Every finding on record at Sky Home Health Care Inc

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR §484.102. Survey Dates: February 11, 12, 13, 14, 2025 Active Census: 7 At this Emergency Preparedness survey, Sky Home Health Care was not found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR §484.102.

Establishment of the Emergency Program (EP) CFR(s): 484.102 §403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.542, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must establish and maintain a [comprehensive] emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements: * (Unless otherwise indicated, the general use of the terms "facility" or "facilities" in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This CONDITION is not met as evidenced by: Based on record review and interview, the home health agency failed to comply with all applicable Federal, State and local emergency preparedness requirements (E0001); failed to develop an emergency plan that included strategies for addressing emergency events which were identified by the agencies Risk Assessment Analysis (E0006); failed to include the type of services the agency had the ability to provide during an emergency, how the agency planned to continue to operate during an emergency, and the delegation of authority (E0007); failed to include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation (E0009); failed to develop and implement emergency preparedness policies and procedures based on the agency-based and community-based risk assessment, utilizing an all-hazards approach (E0013); failed to include procedures to inform state and local emergency officials about homebound patients in need of evacuation from their residences during an emergency (E0019); failed to include procedures to follow up with on-duty staff and patients to determine the services needed (E0021); failed to develop a system in writing that secures and maintains availability of records in the event of an emergency (E0023); failed to develop policies and procedures that address the use of volunteers and collaboration efforts with State and Federal designated health care professionals in an emergency (E0024); failed to develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws (E0029); failed to maintain a communication plan that included names and contact information for staff, entities providing services under arrangement, physicians and volunteers (E0030); failed to maintain a written emergency preparedness plan that included up to date contact information for Federal, State, tribal, regional, and local emergency preparedness staff and other sources of assistance (E0031); failed to develop and maintain a written emergency preparedness communication plan that included a Primary and alternate means for communicating with agency staff, Federal, State, tribal, regional, and local emergency management agencies (E0032); failed to develop and maintain an emergency preparedness communication plan that included a method for sharing medical information for patients under the agency’s care with other health providers to maintain continuity of care (E0033); failed to develop a written means of providing information about the home health agency’s occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee (E0034); failed to develop and maintain an emergency preparedness training and testing program based on the emergency plan set forth (E0036); failed to ensure they provided agency specific initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role (E0037) and failed to conduct, at a minimum, a test to the emergency plan (E0039). The cumulative effect of this systemic problem resulted in the agency being out of compliance with the Condition of Participation 484.102, Establishment of the Emergency Program. Findings include: 1. On 2/13/25 at 9:44 AM, the Administrator provided an undated document titled, "Emergency Preparedness". The EP plan was reviewed on 2/14/25 at 12:10 PM. The plan failed to include a complete emergency plan for this home health agency. 2. During an interview on 2/14/25 at 12:55 PM, the Administrator relayed the home health agency had purchased the EP policy; the agency had not edited the plan to include agency specific policies and procedures in the event of an emergency and verified the EP policy failed to include the required elements in the communication plan.

This visit was for a Medicaid Initial Licensure survey of a Home Health Provider. Survey Dates: February 11, 12, 13 and 14, 2025 12-Month Unduplicated Skilled Admissions: 10 During this Medicaid Initial Licensure Survey, Sky Home Health Care was found to be out of compliance with Conditions of Participation 42 CFR §484.102 Emergency Preparedness and 42 CFR §484.60 Care planning, coordination of services, and quality of care. Based on the Condition-level deficiencies during the February 14, 2025 survey, pursuant to section 1891(a)(3)(D)(iii) of the Social Security Act, your agency is precluded from operating a home health aide training, skills competency and/or competency evaluation programs for a period of two years beginning February 14, 2025 and continuing through February 13, 2027. This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Refer to State Form for additional State Findings. Abbreviations:​ Clinical Manager (CM), Emergency Preparedness (EP), Home Health Aide (HHA), Plan of Care (POC), Registered Nurse (RN), Skilled Nurse (SN), Start of Care (SOC) QR 2/21/25

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on record review, home folder review, and interview, the home health agency failed to ensure orders were received from the physician prior to staff providing services (see G580), failed to ensure the POC was established and reviewed with the physician at SOC (see G588), failed to provide a written visit schedule to all patients (see G614), failed to provide all patients with a written copy of instructions including the clinical manager’s name and contact information (see G622). Due to the scope and severity of these systemic issues, Sky Home Health Care was found out of compliance with 42 CFR 484.60 Condition of participation: Care planning, coordination of services, and quality of care.

