid sacral area. The clinical record also evidenced a POC for certification period 4/22/23 – 6/20/23 which failed to include wound care treatment orders for the three (3) wounds identified on the SOC assessment. During an interview on 9/28/23 beginning at 2:56 PM, the Administrator indicated the PT should have ordered a Skilled Nurse evaluation visit to assess the wounds. 410 IAC 17-13-1(a)(1)(B); 410 IAC 17-13-1(a)(1)(C); 410 IAC 17-13-1(a)(1)(D)(ii, viii, ix) Findings include: 1. Review of Policy 2.1.007 “Plan of Care,” revised 12/1/21, included but not limited to “A POC is developed for all patients...The POC includes...Medications and treatments...Patient specific interventions and education...Required equipment and supplies...” 4. During a home visit observation of LPN 1 providing care for Patient #4 on 9/25/23 beginning at 3:45 PM, Patient #4 reported the last blood sugar they checked at home as 186. Patient # 4 reported they had been working closely with Other Entity C's pharmacist to adjust home insulin and lower daily blood sugar levels to below 200 consistently. Review of Patient #4’s clinical record evidenced a POC for certification period 08/13/23 – 10/11/23 which failed to include the patient’s glucometer and other home blood sugar testing supplies. 5. During a home observation visit of LPN 1 performing care for Patient #5 on 09/26/23 at 09:15 AM, observed the visible outline of flat, circular implant in the left upper area of the patient’s abdomen. During the visit, Patient #5 reported this implant was a Baclofen (a muscle relaxer medication) pump which had been implanted a few years prior to the home visit. Review of Patient #5’s clinical record evidenced a comprehensive recertification assessment on 08/18/23 which referenced the patient’s Baclofen pump. The clinical record also evidenced a POC for certification period 08/18/23 – 10/16/23 which failed to include the patient’s Baclofen pump. During an interview on 09/28/23 at 03:10 PM, when asked where on Patient #5’s POC for certification period 08/18/23 – 10/16/23 the Baclofen pump could be found, the Administrator indicated only interventions and equipment the agency staff would directly perform or use needed to be included in the POC.

