Every finding on record at St.Mary's at Home, LLC

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102 Survey Dates: December 4-5, 2023 Active Census: 291 At this Emergency Preparedness survey, Ascension at Home was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 484.102.

This visit was for a Federal/State Complaint survey of a Deemed HHA provider. Survey Dates: December 4-5, 2023 Complaint 102614 with related deficiencies cited. 12-Month Unduplicated Skilled Admissions: 1525 This deficiency report reflects State Findings cited in accordance with 410 IAC 17. QR Completed by A2 on 12/8/2023

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 interviews, the agency failed to have a signed plan of care (POC) or a verbal POC order from the primary physician before providing services and treatments to patients for 5 of 5 patient record reviews with the potential to affect all patients on service. (Patient #1, #2, #3, #4, #5) Findings include: 7. The record review for Patient #1, certification period 09/06/2023 to 11/04/2023, revealed patient care was provided to Patient #1 without a verbal order or physician-signed order for the following days: 09/06/2023, 09/11/2023, 09/14/2023, 09/19/2023. 8. The record review for Patient #2, certification period 10/31/2023 to 12/29/2023, revealed patient care was provided to Patient #2 without a verbal order or physician-signed order for the following days: 11/02/2023, 11/03/2023, 11/04/2023, 11/07/2023, 11/08/2023, 11/09/2023, 11/10/2023, 11/13/2023, 11/15/2023, 11/17/2023, 11/20/2023, 11/24/2023. 1. A 12/01/22 document titled “Procedure: Start of Care Assessment and OASIS” was provided on 12/04/23 at 3:47 PM, by the Administrator. The document indicated, but was not limited to, “…a. Orders are required for care …”. 2. A 10/12/21 revised policy titled “Care Coordination and Plan of Care” was provided on 12/04/23 at 11:30 AM, by the Administrator. The document indicated, but was not limited to, “… Content of the Plan of Care: … 17. All patient care orders, including verbal orders, must be recorded in the plan of care …”. 3. A 09/29/23 revised policy titled “Orders” was provided on 12/04/23 at 11:30 AM, by the Administrator. The document indicated, but was not limited to, “… 1. If the order is verbal: … b. The individual receiving the order must record and sign it, date it, and enter the time received immediately and have the prescribing person sign it in accordance with the State and Federal regulations … 4. Any order found to be incomplete, illegible or unclear requires the individual to contact the prescribing /ordering physician for clarification …” 4. The record review for Patient #3, was provided by the Administrator on 12/04/23, certification period 11/13/23 to 1/11/23, revealed patient care was provided to Patient #3 without a verbal order or physician-signed order on 11/14/23. 5. The record review for Patient #4, certification period 10/14/23 to 12/12/23, revealed patient care was provided to Patient #4 without a verbal order or physician-signed order for the follow days: 10/16/23, 10/17/23, 10/18/23. 6. The record review for Patient #5, certification period 11/20/23 to 01/18/23, revealed patient care was provided to Patient #5 without a verbal order or physician-signed order for the follow days: 11/21/23, 11/22/23, 11/24/23, 11/29/23, 11/30/23. 9. During an interview on 12/04/23 at 3:00 PM, the Administrator indicated once POC has been completed it would be sent to the doctor, who has 30 days to sign and return to the agency. The Administrator indicated the agency would continue to provide services as recorded on the unsigned POC until the signed POC was returned. 10. During an interview on 12/05/23 at 11:05 AM, the Administrator indicated the staff who perform Start of Care (SOC), Resumption of Care (ROC) and Recertification visits normally call primary physician with nursing services visit frequency and general information but no details regarding what agency will be included in the POC. The Administrator indicated the staff is only documenting they have called the physician; no other information is documented in the patient’s chart. He/She indicated this should be done on all patients.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to maintain an updated individualized plan of care (POC) for 4 of 5 patient record reviews. (Patient #1, #2, #3, #4) Finding includes: 4. The record review for Patient #1, certification period 11/03/2023 to 12/29/2023, was provided by the Administrator on 12/04/23 and revealed the POC did not have interventions for urinary tract infection (UTI) or urinary system. Patient #1 was hospitalized and treated on 11/09.2023 for a UTI. A review of the 11/10/2023 RN OASIS Admission note did not evidence interventions for a UTI. 5. The record review for Patient #2, certification period 10/31/2023 to 12/29/2023, was provided by the Administrator on 12/04/23 and revealed the POC did not have interventions for urinary tract infection (UTI) or urinary system. Patient #2 had a diagnosis of a neuromuscular dysfunction of the bladder. Patient #2 was hospitalized and treated on 12/24/2023 for a UTI and catheter problems. A review of an 11/30/2023 verbal order did not evidence interventions for a UTI, nor was the POC updated to include interventions. 1. A 10/12/21 revised policy titled “Care Coordination and Plan of Care” was provided on 12/04/23 at 11:30 AM, by the Administrator. The document indicated but was not limited to, “… content of the Plan of Care: … 10. All medications and treatments; … 14. Patient – specific interventions and education; … 17. All patient care orders, including verbal orders, must be recorded in the plan of care …”. 2. The record review for Patient #3, certification period 11/13/23 to 1/11/23, was provided by the Administrator on 12/04/23 and revealed the POC did not have interventions for urinary tract infection (UTI) or urinary system, but the 60-day summary indicated Patient #3 was continuing service for UTI complications. 3. The record review for Patient #4, certification period 10/14/23 to 12/12/23, was provided by the Administrator on 12/04/23, and revealed the POC did not have interventions for peripherally inserted central catheter (PICC) (a type of long catheter that is inserted through a peripheral vein, often in the arm, into a larger vein in the body, used when intravenous treatment is required over a long period.) or weekly venipuncture lab draws. The 60-day summary indicated Patient #4 was continuing services and the home health agency would be providing PICC line care. The visit notes from 10/11/23 indicated weekly labs were obtained during the visit and will be collected every Wednesday. 6. During an interview on 12/05/23 at 8:05 AM, the Clinical Supervisor indicated she was unable to locate interventions for the urinary system or UTI for Patient #3. 7. During an interview on 12/05/23 at 8:05 AM, the Administrator indicated Patient #4’s POC did not have interventions for weekly lab draws or PICC line care for current episodes. He/she indicated the interventions for labs and PICC line care were found in the prior episode, but those interventions had not been added to the current episode POC. 8. During an interview on 12/05/23 at 11:35 AM, the Clinical Supervisor indicated all interventions being provided to patients should be on the POC.