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 interviews, the home health agency failed to ensure orders were received from the physician prior to staff providing services for 10 of 10 patient records reviewed (Patients #1, 2, 3, 4, 5, 6, 7, 8, 9 and 10). 4. Patient #4's clinical record evidenced a SOC on 1/21/25 and included a POC for the initial certification period 1/21/25 to 3/21/25 with orders for SN visit frequencies of one visit every other week for 60 days for medication set-up, general systems assessment and medical education. The record evidenced a SN visit was performed on 1/21/25 which included medication set up for two weeks. The POC clinical summary stated, “Skilled Nurse called (Physician B’s) office and he was given the opportunity to participate in this recertification, doctor not available at this time, writer spoke with office staff who will let (Physician B) know about plan of care, writer will fax POC to office.” The record failed to include documentation of collaboration with the physician to establish the POC and SN orders prior to care performed on 1/21/25. During an interview on 2/11/25 at 4:08 PM, the Administrator relayed she did not review the POC with the physician at SOC. During an interview on 2/13/25 at 2:15 PM, Person C, an employee of Physician B, relayed Physician B’s policy was to not give verbal orders over the phone and verified Patient #4’s medical record did not include any telephone discussions with the home health agency on 1/21/25 regarding home health SOC or POC orders. During the interview on 2/13/25 at 2:15 PM, Person D, employee of Physician B, relayed they did not give verbal orders for SOC or POC on 1/21/25. During an interview on 2/13/25 at 4:50 PM, the Administrator relayed she was unable to speak with the physician during the SOC visit on 1/21/25, she filled the med planner based on the medication bottles in the home and she sent the POC via fax to the physician for signature. When asked by Surveyor about medications, the Administrator relayed she didn’t document everything that was discussed. 5. Patient #5's clinical record evidenced a SOC on 1/09/25 and included a POC for the initial certification period 1/09/25 to 3/09/25 with orders for HHA visit frequencies of two hours a day, two days a week for 60 days. The record evidenced HHA visits were performed on 1/09/25, 1/13/25, 1/16/25, 1/20/25, 1/23/25, 1/27/25 and 1/30/25. The POC clinical summary stated “Skilled Nurse called MD office and provided the opportunity for MD to participate in SOC/POC. At this time, MD was not available for phone conversation. Writer to fax POC to MD office per staff.” The record failed to include documentation of collaboration with the physician to establish the POC and HHA orders prior to care performed on 1/09/25. During an interview on 2/11/25 at 4:12 PM, the Administrator relayed the physician was unavailable to review the POC and she faxed the POC to Physician E’s office. During an interview on 2/13/25 at 3:05 PM, Person H, an employee of Physician E, relayed the medical record for Patient #5 did not include any telephone order documentation on 1/09/25 for SOC or the POC. During an interview on 2/13/25 at 4:32 PM, the Administrator relayed she put in the wrong verbal SOC date and relayed she received the Evaluation, SOC and POC orders all at once in the same phone call to the physician on 1/08/25. 6. Patient #6's clinical record evidenced a SOC on 1/14/25 and included a POC for the initial certification period 1/14/25 to 3/14/25 with orders for SN visit frequencies of one visit every other week for medication set-up. The record evidenced a SN visit was performed on 1/14/25 which included medication set up for two weeks. The POC clinical summary stated, “Skilled Nurse called (Physician B’s) office and he was given the opportunity to participate in this recertification, doctor not available at this time, writer spoke with office staff who will let (Physician B) know about plan of care, writer will fax POC to Physician B’s office.” The record failed to include documentation of collaboration with the physician to establish the POC and SN orders prior to care performed on 1/14/25. During an interview on 2/11/25 at 4:14 PM, the Administrator relayed Physician B was unavailable and she did not review the POC with the physician at SOC. During an interview on 2/13/25 at 2:21 PM, Person C, an employee of Physician B, relayed Physician B’s policy was to not give verbal orders over the phone and verified Patient #6’s medical record did not include any telephone discussions with the home health agency on 1/14/25 regarding home health SOC or POC orders. She also relayed Physician B was not aware of Patient #6 being transferred from Entity L to a new home health agency. During an interview on 2/13/25 at 4:19 PM, the Administrator relayed she was unable to speak with the physician during the SOC visit on 1/14/25, she filled the med planner based on the medication bottles in the home and she sent the POC via fax to the physician for signature. When asked by Surveyor about POC diagnosis, the Administrator relayed she didn’t document everything that was discussed. 7. Patient #7's clinical record evidenced a SOC on 1/07/25 and included a POC for the initial certification period 1/07/25 to 3/07/25 with orders for SN visit frequencies of one visit every other week for medication set-up, general systems assessment and medical education. The record evidenced a SN visit was performed on 1/07/25 which included medication set up for two weeks. The POC clinical summary stated, “Physician B given the opportunity to participate in start of care/plan of care, doctor not available at this time.” The record failed to include documentation of collaboration with the physician to establish the POC and SN orders prior to care performed on 1/07/25. During an interview on 2/11/25 at 4:17 PM, the Administrator relayed she called the physician’s office and he was not available to review the POC. She confirmed she faxed the POC to Physician B for his review. During an interview on 2/13/25 at 2:30 PM, Person C, an employee of Physician B, relayed Physician B’s policy was to not give verbal orders over the phone and verified Patient #7’s medical record did not include any telephone discussions with the home health agency on 1/07/25 regarding home health SOC or POC orders. She also relayed Physician B was not aware of Patient #7 being transferred from Entity L to a new home health agency until 1/30/25. During an interview on 2/13/25 at 4:29 PM, the Administrator relayed she was unable to speak with the physician during the SOC visit on 1/07/25, she placed the medications in the med planner based on the medication bottles in the family provided. When asked by Surveyor about POC medications, the Administrator relayed she was unsure if she documented the discussion with the physician. 