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 all services and treatments were performed as ordered by the attending physician or other authorized practitioner and all orders for medical care were signed, per provider policy, for 6 of 14 patient records reviewed (Patient #2, 3, 4, 5, 8, and 13). During an observation of a home visit with Patient #1, lymphedema boots were observed in the home. Patient #1 confirmed they wore them every night. A review of Patient #1’s clinical record for certification period 9/9/2023 – 11/7/2023, failed to identify an order for the use of lymphedema boots. During an interview on 9/27/2023 at 3:40 PM, the Administrator confirmed there was no written or verbal order for lymphedema boots in the clinical record. A review of Patient #7’s clinical record failed to evidence physician orders for care provided for certification period 4/16/2023 – 5/23/2023. A review of nursing visit notes indicated licensed practical nurse (LPN) 2 provided skilled nursing care to Patient #7 on 4/25/2023 without a physician’s order. Review of Patient # 2’s clinical record evidenced a POC for certification period 9/09/23 - 11/07/23 which included an incomplete verbal order for the POC. The verbal order failed to include the name of the physician designee who relayed the order to the physical therapist. The clinical record failed to evidence the POC was signed and returned by the physician resulting in the agency failed to ensure services were being performed according to physician orders in the POC. The clinical record evidenced Physical Therapy visits were performed on 9/12/23, 9/14/23, 9/19/23, 9/21/23 and 9/26/23 and Occupational Therapy visits were performed on 9/11/23, 9/18/23 and 9/20/23. During an interview on 9/26/23 beginning at 1:40 PM, the Alternate Clinical Manager indicated the clinical record for Patient #2 evidenced an incomplete verbal order. During an interview on 9/27/23 beginning at 11:16 AM, PT 1 indicated the complete verbal order should have been documented including what orders were received, who gave the verbal order, date and time order was received. Review of Patient # 3’s clinical record evidenced a POC for certification period 8/02/23 - 9/30/23 which included an incomplete verbal order for the POC. The verbal order failed to include the name of the physician designee who relayed the order to the physical therapist. The clinical record failed to evidence the POC was signed and returned by the physician resulting in the agency failed to ensure services were being performed according to physician orders in the POC. The clinical record evidenced Physical Therapy visits were performed on 8/04/23, 8/07/23, 8/09/23, 8/15/23, 8/17/23, 8/21/23, 8/25/23, 8/28/23, 8/31/23, 9/05/23, 9/07/23, 9/14/23, 9/15/23, 9/18/23, 9/21/23 and 9/25/23. During an interview on 9/26/23 beginning at 1:40 PM, the Alternate Clinical Manager indicated the clinical record for Patient #3 evidenced an incomplete verbal order and the home health agency did not have a signed POC back from the physician. Review of Patient #8’s clinical record evidenced a POC for certification period 8/29/23 - 10/27/23 which included an incomplete verbal order for the POC. The verbal order failed to include the name of the physician designee who relayed the order to the physical therapist. The clinical record failed to evidence the POC was signed and returned by the physician resulting in the agency failed to ensure services were being performed according to physician orders in the POC. The clinical record evidenced Skilled Nurse visits were performed on 9/05/23, 9/11/23, 9/18/23 and 9/25/23. During an interview on 9/29/23 at 12:31 PM, RN 2 indicated the verbal order documentation should have included date, time, name of who gave the order and order details and should have been placed on a physician’s order to be sent and signed by the physician. Review of Patient #13’s clinical record evidenced a POC for certification period 4/22/23 - 6/20/23 which included an incomplete verbal order for the POC. The verbal order failed to include the name of the physician designee who relayed the order to the physical therapist. The clinical record failed to evidence the POC was signed and returned by the physician resulting in the agency failed to ensure services were being performed according to physician orders in the POC. The clinical record evidenced Occupational Therapy visits were performed on 4/24/23 and 5/19/23 and Physical Therapy visits were performed on 4/25 and 5/18/23. During an interview on 9/27/23 beginning at 3:15 PM, the Administrator indicated the clinical record for Patient #3 failed to include a complete verbal order for the POC. 410 IAC 17-13-1(a) Findings include: 1. Review of Policy 2.1.008 “Physician Orders,” revised 9/1/23, included but not limited to, “The Plan of Care (POC), telephone and or verbal orders must be signed and dated...within a timely manner per state regulation...Indiana...30 days...Verbal or telephone orders are entered into the software system when received and include the time and date the verbal order was received, ordering physician/authorized practitioner, name of physician designee when applicable, clinician that relayed the order (if appropriate), and the clinician accepting the order. 4. Review of Patient #4’s clinical record evidenced a POC for certification period 8/13/23 - 10/11/23 which included an incomplete verbal order for the POC. The verbal order failed to include the name of the physician designee who relayed the order to the nurse. The clinical record failed to evidence the POC was signed and returned by the physician resulting in the agency failed to ensure services were being performed according to physician orders in the POC. The clinical record evidence skilled nursing (SN) visits were performed for Patient #4 on 08/15/23, 08/18/23, 08/21/23, 08/25/23, 08/28/23, 08/31/23, 09/05/23, 09/08/23, 09/11/23, 09/15/23, 09/18/23, 09/22/23, and 09/25/23. During an interview on 09/27/23 at 03:30 PM, the Administrator was asked where the provider-signed POC was for Patient #4. They said they would look for it. During an interview on 09/28/23 at 03:10 PM, the Administrator was asked where the provider-signed POC was for Patient #4. They again said they would look for it. The Administrator failed to provide the requested provider-signed POC. 5. Review of Patient #5’s clinical record evidenced a POC for certification period 08/18/23 – 10/16/23 which included an incomplete verbal order for the POC. The verbal order failed to include the name of the physician designee who relayed the order to the nurse. The clinical record failed to evidence the entire POC was signed and returned by the physician resulting in the agency failed to ensure services were being performed according to physician orders in the POC. The clinical record evidenced SN visits performed for wound care and / or urine catheter care Patient #5 on 08/18/23, 08/21/23, 08/25/23, 08/29/23, 09/01/23, 09/08/23, 09/12/23, 09/15/23, 09/19/23, and 09/22/23. A home visit observation of a SN visit by LPN 1 performing wound care for Patient #5 was conducted on 09/26/23 at 08:38 AM. During an interview on 09/28/23 at 03:10 PM, the Alternate Clinical Manager indicated they could not find a provider-signed and returned page 1 of the POC for certification period 08/18/23 – 10/16/23 in Patient #5’s clinical record.

