Every finding on record at St Vincent Home Care, LLC

Focused Emergency Preparedness Survey was conducted by the Indiana State Department of Health in accordance with 42 CFR 494.102 due to recent developments of the COVID-19 pandemic. Survey date: 9/7/2021 to 9/14/2021 Facility #: IN005289 Provider #: 157083 At this Focused Infection Control Emergency Preparedness survey, Ascension At Home was found to be in compliance with 42 CFR 484.102 Emergency Preparedness Requirements for Medicare Participating Providers and Suppliers for Home Health Agencies. Quality Review Completed on 9/29/21 by Area 3

This visit was for a Federal Recertification and State Re-Licensure Survey of a Medicare Home Health provider in conjunction with 1 complaint. Complaint #: IN29431 Unsubstantiated. Survey Date: 9/7/2021 to 9/14/2021 Facility #: IN005289 Provider #: 157083 These deficiencies reflects State Findings cited in accordance with 410 IAC 17. Quality Review Completed on 9/29/21 by Area 3

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 registered nurse or the physical therapist failed to conduct an initial assessment within 48 hours of the patient’s return home in 1 of 6 records reviewed patients within their first certification period. (Patient #3) Findings Include: 1. Review of a revised dated 12/1/17 agency policy titled,’ “Initial and Comprehensive Patient Assessments” Policy 2.017 indicated, “Purpose: To provide guidance on performing initial and comprehensive assessments for all home health care patients. Policy: Initial and comprehensive patient assessments will be performed for all home health patients in accordance with applicable laws and this policy. Procedure…Initial Assessments…Timing: Unless a physician designates a specific start of care date, an initial assessment visit must be performed on all Medicare patients within 48 hours of either (a) the referral or (b) the patient’s return home...” 2. The clinical record of patient #3 was reviewed on 9/9/21 and indicated a start of care date of 8/19/21. The record contained a document dated 8/16/21 titled, “New Patient Referral” from Entity M, containing orders for physical therapy, occupational; therapy, and speech therapy for order date of 8/16/21. The agency failed to conduct an initial assessment within 48 hours of receiving patient #3's referral. During an interview on 9/13/21 at 11:50 AM the administrator stated, “It is untimely initiation of care and must be corrected.” 410 IAC 17-14-1(a)(1)(A)

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review the agency failed to ensure the medication list included all medications taken by patients including PRN (as needed) medications and reviewed by an RN (registered nurse) in therapy only cases in 7 out of 12 active records reviewed. (Patient #3 ,4, 5, 7, 9, 10,12) Findings include: 1. Review of an agency policy revision date of 6/30/11 titled, "Drug Regimen Review” Policy 2.008 created indicated, “Purpose: To provide guidance on the requirements and components of a comprehensive drug regimen review. Policy: Drug regimen review shall be incorporated into the comprehensive assessment for all patients serviced by the agency. A list of all current medications, including OTC (over the counter), herbal remedies, vitamins, and minerals shall be initiated at the time of admission to the agency and will be updated as changes occur. The medications list shall be utilized for ongoing review to identify any potential adverse effects and drug reactions… Procedure: 2. In rehabilitation therapy only cases, the patient’s therapist will submit a list of patient medications, which the therapist collects during the comprehensive assessment, to an agency nurse for review…” 2. The clinical record of patient #3 was reviewed on 9/9/21 and indicated a start of care date of 8/19/21. The record contained a plan of care for initial certification period 8/19/21 to 10/17/21 that indicated, “Medications: Atorvastatin 80 mg (milligrams) daily oral, Bupropion HCL 100 mg 2 times daily oral, Furosemide 20 mg daily oral, Lisinopril 5 mg oral daily, Metoprolol succinate ER 25 mg daily oral, Miralax 17 grams oral powder 1 packet as needed /PRN constipation, Mirtazapine 30 mg oral daily, PNV-Omega 28 mg-1 mg-300 mg capsule oral daily, Stimulant Laxative Plus 8.6mg-50 mg oral 2 times daily, Tramadol 50 mg oral as needed/PRN…” The record contained an agency document with a review date of 8/19/21 titled, “Medication Report” reviewed and digitally signed by Employee O, the physical therapist who completed the patient’s start of care and admission. The record failed to evidence all current medication that patient #3 