8. Patient #8's clinical record evidenced a SOC on 1/14/25 and included a POC for the initial certification period 1/14/25 to 3/14/25 with orders for SN visit frequencies of one visit every other week for medication set-up. The record evidenced a SN visit was performed on 1/14/25 which included medication set up for two weeks. The POC clinical summary stated, “Skilled Nurse called (Physician B’s) office and he was given the opportunity to participate in this recertification, doctor not available at this time, writer spoke with office staff who will let (Physician B) know about plan of care, writer will fax POC to Physician B’s office.” The record failed to include documentation of collaboration with the physician to establish the POC and SN orders prior to care performed on 1/14/25. During an interview on 2/11/25 at 4:20 PM, the Administrator relayed Physician B was unavailable and she did not review the POC with the physician at SOC. During an interview on 2/13/25 at 2:38 PM, Person C, an employee of Physician B, relayed Physician B’s policy was to not give verbal orders over the phone and verified Patient #8’s medical record did not include any telephone discussions with the home health agency on 1/14/25 regarding home health SOC or POC orders. During an interview on 2/13/25 at 4:25 PM, the Administrator relayed she filled the med planner based on the medication bottles in the home and she was unsure if she documented the discussion with the physician about the medications, diagnosis and POC. 9. Patient #9's clinical record evidenced a SOC on 1/21/25 and included a POC for the initial certification period 1/21/25 to 3/21/25 with orders for SN visit frequencies of one visit every other week for 60 days for medication set-up. The record evidenced a SN visit was performed on 1/21/25 which included medication set up for two weeks. The POC clinical summary stated “Skilled Nurse called MD office and provided the opportunity for MD to participate in SOC/POC. At this time, MD was not available for phone conversation. Writer to fax POC to MD office per staff.” The record failed to include documentation of collaboration with the physician to establish the POC and SN orders prior to care performed on 1/21/25. During an interview on 2/13/25 at 2:45 PM, Person C, an employee of Physician B, relayed Physician B’s policy was to not give verbal orders over the phone and verified Patient #9’s medical record did not include any telephone orders given to the home health agency on 1/21/25. Person C confirmed the physician office medical record did reflect an order signed by Physician B on 1/22/25 to evaluate patient for home health. During the interview on 2/13/25 at 2:45 PM, Person D, an employee of Physician B, relayed they did not give verbal orders for SOC or POC on 1/21/25. During an interview on 2/13/25 at 4:42 PM, the Administrator relayed she received the Evaluation, SOC and POC orders all at once in the same phone call to the physician. When Surveyor asked where this was documented, she relayed she didn’t document the entire conversation verbatim. 10. Patient #10's clinical record evidenced a SOC on 1/09/25 and included a POC for the initial certification period 1/09/25 to 3/09/25 with orders for SN visit frequencies of one visit every other week for 60 days for med set-up. The record evidenced a SN visit was performed on 1/09/25 which included medication set up for two weeks. The POC clinical summary stated “Skilled Nurse called MD office and provided the opportunity for MD to participate in SOC/POC. At this time, MD was not available for phone conversation. Writer to fax POC to MD office per staff.” The record failed to include documentation of collaboration with the physician to establish the POC and SN orders prior to care performed on 1/09/25. During an interview on 2/13/25 at 3:10 PM, Person H, an employee of Physician E, relayed the medical record for Patient #10 did not include any telephone order documentation on 1/09/25 for SOC or the POC and verified the physician office medical record received a POC via fax from the home health agency on 1/30/25. During an interview on 2/13/25 at 4:32 PM, the Administrator relayed she called the physician office to ask if he wanted to participate in the POC. She received the Evaluation, SOC and POC orders all at once in the same phone call to the physician and she was unsure if she documented it. Findings include: 1. Patient #1’s clinical record indicated a SOC of 1/14/25 and included a POC for the initial certification period of 1/14/25 – 3/14/25, with orders for SN visit frequencies of one visit every other week for “medication set-up, general systems assessment, and medical education.” The record evidenced a SN visit was performed on 1/14/25 which included medication set up for two weeks. The POC indicated Alternate Clinical Manager called Physician B’s office on 1/14/25 and the physician was “given the opportunity to participate in” the POC. Alternate CM documented she spoke with Person D, an employee of Physician B’s office, “who will let doctor know about plan of care, writer will fax POC to [Physician B]’s office.” The record failed to evidence documentation of collaboration with the physician to establish the POC and SN orders, including current medication orders, prior to care performed on 1/14/25. During an interview on 2/13/25 at 1:35 PM, Person C and Person D, employees of Physician B’s office, relayed