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 notify the patient at least 15 days prior to discharge for 1 of 4 discharged patient records reviewed (Patient #13). Findings include: 1. Review of policy 2.1.004 “Patient Discharge / Transfer Process” indicated revisions to plan for patient’s discharge will be communicated to the patient, patient’s representative if any, caregiver, if any, all physicians issuing orders and patient’s primary care practitioner or health care professional who will provide care and services to patient after discharge, if any and indicated patients are notified of discharge as soon as possible prior to discharge as outlined in Notice of Non-Coverage, Expedited Determination and Reconsideration for Discharge Policy. 2. Review of policy 2.1.017 “Coordination of Care, From Admit Through Discharge” indicated coordination of care with physician / authorized practitioner at admission, throughout care, and at discharge, coordination of services is promoted through routine communication with the patient’s physician and indicated patient/caregiver will be notified regarding transfer / discharge. 3. Review of Patient #13’s clinical record evidenced a Physical Therapist (PT) Start of Care visit dated 4/22/23 and a Plan of Care (POC) for certification period 4/22/23 – 6/20/23 . The clinical record evidenced an Occupational Therapist (OT) evaluation on 4/24/23 and a Physical Therapy Assistant (PTA) visit on 4/25/23. The clinical record evidenced a discharge date of 4/26/23. The clinical record included a client coordination note on 4/27/23 reporting Patient #13 went to the Emergency Room (ER) on 4/26/23. A client coordination note titled Discharge/Transfer Summary-Agency Only dated 5/02/23 evidenced patient was transferred to Entity E on 4/26/23 for an unknown reason. The clinical record evidenced an OT Data Collection Only visit recorded on 5/02/23 indicating patient was transferred to an inpatient facility-Patient not discharged from agency. A client coordination note dated 5/08/23 indicated a missed PT visit due to patient admitted to inpatient facility. A client coordination note dated 5/11/23 indicated Patient #13 was a patient at Entity F. The clinical record evidenced a PT Resumption of Care Assessment dated 5/18/23, an OT Evaluation dated 5/19/23 and a PT Discharge-Data Collection Only visit dated 5/26/23. The clinical record for Patient #13 failed to evidence any documentation regarding discharge reason or collaboration with the patient, caregiver or physician for discharge and failed to evidence documentation that Patient #13 was notified at least 15 days prior to discharge. 4. During an interview on 9/28/23 beginning at 2:56 PM, the Administrator indicated they think Patient #13’s discharge date of 4/26/23 was a data entry error and Patient #13 was discharged from the home health agency on 5/26/23. The clinical record for Patient #13 failed to evidence discharge reason documentation and collaboration with the patient, caregiver and physician regarding the discharge.

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the licensed practical nurse (LPN) reported a wound change to the registered nurse (RN) for 1 of 4 active records reviewed of patients with wounds (Patient #5.) Findings include: 1. Review of LPN job description included but not limited to, “...Continually observes and reports the patient’s nursing needs to supervising RN...” 2. Review of Patient #5’s clinical record included a skilled nursing note for 9/12/23 which indicated Wound #3 demonstrated tunneling and noted the depth as extensive; wound notes on 9/8/23 document Wound #3 without tunneling and with a depth of partial thickness. The clinical record failed to evidence LPN 1 notified an RN of the change in Patient #5’s wound status. During an interview on 9/27/23 at 12:07 PM, LPN 1 indicated they would have updated the RN during the weekly team meeting. During an interview on 9/28/23 at 3:10 PM, the Alternate Clinical Manager reported the team meeting notes should have been documented in coordination notes or OASIS start of care. The Alternate Clinical Manager accessed the patient’s clinical record and indicated they were unable to locate team meeting notes for Patient #5 in the clinical record. 410 IAC 17-12-2(g)

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, observation, and interview, the agency failed to ensure all patients and/or caregivers received written information with the name and contact information of the home health agency’s clinical manager for 1 of 1 agency, with the potential to affect all patients of the agency. Findings include: On 9/28/2023, review of the agency admission packet failed to include the name and contact information of the clinical manager. During an interview on 09/28/2023 at 2:56 PM, the administrator indicated his/her contact information is included as the administrator but not as the clinical manager.

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the licensed practical nurse (LPN) failed to adequately assess heart and breath sounds for 1 of 2 LPNs observed during home visits (LPN 1.) Findings include: 1. Review of the LPN job description included but not limited to “Provides high quality clinical services within the scope of practice…” 2. Review of “Auscultation of the respiratory system” by Malay Sarkar, Irappa Madabhavi, Narasimhalu Niranjan, and Megha Dogra, published in 2015 and found on the National Institutes of Health website at ncbi.nlm.nih.gov, included but not limited to “Using the diaphragm [the larger, flat portion] of the stethoscope [medical instrument used to listen to heart sounds or breathing], start auscultation [listening to body sounds] anteriorly [in the front] at the apices [top of the lungs], and move downward till no breath sound is appreciated [found]. Next, listen to the back, starting at the apices and moving downward. At least one complete respiratory cycle should be heard at each site.” 3. Review of chapter 9 of Nursing Skills edited by K. Ernstmeyer and E. Christman, published in 2021, and found on the National Institutes of Health website at https://www.ncbi.nlm.nih.gov/books/NBK593199/ indicated when auscultating for heart sounds, “The apical pulse should be counted over a 60-second period… it is important to identify the S1 [‘lub’] and S2 [‘dub’] sounds, evaluate the rate and rhythm of the heart, and listen for any extra heart sounds.” 4. During a home visit observation of LPN 1 providing care for Patient #4 on 9/25/23 at 03:40 PM, observed LPN 1 auscultate Patient’s breath sounds in six locations on the front of the body and auscultated at the apical site for 3 seconds. The LPN failed to auscultate any breath sounds on Patient’s back and failed to auscultate the apical pulse for a full 60 seconds. 5. During a home visit observation of LPN 1 providing care for Patient #5 on 9/26/23 starting at 08:38 AM, observed LPN 1 auscultate Patient’s breath sounds in six locations on the front of the body and auscultated the apical site for 5 seconds. The LPN failed to auscultate the apical pulse for a full 60 seconds and failed to auscultate any breath sounds on the patient’s back. 6. During an interview on 9/27/23 at 3:30 PM, the Alternate Clinical Manager reported a complete respiratory assessment included listening to all fields of the lungs; front, back, upper, and lower. The Alternate Clinical Manager indicated respiratory assessment was to be done for each regular nurse visit. 7. During an interview on 9/29/23 at 2:18 PM, the Administrator indicated the expectation was for nursing staff to auscultate apical heart sounds for a full 60 seconds.