was currently prescribed and failed to evidence a RN (Registered Nurse) had reviewed the patient medication report for discrepancies, interactions, and drug duplications. The record contained a document dated 8/16/21 titled, “New Patient Referral” from Entity M, containing orders for home care, history and physical and active medications including but not limited to, “…Lidocaine-Prilocaine 2.5-2.5% External Cream 1 application topically to affected areas BID (twice daily) prn (as needed), Lotrisone 1-0.05% External Cream Clotrimazole with Betamethasone External Cream 1-0.05% 1 application topically to affected area 2 times per day, Novolog Flex Pen 100 unit/ml (milliliter) Subcutaneous Solution Pen Injector Insulin Aspart Subcutaneous Solution 100/ml 2 units sq (subcutaneous) for BS (blood sugar) greater than 200…” During an interview on 9/8/21 at 2:20 PM, patient #3 confirmed that the home heath aide rubs a cream on her legs and feet that helps decrease the sharp pain. When the ST (Speech Therapist) asked Person A, the home health aide, from Entity B, about patient #3’s blood sugar the caregiver indicated that Person N was monitoring patient #3’s blood sugar and did not know. Person A stated, "it was 82 day before yesterday." 3. During a home visit observation 9/8/21 at 12:25 PM, with patient #5, small oxygen cylinders was observed laying on their sides in a great room next to entry hallway. Patient #5 was in the living room sitting in a recliner. Patient #5 had a nasal cannula in her nose. The nasal cannula was connected to connection tubing down the hall way connected to a oxygen concentrator. The physical therapist , Employee D checked patient #5’s oxygen saturation using a figure probe pulse oximeter. The physical therapist asked patient #5 if the oxygen was still set at 2 liters or did the patient had to increase it. The clinical record of patient #5 was reviewed on 9/9/21 and indicated a start of care date of 8/18/21. The record contained a plan of care for the initial certification period 8/18/21 to 10/16/21 which failed to list oxygen and amount patient is to receive on the section titled, “Medications.” Review of an agency document with a review date of 8/20/21 and 8/24/21 titled, “Client Medication Report” indicated was reviewed and digitally signed by Employee D, the physical therapist of patient #5. The record failed to evidence a RN (Registered Nurse) had reviewed the patient medication report for discrepancies, interactions, and drug duplications. 4. The clinical record of patient #10 was reviewed on 9/10/21 and indicated a start of care date of 7/30/21. The record contained a plan of care for initial certification period of 7/30/21 to 9/27/21 which failed to evidence oxygen and amount patient is to receive on the section titled, “Medications.” The plan of care in the section titled “Patient’s Expressed Goals:” indicated “I want to get better and not need oxygen.” Review of an agency document dated 7/30/21 titled, “Visit Note Report” with visit type “RN OASIS Admission” indicated on page 6 in the section titled, “Indicate Safety Hazards…Oxygen in use.” Further review of the comprehensive assessment indicated on page 19 in the section titled, “Narrative…Patient is to have home oxygen…Entity O is to deliver on Monday…” Review of an agency document titled, “Client Medication Report” fails to evidence oxygen amount, route, and how often client is receiving. 5. The clinical record of patient #12 was reviewed on 9/14/21 and indicated a start of care date of 5/26/21. The record contained a plan of care for recertification period of 8/3/21 to 10/1/21 which failed to evidence ipratropium-albuterol 0.5 mg-2.5 mg/3 ml(milliliters) inhalation solution 3 ml inhaled 4 times a day as needed for wheezing or shortness of breath. Review of an agency document titled, “Client Medication Report” indicated patient medication Ipratropium 0.5 mg-Albuterol 3 mg (2.5 mg base)/ 3 ml nebulizer solution 3 ml every 6 hours inhalation. 