Physician B’s policy was to not give verbal orders over the phone. They reported the physician’s office had not given the home health agency verbal orders for Patient’s POC, including the Patient’s current medications. The physician office staff reported they thought Patient was receiving skilled nursing services from Entity L, a home health agency. During an interview on 2/18/25 beginning at 2:35 PM, Alternate Clinical Manager reported during the SOC visit, she would perform a medication reconciliation by reviewing all medication bottles in the home. Alternate Clinical Manager also reported she would review the plan of care, including current medications, diagnoses, etc, with Person D at SOC, as Physician B was unavailable. When queried where this was documented, Alternate CM reported she documented in the POC summary and coordination notes, however she did not document the entire conversation with Person D. 2. Patient #2’s clinical record indicated a SOC of 1/14/25 and included a POC for the initial certification period of 1/14/25 – 3/14/25, with orders for SN visit frequencies of one visit every other week for “medication set-up, general systems assessment, and medical education.” The record evidenced a SN visit was performed on 1/14/25 which included medication set up for two weeks. The POC indicated Alternate Clinical Manager called Physician B’s office on 1/14/25 and the physician was “given the opportunity to participate in” the POC. Alternate CM documented she spoke with Person D, an employee of Physician B’s office, “who will let doctor know about plan of care, writer will fax POC to [Physician B]’s office.” The record failed to evidence documentation of collaboration with the physician to establish the POC and SN orders, including current medication orders, prior to care performed on 1/14/25. During an interview on 2/13/25 at 2:02 PM, Person C and Person D relayed Physician B’s policy was to not give verbal orders over the phone. They reported the physician’s office had not given the home health agency verbal orders for Patient’s POC, including the Patient’s current medications. The physician office staff reported they thought Patient was receiving skilled nursing services from Entity L. During an interview on 2/18/25 beginning at 2:35 PM, Alternate Clinical Manager reported during the SOC visit, she would perform a medication reconciliation by reviewing all medication bottles in the home. Alternate Clinical Manager also reported she would review the plan of care, including current medications, diagnoses, etc, with Person D at SOC. When queried where this was documented, Alternate CM reported she documented in the POC summary and coordination notes, however she did not document the entire conversation with Person D. 3. Patient #3’s clinical record indicated a SOC of 1/07/25 and included a POC for the initial certification period of 1/07/25 – 3/07/25, with orders for SN visit frequencies of one visit every other week for “medication set-up, general systems assessment, and medical education.” The record evidenced a SN visit was performed on 1/07/25 which included medication set up for two weeks. The POC’s clinical summary indicated Alternate Clinical Manager called Physician B’s office on 1/07/25 and the office was “given the chance to discuss” the care plan. The record failed to evidence documentation of collaboration with the physician to establish the POC and SN orders, including current medication orders, prior to care performed on 1/14/25. During an interview on 2/13/25 at 2:08 PM, Person C and Person D relayed Physician B’s policy was to not give verbal orders over the phone. They reported the physician’s office had not given the home health agency verbal orders for Patient’s POC, including the Patient’s current medications. During an interview on 2/18/25 beginning at 2:35 PM, Alternate Clinical Manager reported during the SOC visit, she would perform a medication reconciliation by reviewing all medication bottles in the home. Alternate Clinical Manager also reported she would review the plan of care, including current medications, diagnoses, etc, with Person D at SOC. When queried where this was documented, Alternate CM reported she documented in the POC summary and coordination notes, however she did not document the entire conversation with Person D.

Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient's condition or needs require, but no less frequently than once every 60 days, beginning with the 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 POC was established and reviewed with the physician at SOC for 10 of 10 records reviewed (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9 and 10). Findings include: 1. The agency policy “Physician Responsibilities” indicated the plan of care for the patient will be developed in consultation with the physician and with the involvement of the patient and appropriate caregivers; documentation of physician notification is maintained in the patient’s clinical record, on either a communication form or a verbal/telephone order form and includes the date and time of all contact attempts, name of person taking the message, name of physician, action taken and/or orders obtained, reason for notification and physician’s response and directly after receiving a verbal/telephone order, the licensed staff member will complete a Physician Order form, stating the order, as received. 2. The undated agency policy “Plan of Care Requirements” indicated Physician’s orders may be required under certain program requirements and the agency has a responsibility to obtain physician’s orders prior to initiation of the care/services and to notify the physician of any changes in the patient’s condition. 