Rehab services supervised by PT, OT CFR(s): 484.75(c)(2) Rehabilitative therapy services are provided under the supervision of an occupational therapist or physical therapist that meets the requirements of §484.115(f) or (h), respectively. This ELEMENT is not met as evidenced by: Based on record review and interview, the Physical Therapist (PT) failed to supervise the Physical Therapy Assistant (PTA) according to agency policy for 1 of 3 active records reviewed where patient received PT services (Patient #3). Findings include: 1. Review of Policy 6.008 “Physical Therapist Assistant (PTA) Supervision” indicated the PT provides supervision for every patient receiving care by the PTA to ensure that the patient is receiving satisfactory care and the PT must reassess the earlier of every 30 days or every 15 physical therapy visits. 2. Review of Patient #3’s clinical record evidenced PTA visits were performed on 8/04/23, 8/07/23, 8/09/23, 8/15/23, 8/17/23, 8/25/23, 8/28/23, 8/31/23, 9/05/23 and 9/07/23 this certification period. Physical Therapist Supervisory visits were performed on 4/28/23 and 9/14/23. The clinical record failed to evidence PT Supervisory visits were performed at least every 30 days for the months of May, June, July and August. 3. During an interview on 9/26/23 beginning at 1:40 PM, the Administrator indicated the clinical record for Patient #3 failed to evidence PT Supervisory visits completed at least every 30 days in May, June, July and August, 2023. 410 IAC 17-14-1(b)(1)

Coordinate patient care CFR(s): 484.105(c)(2) Coordinating patient care, This ELEMENT is not met as evidenced by: Based on record review and interview, the Clinical Manager failed to ensure coordination between the home health agency and a Personal Service Agency (PSA) for 2 of 2 patients who reported during their home visit observations that they received services from a PSA (Patient #4 and 5). Findings include: 1. Review of Policy 2.1.017 “Coordination of Care, From Admit Through Discharge,” revised 9/1/23, included but not limited to “During the course of care and services: The Executive Director and Clinical Director will coordinate patient care and services...when the patient receives services from other organizations...care is coordinated to ensure patient’s needs are met...” 2. Review of Patient Care Manager job description included but not limited to “Home Health Patient Care Manager is responsible for the overall supervision and coordination of clinical services...coordinates all aspects of care with all disciplines...any other health care providers...” 3. During a home visit observation of LPN 1 providing care to Patient #4 on 9/25/23 beginning at 3:45 PM, Patient #4 reported they receive PSA services through Other Entity G that was arranged by Other Entity C. Patient #4 indicated they would like the PSA helper to come earlier. Review of Patient # 4’s clinical record failed to evidence coordination of care between home health agency and PSA agency. During an interview on 9/29/23 at 02:18 PM, the Administrator was asked for documentation of coordination of care between Other Entity G and the home health agency. The Administrator indicated they would look for the information. The documentary evidence was not provided by survey exit. 4. During a home visit observation of LPN 1, during the provision of care for Patient #5 on 9/26/23 beginning at 08:38 AM, Patient #5 reported they received PSA services intermittently from Other Entity H and were eligible for up to 13 hours of services per week. Review of Patient #5’s clinical record failed to evidence coordination of care between the home health agency and PSA agency. During an interview on 9/28/23 at 3:10 PM, the Alternate Clinical Manager was asked to provide evidence of coordination of care between the home health agency and Patient’s PSA agency. The Alternate Clinical Manager verbalized they would need to find the documentation. The documentation was not provided by survey exit. During an interview on 9/29/23 at 2:18 PM, the Administrator was asked for documentation of coordination of care between the home health agency and Other Entity H. The administrator was unable to provide the documentation.