6. During an interview on 9/13/21 at 9:59 AM, the administrator confirmed all medications including any over the counter medications and oxygen should be on the medication list and plan of care. 7. During an interview on on 9/13/21 at 10:15 AM, the administrator and clinical manager confirmed the medications for therapy only cases are reviewed by the RN (Registered Nurse). The agency document titled, " Client Medication Report " is to have the RN name and date of review as well as the therapist who completed the medication list. 8. The clinical record of patient #4 was reviewed on 09/07/21 and indicated a start of care of 04/23/21. The record contained discharged orders from discharging hospital dated 04/23/21 indicated on medication sheet the patient had a baclofen (baclofen acts in the spinal cord, and improves hyperactive reflexes and excessive muscle tone) pump (a system that consists of a pump and a catheter that brings the medication from the pump into the spinal fluid. The pump is a round metallic disc which is surgically implanted under the skin of the abdomen and requires refills every 1-6 months and the battery life of the pump lasts 5-7 years). During an interview on 09/13/21 at 2 PM with person L, family member of patient #4, indicated the patient does have a Baclofen pump and it is in patient’s abdomen. During an interview with employee E on 09/13/21 at 1 PM, stated yes, a Baclofen pump should be on the medication list. The medication list failed to evidence all medications the patient was prescribed. 9. The clinical record of patient #7 was reviewed on 09/07/21 and indicated a start of care of 09/02/21. The record contained a Client Medication Report that was reviewed, digitally signed, and dated 09/04/21 by the therapist. During an interview with employee F on 09/13/21 at 10:15 AM, stated that in therapy only cases, the client medication report needs to be reviewed by an RN (registered nurse). The agency failed to review patients’ medications per agency's policy. 10. The clinical record of patient #9 was reviewed on 09/10/21 which contained a plan of care with a start of care date of 08/18/21 for a certification period of 08/18/21 to 10/07/21. The patient’s diagnoses are but not limited to: Chronic Obstructive Pulmonary Disease, Hypertension, Type 2 Diabetes Mellitus, Dependence on Supplemental Oxygen. The medications listed on the plan of care were: Acetaminophen 325 mg tablet 2 tablets every 4 hours/prn (as needed) oral for pain, Albuterol Sulfate 2.5 mg/3 ml (0.083%) solution for nebulization 3 ml every 6 hours inhalation for difficulty breathing, Carvedilol 25 mg 1 tablet 2 times daily oral for heart rate control, Furosemide 40 mg tablet 1 tablet in the morning, 2 tablets at noon for water gain. The clinical record contained a document titled RN Oasis Admission dated 08/18/21 which indicated the patient was using oxygen, 2 liters per nasal cannula. During an interview with patient #9 on 09/16/21 at 10:09 AM, when queried if patient was on oxygen, with patient stating yes. The medication list failed to evidence all medications the patient was prescribed. 410 IAC 17-14-1(a)(1)(B)

Within 48 hours of the patient's return CFR(s): 484.55(d)(2) Within 48 hours of the patient's return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This ELEMENT is not met as evidenced by: Based on record review and interview, the registered nurse or the physical therapist failed to conduct an resumption of care assessment within 48 hours of the patient’s return home in 1 of 1 resumption of care records reviewed. (Patient #12) Findings Include: 1. Review of a revised dated 12/1/17 agency policy titled’ “Initial and Comprehensive Patient Assessments” Policy 2.017 indicated “Purpose: To provide guidance on performing initial and comprehensive assessments for all home health care patients. Policy: Initial and comprehensive patient assessments will be performed for all home health patients in accordance with applicable laws and this policy. Procedure…Initial Assessments…Timing: Unless a physician designates a specific start of care date, an initial assessment visit must be performed on all Medicare patients within 48 hours of either (a) the referral or (b) the patient’s return home...” 2. The clinical record of patient #12 was reviewed on 9/14/21and indicated at start of care date of 6/4/21 and a resumption of care date of 8/20/21. The record contained an agency document dated 8/17/21 titled, “Client Coordination Note Report” from Employee G, patient #12’s physical therapist. The document indicated, “Received text from daughter, patient came home yesterday. Please be on the lookout for ROC (Resumption of Care) orders.” Review of the clinical record further evidenced a document dated 8/17/21titled, “Patient Discharge Orders” indicating “…Heart Failure Education Required? Yes…Therapies Needed physical therapy evaluation and treatment needed, occupational evaluation and treatment needed Additional Discharge Instructions Skilled Nursing, Telehealth monitoring, and Home Health Aide orders received verbal…” The agency failed to evidence the ROC was conducted within 48 hours of patient #12's referral. During an interview on 9/14/21 at 10:22 AM administrator confirmed the agency policy to admit is 48 hours after discharge or as the physician orders.