6. Patient #4's clinical record evidenced a SOC on 1/21/25 and included a POC for the initial certification period 1/21/25 to 3/21/25 which included a clinical summary that stated “Skilled Nurse called Dr. Coats’s office and he was given the opportunity to participate in this recertification, doctor not available at this time, write spoke with office staff who will let Dr. Coats know about plan of care, writer will fax POC to office.” The record failed to include documentation of collaboration with the physician to establish the POC on 1/21/25. During an interview on 2/11/25 at 4:08 PM, the Administrator relayed she did not review the POC with the physician at SOC. During an interview on 2/13/25 at 2:15 PM, Person C, an employee of Physician B, relayed Physician B’s policy was to not give verbal orders over the phone and verified Patient #4’s medical record did not include any telephone discussions with the home health agency on 1/21/25 regarding home health SOC or POC orders. During the interview on 2/13/25 at 2:15 PM, Person D, employee of Physician B, relayed they did not give verbal orders for SOC or POC on 1/21/25. During an interview on 2/13/25 at 4:50 PM, the Administrator relayed she was unable to speak with the physician during the SOC visit on 1/21/25 and she sent the POC via fax to the physician for signature. 7. Patient #5's clinical record evidenced a SOC on 1/09/25 and included a POC for the initial certification period 1/09/25 to 3/09/25 which included a clinical summary that stated “Skilled Nurse called MD office and provided the opportunity for MD to participate in SOC/POC. At this time, MD was not available for phone conversation. Writer to fax POC to MD office per staff.” The record failed to include documentation of collaboration with the physician to establish the POC on 1/09/25. The POC evidenced a verbal SOC date of 1/08/25 and the clinical record evidenced the POC was not created until 1/09/25. The clinical record failed to evidence accurate SOC date documentation. During an interview on 2/11/25 at 4:12 PM, the Administrator relayed the physician was unavailable to review the POC and she faxed the POC to Physician E’s office. During an interview on 2/13/25 at 3:05 PM, Person H, an employee of Physician E, relayed the medical record for Patient #5 did not include any telephone order documentation on 1/09/25 for SOC or the POC. During an interview on 2/13/25 at 4:32 PM, the Administrator relayed she put in the wrong verbal SOC date and relayed she received the Evaluation, SOC and POC orders all at once in the same phone call to the physician on 1/08/25. 8. Patient #6's clinical record evidenced a SOC on 1/14/25 and included a POC for the initial certification period 1/14/25 to 3/14/25 which included a clinical summary that stated “Skilled Nurse called (Physician B’s) office and he was given the opportunity to participate in this recertification, doctor not available at this time, writer spoke with office staff who will let (Physician B) know about plan of care, writer will fax POC to Physician B’s office.” The record failed to include documentation of collaboration with the physician to establish the POC on 1/14/25. During an interview on 2/11/25 at 4:14 PM, the Administrator relayed she did not review the POC with the physician at SOC. During an interview on 2/13/25 at 2:21 PM, Person C, an employee of Physician B, relayed Physician B’s policy was to not give verbal orders over the phone and verified Patient #6’s medical record did not include any telephone discussions with the home health agency on 1/14/25 regarding home health SOC or POC orders. She also relayed Physician B was not aware of Patient #6 being transferred from Entity L to a new home health agency. During an interview on 2/13/25 at 4:19 PM, the Administrator relayed she didn’t document everything that was discussed with the physician during the SOC visit on 1/14/25. 9. Patient #7's clinical record evidenced a SOC on 1/07/25 and included a POC for the initial certification period 1/07/25 to 3/07/25 which included a clinical summary that stated, “Physician B given the opportunity to participate in start of care/plan of care, doctor not available at this time.” The record failed to include documentation of collaboration with the physician to establish the POC on 1/07/25. During an interview on 2/11/25 at 4:17 PM, the Administrator relayed she called the physician’s office and he was not available to review the POC. She confirmed she faxed the POC to Physician B for his review. During an interview on 2/13/25 at 2:30 PM, Person C, an employee of Physician B, relayed Physician B’s policy was to not give verbal orders over the phone and verified Patient #7’s medical record did not include any telephone discussions with the home health agency on 1/07/25 regarding home health SOC or POC orders. She also relayed Physician B was not aware of Patient #7 being transferred from Entity L to a new home health agency until 1/30/25. During an interview on 2/13/25 at 4:29 PM, the Administrator relayed she thought she documented collaboration with the physician in a communication note and she didn’t document everything that was discussed with the physician during the SOC visit on 1/07/25. 10. Patient #8's clinical record evidenced a SOC on 1/14/25 and included a POC for the initial certification period 1/14/25 to 3/14/25 which included a clinical summary that stated “Skilled Nurse called (Physician B’s) office and he was given the opportunity to participate in this recertification, doctor not available at this time, writer spoke with office staff who will let (Physician B) know about plan of care, writer will fax POC to Physician B’s office.” The record failed to include documentation of collaboration with the physician to establish the POC on 1/14/25. During an interview on 2/11/25 at 4:20 PM, the Administrator relayed Physician B was unavailable and she did not review the POC with the physician at SOC. During an interview on 2/13/25 at 2:38 PM, Person C, an employee of Physician B, relayed Physician B’s policy was to not give verbal orders over the phone and verified Patient #8’s medical record did not include any telephone discussions with the home health agency on 1/14/25 regarding home health SOC or POC orders. During an interview on 2/13/25 at 4:25 PM, the Administrator relayed she was unsure if she documented the discussion with the physician about the medications, diagnosis and POC. 11. Patient #9's clinical record evidenced a SOC on 1/21/25 and included a POC for the initial certification period 1/21/25 to 