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to communicate information on the plan of care (POC) to the primary physician, resulting in patient care being provided without a physician order for 5 of 5 patient record reviews with the potential to affect all patients on service. (Patient # 1, #2, #3, #4, #5) Findings include: The record review for Patient #1, was provided by the Administrator on 12/04/23, with a certification period of 09/06/2023 to 11/04/2023. No communication with the Primary Physician was documented in Patient #1’s chart regarding the services and treatments provided on 11/27/2023, which resulted in a hospitalization. The record review for Patient #2, was provided by the Administrator on 12/04/23, with a certification period of 10/31/2023 to 12/29/2023. No communication with the Primary Physician was documented in Patient #1’s chart regarding the services and treatments provided between 11/02/2023 to 12/01/2023. 1. A 10/12/21 revised policy titled “Care Coordination and Plan of Care” was provided on 12/04/23 at 11:30 AM, by the Administrator. The document indicated, but was not limited to, “… 1. Assure communication with all physicians or allowed practitioners involved in the plan of care …” 2. A 03/10/21 revised document titled "Job Description" was provided by the Administrator on 12/04/23, indicated job duties for License Practical Nurse included providing effective communication with physicians 3. An undated document titled "Job Description" was provided by the Administrator on 12/04/23, indicated job duties for a Home Health Registered Nurse included implementing, developing, and documenting the POC as well as providing effective communication to physicians and other health care professions. 4. The record review for Patient #3, was provided by the Administrator on 12/04/23, with a certification period of 11/13/23 to 01/11/23, no communication with the Primary Physician documented in Patient #3’s chart, regarding the services and treatments, provided on 11/14/23. 5. The record review for Patient #4, was provided by the Administrator on 12/04/23, certification period 10/14/23 to 12/12/23, no communication with the Primary Physician documented in Patient #4’s chart, regarding services and treatments, provided between 10/14/23 to 10/19/23. 6. The record review for Patient #5, was provided by the Administrator on 12/04/23, certification period 11/20/23 to 01/18/23, no communication with the Primary Physician documented in Patient #5’s chart, regarding services and treatments, provided between 11/20/23 to 12/04/23. 9. During an interview on 12/05/23 at 11:05 AM, the Administrator indicated the staff does contact the doctor on days a Start of Care (SOC), Resumption of Care (ROC), and Recertification visits are performed but would not go over services and treatment being provided on the plan of care (POC) and would not obtain an order for interventions agency would be providing to the patient.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to maintain patient information within the electronic medical record (EMR) system for 1 of 4 active records reviewed. (Patient #1) Findings include: A 11/20/2022 policy titled Complaints and Grievances was provided by the Administrator on 12/04/2023 at 11:30 AM. The policy indicated, but was not limited to, "Purpose: ... required documentation ... Equipment: 1. EMR QI Event report ... 4. The Director of Clinical Services or designee will be responsible for the following: a. Open the QI Event report in the EMR to begin documentation ... d. Retain a copy ... to the patient's clinical record as an addendum to the QI Complaint event." The clinical record for Patient #1, start of care (SOC) date 11/10/2023, certification period 11/10/2023 to 01/08/2024, was reviewed on 12/04/2023. A review of a 10/27/2023 Visit Note indicated former LPN 5 collected Patient #1's urinalysis (UA) by a clean catch method. The UA was taken to the lab. There is no evidence in the record indicating the RN or office personnel were notified that the lab needed to be followed up with the physician. During an interview on 12/04/2023 at 2:40 PM, the Administrator was asked to locate the urinalysis result in Patient #1’s EMR. The Administrator was unable to identify the urinalysis result in the EMR. A review of the QI (complaint log) report on 12/04/2023 did not provide evidence of Patient #1’s complaint. A review of the QI (infection log) information on 12/04/2023 did not list Patient #1’s urinary tract infection. At that time, the Administrator could not determine why Patient #1’s complaint, infection report, or urinalysis result were not generated in the EMR system. During an interview on 12/05/2023 at 8:50 AM, the Administrator and Clinical Supervisor stated the urinalysis result and QI (infection/complaint) reports were deleted from the electronic medical record (EMR) because the patient went to the hospital before the first visit of the new certification period starting 11/10/2023. The Administrator stated that the agency cannot submit their OASIS (data set that measures quality and outcomes) if a visit was not made after the SOC, resumption of care (ROC), or a Recertification visit for that episode but before the patient returns from the hospital. Both were unaware the documents were missing and that the EMR system deletes information. Both were unsure if other patients were affected. The Administrator stated the IT (computer technician) department was working on a solution so it does not happen again.