Discharge or Transfer Summary Content CFR(s): 484.58(b)(1) Standard: Discharge or transfer summary content. The HHA must send all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care. This STANDARD is not met as evidenced by: Based on record review and interview the HHA failed to send all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility and/or health care practitioner to ensure the safe and effective transition of care in 6 out of 8 closed records. (Patient # 13, 14, 15, 16, 18, 19) 4. The clinical review of patient #13 revealed the patient was admitted on 04/30/21 with diagnoses of but not limited to Hemiplegia (paralysis of one side of the body) , disc degeneration (refers to symptoms of back or neck pain caused by wear-and-tear on a spinal disc) , and osteoarthritis (degenerative joint disease or wear and tear arthritis). The patient was to receive occupational, speech and physical therapy. A discharge-transfer summary report was written on 06/04/21 indicating the patient was discharged to home, however the occupational therapist wrote a note on 06/05/21, discharging patient, and speech therapist noted on 06/08/21, stating patient had been discharged on 06/03/21. During an interview on 09/13/21 at 9:21 AM with employee F, administrator, stated discharge summaries in the patients’ charts are written but not sent out to anyone. Employee F stated there was no coordination of care. The agency failed to provide all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility and/or health care practitioner to ensure the safe and effective transition of care. 5. The clinical record review of patient #14 revealed the patient was admitted on 04/22/21 with diagnoses of but not limited to infection, MRSA (Methicillin-resistant Staphylococcus aureus infection that is resistant to many antibiotics), and osteomyelitis (inflammation or swelling that occurs in the bone). Patient was to receive physical therapy. The clinical record evidenced a discharge-transfer summary report dated 07/19/21 with note written by physical therapist on 07/25/21. The record failed to evidence discharge summary with coordination of care. During an interview on 09/13/21 at 9:21 AM with employee F, administrator, stated discharge summaries in the patients’ charts are written but not sent out to anyone. Employee F stated there was no coordination of care. The agency failed to provide all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility and/or health care practitioner to ensure the safe and effective transition of care. 6. The clinical record review of patient #16 revealed the patient was admitted on 02/24/21 with diagnoses of but not limited to pressure ulcer of right buttock, deficiency of B group vitamins, thrombocytopenia (a condition in which you have a low blood platelet count. Platelets (thrombocytes) are colorless blood cells that help blood clot), and long-term use of opiate analgesic. Patient was to receive skilled nursing services, physical therapy, occupational therapy, and home health aide services. The clinical record revealed a discharge-transfer summary report dated 03/19/21, stating patient was discharged to hospice/home. The record failed to evidence discharge summary with coordination of care. During an interview on 09/13/21 at 9:21 AM with employee F, administrator, stated discharge summaries in the patients’ charts are written but not sent out to anyone. Employee F stated there was no coordination of care. The agency failed to provide all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility and/or health care practitioner to ensure the safe and effective transition of care. 7. The clinical record review of patient #18 revealed the patient was admitted on 07/16/21 with diagnoses of but not limited to alzheimer’s ( a type of dementia that affect memory, thinking, and behaviors), dementia (a general term for the impaired ability to remember, think or make decisions that interferes with doing everyday activities), pulmonary fibrosis (a lung disease that occurs when lung tissues becomes damaged and scarred), and Type 2 diabetes mellitus (an impairment in the way the body regulates and uses