3/21/25 which included a clinical summary that stated “Skilled Nurse called MD office and provided the opportunity for MD to participate in SOC/POC. At this time, MD was not available for phone conversation. Writer to fax POC to MD office per staff.” The POC evidenced Physician B’s signature on 1/09/25, 12 days prior to SOC.” The record failed to include documentation of collaboration with the physician to establish the POC on 1/21/25. During an interview on 2/13/25 at 2:45 PM, Person C, an employee of Physician B, relayed Physician B’s policy was to not give verbal orders over the phone and verified Patient #9’s medical record did not include any telephone orders given to the home health agency on 1/21/25. Person C confirmed the physician office medical record did reflect an order signed by Physician B on 1/22/25 to evaluate patient for home health. During the interview on 2/13/25 at 2:45 PM, Person D, an employee of Physician B, relayed they did not give verbal orders for SOC or POC on 1/21/25. During an interview on 2/13/25 at 4:42 PM, the Administrator relayed she received the Evaluation, SOC and POC orders all at once in the same phone call to the physician. When Surveyor asked where this was documented, she relayed she didn’t document the entire conversation verbatim and she was unsure why the physician signed the POC on 1/09/25. She relayed the POC should have been sent back to Physician B for an accurate signature date. 12. Patient #10's clinical record evidenced a SOC on 1/09/25 and included a POC for the initial certification period 1/09/25 to 3/09/25 which included a clinical summary that stated “Skilled Nurse called MD office and provided the opportunity for MD to participate in SOC/POC. At this time, MD was not available for phone conversation. Writer to fax POC to MD office per staff.” The record failed to include documentation of collaboration with the physician to establish the POC on 1/09/25. During an interview on 2/13/25 at 3:10 PM, Person H, an employee of Physician E, relayed the medical record for Patient #10 did not include any telephone order documentation on 1/09/25 for SOC or the POC and verified the physician office medical record received a POC via fax from the home health agency on 1/30/25. During an interview on 2/13/25 at 4:32 PM, the Administrator relayed she called the physician office to ask if he wanted to participate in the POC. She received the Evaluation, SOC and POC orders all at once in the same phone call to the physician and she was unsure if she documented it. 3. Patient #1’s clinical record evidenced a SOC of 1/14/25 and included a POC for the initial certification period of 1/14/25 – 3/14/25. The POC’s clinical summary indicated Alternate Clinical Manager called Physician B’s office on 1/14/25 and the physician was “given the opportunity to participate in” the POC. Alternate CM documented she spoke with Person D, an employee of Physician B’s office, “who will let doctor know about plan of care, writer will fax POC to [Physician B]’s office.” The record failed to evidence documentation of collaboration with the physician to establish the POC. During an interview on 2/13/25 at 1:35 PM, Person C and Person D, employees of Physician B’s office, relayed Physician B’s policy was to not give verbal orders over the phone. They reported the physician’s office clinical record failed to evidence telephone discussions with the home health agency on 1/14/25 regarding home health SOC or POC orders. During an interview on 2/13/25 beginning at 2:35 PM, Alternate Clinical Manager reported the POC was reviewed with Person D after completing the SOC visit, as MD was unavailable. When queried where this was documented, Alternate CM reported she documented in the POC summary and coordination notes, however she did not document the entire conversation with Person D. 4. Patient #2’s clinical record evidenced a SOC of 1/14/25 and included a POC for the initial certification period of 1/14/25 – 3/14/25. The POC’s clinical summary indicated Alternate Clinical Manager called Physician B’s office on 1/14/25 and the physician was “given the opportunity to participate in” the POC. Alternate CM documented she spoke with Person D “who will let doctor know about plan of care, writer will fax POC to [Physician B]’s office.” The record failed to evidence documentation of collaboration with the physician to establish the POC. During an interview on 2/13/25 at 2:02 PM, Person C and Person D relayed Physician B’s policy was to not give verbal orders over the phone. They reported the physician’s office clinical record failed to evidence telephone discussions with the home health agency on 1/14/25 regarding home health SOC or POC orders. During an interview on 2/13/25 beginning at 2:35 PM, Alternate Clinical Manager reported the POC was reviewed with Person D after completing the SOC visit, as MD was unavailable. When queried where this was documented, Alternate CM reported she documented in the POC summary and coordination notes, however she did not document the entire conversation with Person D. 5. Patient #3’s clinical record evidenced a SOC of 1/07/25 and included a POC for the initial certification period of 1/07/25 – 3/07/25. The POC’s clinical summary indicated Alternate Clinical Manager called Physician B’s office on 1/07/25 and the office was “given the chance to discuss” the care plan. The record failed to evidence documentation of collaboration with the physician to establish the POC. During an interview on 2/13/25 at 3:08 PM, Person C and Person D relayed Physician B’s policy was to not give verbal orders over the phone. They reported the physician office’s clinical record failed to evidence telephone discussions with the home health agency on 1/07/25 regarding home health SOC or POC orders. During an interview on 2/13/25 beginning at 2:35 PM, Alternate Clinical Manager reported the POC was reviewed with Person D after completing the SOC visit, as MD was unavailable. When queried where this was documented, Alternate CM reported she documented in the POC summary and coordination notes, however she did not document the entire conversation with Person D.

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on home folder review during observation and interview, the home health agency failed to provide a written visit schedule to all patients for 3 of 3 home visit observations (Patients #1, 2, 3). Findings include: 1. During a home visit observation with Patient #1 on 2/11/25 beginning at 12:10 PM, Patient’s home folder was reviewed. The folder failed to evidence a written visit schedule was provided to Patient. During an interview with Patient #1 on 2/12/25 beginning at 2:38 PM, they reported the agency had not provided a written visit schedule. 2. During a home visit observation with Patient #2 on 2/11/25 beginning at 12:43 PM, Patient’s home folder was reviewed. The folder failed to evidence a written visit schedule was provided to Patient. During an interview with Patient #2 on 2/12/25 beginning at 2:54 PM, they reported the agency had not provided a written visit schedule. 3. During a home visit observation with Patient #3 on 2/11/25 beginning at 1:54 PM, Patient’s home folder was reviewed. The folder failed to evidence a written visit schedule was provided to Patient. During an interview with Patient #3 on 2/12/25 beginning at 3:26 PM, they reported the agency had not provided a written visit schedule. 4. During an interview with Administrator on 2/13/25 beginning at 2:35 PM, she reported the agency had not provided any patients with written visit schedules.

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 home folder review during home visit observation, sample home folder review, and interview, the home health agency failed to provide all patients with a written copy of instructions including the clinical manager’s name and contact information for 3 of 3 home visit observations (Patients #1, 2, 3). Findings include: 1. The review of the agency’s sample home folder failed to evidence the clinical manager’s name and contact information. 2. During a home visit observation with Patient #1 on 2/11/25 beginning at 12:10 PM, Patient's home folder was reviewed. The folder failed to evidence the clinical manager’s name and contact information was provided. 3. During a home visit observation with Patient #2 on 2/11/25 beginning at 12:43 PM, Patient's home folder was reviewed. The folder failed to evidence the clinical manager’s name and contact information was provided. 4. During a home visit observation with Patient #3 on 2/11/25 beginning at 1:54 PM, Patient's home folder was reviewed. The folder failed to evidence the clinical manager’s name and contact information was provided. 5. During an interview with Administrator on 2/13/25 beginning at 12:48 PM, she confirmed the clinical manager's name and contact information was not included in the agency's home folder.

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, policy review, and interview, the home health agency failed to ensure all staff followed standard precautions and agency infection control procedures for 2 of 3 home visit observations (Patients #2, 3). Findings include: 1. The review of agency policy 7.14 “Precautions for All Health Care Workers,” indicated after gloves were removed, staff should perform hand hygiene with “thorough hand washing or hand sanitizer.” 2. The review of agency policy “Visit Bag Policy and Procedure” indicated all equipment must be “cleaned” with disinfectant wipes prior to returning it to the bag. 3. The review of manufacturer’s instructions for Sani-Cloth disinfectant wipes, dated 2021 and obtained from www.pdihc.com, evidenced equipment disinfected with a Sani-Cloth wipe should be allowed “to remain wet for two (2) minutes” and air dry. 4. During a home visit observation with Patient #2 on 2/11/25 beginning at 12:43 PM, Alternate Clinical Manager was observed conducting a skilled nurse visit. During the visit, Alternate CM failed to perform hand hygiene immediately after removing gloves on two occasions. 5. During a home visit observation with Patient #3 on 2/11/25 beginning at 1:54 PM, Alternate Clinical Manager was observed conducting a skilled nurse visit. During the visit, Alternate CM failed to perform hand hygiene immediately after removing gloves on three occasions. At the end of the visit, Alternate CM wiped reusable vital sign equipment with Sani-Cloths, then placed the equipment immediately into her nursing bag. The nurse failed to allow the disinfectant to dry according to manufacturer’s instructions. 6. During an interview with Alternate Clinical Manager on 2/11/25 beginning at 4:36 PM, she reported hand hygiene should be performed after removing gloves. When queried if she recalled any infection control breaches during the home visits performed, Alternate CM stated, “not that I’m aware of.” Alternate CM also reported she cleaned her reusable equipment with Sani Wipes. The nurse stated she thought the dry time for the Sani Wipes was “2-3 minutes,” and she would put the equipment onto a clean section of a barrier to dry prior to returning the equipment to the bag.