sugar (glucose) as a fuel). Patient was to receive physical therapy. The clinical record revealed a discharge summary report with no coordination of care. During an interview on 09/13/21 at 9:21 AM with employee F, administrator, stated discharge summaries in the patients’ charts are written but not sent out to anyone. Employee F stated there was no coordination of care. The agency failed to provide all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility and/or health care practitioner to ensure the safe and effective transition of care. 1. Review of an agency policy revision date of 2/24/21 titled, "Patient Transfer and Discharge," Policy 2.012 indicated, "Purpose: To Provide guidance on the process for patient transfer to a new provider and/or discharging a patient from home health services. Policy: The agency will have a documented process to ensure prompt and orderly transfer of a patient to a new service provide (e.g., acute care hospital, hospice) if the agency is unable to meet their needs. When the patient is transferred to another health facility, a copy of the record or abstract of care and services provided shall be sent to the receiving facility...Patient Discharge...5. The agency shall provide a copy of the patient's discharge summary within 5 business days of patient discharge 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 agency (if any)..." 2. The clinical record of patient #15 was reviewed on 9/14/21 and indicated a start of care date of 12/28/20. The record contained a document dated 7/28/21 titled, “Visit Note Report RN Discharge Data Collection Only-No Visit Made.” The discharge comprehensive assessment indicated, “Narrative… Patient had abdominal surgical, and midline abdominal incision did not heal. Patient has non-agency caregivers that currently provide care assistance with ADLs (Activities of Daily Living). Patient is being discharged from agency effective 7/28/21.” The clinical record contained an agency document dated 6/27/21 titled, “Discharge-Transfer Summary Report” with a fax cover sheet documenting it was faxed to patient #15’s physician. The document indicted last visit date of 6/24/21. The document further indicated, patient #15’s plan of care for certification period 6/26/21 to 8/24/21 information. The document failed to provide pertinent medical information of the patient’s current health status at discharge to the receiving provider.. During an interview on 9/13/21 at 9:21AM, the administrator confirmed there was no discharge summary. The administrator verified in the electronic record there was no order for discharge or discharge summary detailing why patient was discharge. 3. The clinical record of patient #19 was reviewed on 9/10/21 and indicated a start of care date of 7/12/21. The record contained a document dated 8/15/21 titled, “Visit Note Report RN Transfer Data Collection Only-No Visit Made.” The transfer comprehensive assessment indicated, “Narrative…SN (Skilled Nurse) sent patient to ER (Emergency Room) on 8/18/21. Patient was admitted and to undergo right below the knee amputation 8/19/21.” The clinical record contained an agency document dated 8/19/2 titled, “Order” indicated, “Order Type: Hospital Hold. Patient has been admitted due to surgery to amputate right leg below the knee.” The clinical record contained an agency document dated 9/9/21 titled, “Discharge-Transfer Summary Report” with the fax confirmation to patient #19’s physician. The document further indicated, patient #19’s plan of care for certification period 7/12/21 to 9/9/21 information. The document failed to provide pertinent medical information of the patient’s current health status at the time of transfer to the receiving provider. The clinical record failed to evidence any records of pertinent information regarding patient #19 was sent to the receiving facility upon the patient’s transfer. During an interview on 9/13/21at 9:56 AM, the administrator and clinical manager confirmed no transfer information was provided the receiving facility. The administrator stated, “They did not choose the right note type to add the narrative from the visit note to the summaries.”