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 skilled nurse failed to conduct a thorough and complete assessment for 3 of 3 home visit observations (Patient #1, 2, 3). Findings include: 1. The agency policy 5.6 “Guidelines for Assessment” indicated a “complete” pain assessment included “Characteristics of pain, such as … Intensity of pain (e.g., as measured on a standardized pain scale) … Descriptors of pain … Factors such as activities, care, or treatment that precipitate or exacerbate pain … Strategies and factors that reduce pain ….” The patient’s current problems and needs were to be continuously evaluated. 2. A review of an online nursing textbook titled “Nursing Skills,” dated 2021 and obtained from www.ncbi.nlm.nih.gov, indicated the nursing assessment of the abdomen should include listening for bowel sounds in the 4 abdominal quadrants and asking the patient the date of their last bowel movement (BM). 3. During a home visit observation with Patient #1 on 2/11/25 beginning at 12:10 PM, Alternate Clinical Manager was observed conducting a skilled nurse visit. When listening to Patient’s bowel sounds, Alternate Clinical Manager assessed the upper quadrants only, failing to listen to the lower quadrants. The nurse failed to ask Patient the date of their last BM. The review of Patient #1’s clinical record included a POC for the initial certification period of 1/14/25 – 3/14/25. The POC included an order for skilled nursing services, to include “general systems assessment.” 4. During a home visit observation with Patient #2 on 2/11/25 beginning at 12:43 PM, Alternate Clinical Manager was observed conducting a skilled nurse visit. Patient reported a headache, and the nurse failed to conduct a full pain assessment, including intensity of pain, factors that alleviate or worsen pain, etc. When listening to Patient’s bowel sounds, Alternate Clinical Manager assessed the upper quadrants only, failing to listen to the lower quadrants. The nurse also failed to ask Patient the date of their last BM. The review of Patient #2’s clinical record included a POC for the initial certification period of 1/14/25 – 3/14/25. The POC included an order for skilled nursing services, to include “general systems assessment.” 5. During a home visit observation with Patient #3 on 2/11/25 beginning at 1:54 PM, Alternate Clinical Manager was observed conducting a skilled nurse visit. Patient reported pain in left chest, knees, and feet, and swelling to the feet. Alternate Clinical Manager failed to conduct a full pain assessment, including intensity of pain, factors that alleviate or worsen pain, etc, and failed to perform a physical assessment of Patient’s edema. When listening to Patient’s bowel sounds, Alternate Clinical Manager assessed the upper quadrants only, failing to listen to the lower quadrants. The nurse failed to ask Patient the date of their last BM. The review of Patient #3’s clinical record included a POC for the initial certification period of 1/07/25 – 3/07/25. The POC included an order for skilled nursing services, to include “general systems assessment.” 6. During an interview with Alternate Clinical Manager on 2/11/25 beginning at 4:36 PM, she reported she did not assess Patient #2 and #3’s pain intensity and did not assess Patient #3’s edema. Alternate Clinical Manager reported if the patient was not reporting constipation, she would only listen to bowel sounds in the upper quadrants to ensure she could hear a “gurgle.” The nurse reported she did not assess for the date of the last BM, as the patients would self-report if their bowel movements were not regular.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the skilled nurse failed to provide all services according to the plan of care for 1 of 1 records reviewed of a patient who was hospitalized (Patient #1) and 1 of 3 home visit observations (Patient #2). Findings include: 1. The review of Patient #1’s clinical record included a POC for the initial certification period of 1/14/25 – 3/14/25, which indicated Patient was to receive one SN visits every two weeks for “medical education.” The POC evidenced nursing interventions included but were not limited to “teach methods to relieve/control symptoms of vertigo” The record failed to evidence the frequency the teaching was to be performed. The record indicated Alternate Clinical Manager conducted a SOC comprehensive assessment on 1/14/25. Patient reported dizziness during the visit. The record failed to evidence the nurse provided teaching regarding vertigo according to the POC. The record indicated Patient called EMS on 1/16/25 reporting dizziness, and was admitted to a local hospital. Alternate Clinical Manager conducted a resumption of care comprehensive assessment on 1/21/25, during which Patient reported continued dizziness. The record failed to evidence the nurse provided teaching regarding vertigo according to the POC. During an interview on 2/13/25 beginning at 2:35 PM, Alternate Clinical Manager reported she provided teaching to Patient during the SOC and resumption of care visits. The nurse was unable to find documentation of this teaching, and reported the agency’s EMR did not have a section to document teaching provided. 2. The review of Patient #2’s clinical record included a POC for the initial certification period of 1/14/25 – 3/14/25, which indicated Patient was to receive one SN visit every two weeks for medication set-up. The POC evidenced orders for the medications Gabapentin (a medication used to treat nerve pain and/or numbness), 100 milligrams (mg), two capsules twice a day, and Docusate (a medication used to treat constipation) 100 mg, one capsule twice a day. During a home visit observation with Patient #2 on 2/11/25 beginning at 12:43 PM, Alternate Clinical Manager was observed filling Patient’s medication trays for the next two weeks. The following discrepancies were evidenced when comparing Patient’s POC with the medications Alternate Clinical Manager filled in the trays: a. Gabapentin was ordered as two capsules twice a day. Alternate Clinical Manager filled the medication trays with one capsule twice a day. b. Docusate was ordered as one capsule twice a day. Alternate Clinical Manager filled the medication trays with one capsule once a day. After Clinical Manager reported she had completed Patient’s medication tray set up, an interview was conducted. She confirmed she had filled the Gabapentin and Docusate medications incorrectly and stated it was due to her “talking.”

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 a discharge summary to the physician within five days of discharge for 1 of 3 discharge records reviewed (Patient #6). Findings include: 1. The undated agency policy “Transfer & Transfer Policy” indicated a written discharge summary must be completed, and a copy sent to the physician within five (5) business days of the discharge will be maintained in the clinical record. 2. Patient #6’s clinical record evidenced a discharge date of 1/28/25. The clinical record failed to include a discharge summary that was faxed to the physician within five days of discharge. During an interview on 2/13/25 at 1:08 PM, the Administrator relayed she was unsure why she had not completed a discharge summary for Patient #6 and verified a discharge summary had not been faxed to the physician.