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 agency failed to ensure personal care services and therapists were provided according to the written plan of care for 2 of 12 complete records reviewed. (Patients #6 and 9) 1. Review of an agency policy # 2.003 titled “Scope of Services and Clinical Supervision” created 11/01/11 with last revision dated 12/01/17, revealed “…the services provided will be in accordance with a plan of care ordered by the patient’s physician”. 2. Review of the plan of care for patient #6 on 09/10/21, with a start of care 08/19/21 that evidenced a certification period of 08/19/21 to 10/17/21 revealed orders for SN: 1 x 1 WK; HHA (home health aide) services effective 08/22/21: 3 X WK for 8 WK; PT (physical therapy): 2 x WK x 1 WK, 3 x WK x 3 WK, 2 x WK x 5 WK; and OT (occupational therapy): 1 x WK x 1 WK. The clinical record reveled HHA visits were made on 08/24/21, 08/26/21, 08/30/21, 09/01/21, 09/03/21, and 09/10/21. The agency failed to ensure home health aide visits were provided 3 times a week as ordered on the plan of care. The clinical record revealed the SN occurred on 08/25/21. The agency failed to provide SN services 1 x 1 WK, as ordered on the plan of care. The clinical record revealed a PT visit on 08/19/21. The agency failed to provide PT 2 X WK x 1 WK, as ordered on the plan of care. The clinical record revealed a OT visit on 08/24/21. The agency failed to provide OT 1 X WK x 1 WK as ordered on the plan of care. An interview was conducted with Employee I on 09/10/21 at 1 pm, when queried if there were any other visit records available, Employee I stated no. 3. The review of the plan of care for patient #9 on 09/10/21, with a start of care 08/18/21 that evidenced a certification period of 08/18/21 to 10/16/21 revealed orders for SN: 2 x WK x 1 WK, 3 x WK x 2 WK, 2 x WK x 5 WK, 1 x WK x 1 WK and PT 1 x WK x 1 WK, The clinical record revealed SN visits were made on 08/18/21, 08/20/21, missed visits the week of 08/23/21 through 08/29/21, 08/31/21, 09/03/21, and 09/07/21. The agency failed to provide SN visits as ordered on the plan of care. An interview was conducted with Employee I on 09/10/21 at 1 pm, when queried if there were any other visit records available, Employee I stated no. 410 IAC 17-13-1(a)

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 agency failed to ensure the individualized plan of care was supported by the comprehensive assessment and included all interventions and measurable goals identified by the agency and patient, all durable medical equipment (DME) and supplies, advance directives, medications, allergies, all treatment orders, diet, safety measures, diagnoses being supported by the comprehensive assessment, and call parameters individualized to the patients cardiopulmonary, endocrine, pain, and nutritional assessments, include nutritional requirements, indications for use and locations of topical medications, infection control precautions, patient-specific education and training provided, and the acceptance of orders that may be received/accepted by an outside physician, in 12 of 12 patient records reviewed. (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11,12). Findings include: 10. During a home visit on 09/08/21 at 10 AM with patient #4, the patient observed had a wheelchair with pressure reduction cushion, specialty hospital bed and pressure reduction mattress, hospital bedside table, electric hoyer lift to lift and transfer patient from bed to bathroom for personal needs, tub bench for showers, elevated toilet seat, wound care supplies, bowel incontinence supplies, suprapubic catheter supplies, ointments, and normal saline. The clinical record review of patient #4 was done on 09/10/21 indicated a start of care date of 04/23/21. The record contained a plan of care for a recertification period of 08/22/21 ton10/20/21. Patient’s diagnoses is but not limited to: Disruption of Internal Operation (Surgical Wound), Encounter for attention to Cystostomy (surgical creation of an opening into the bladder; creating a opening for bladder drainage), Multiple Sclerosis (a disease that affects the central nervous system), quadriplegia (paralysis of all four limbs), and Type 2 Diabetes (a condition results from insufficient production of insulin that causes high blood sugars). The clinical record contained discharged orders from entity R, dated 04/21/21, revealed the patient had a Baclofen pump (a system that consists of a pump and a catheter that brings the medication from the pump into the spinal fluid). The pump is a round metallic disc which is surgically implanted under the skin of the abdomen and requires refills every 1-6 months and the battery life of the pump lasts 5-7 years. Baclofen is used for muscle spasms that are caused by certain conditions, ex: Multiple Sclerosis. The DME supplies listed on the plan of care were: "Bedside utensils, Betadine-like products, creams/ointments, adaptive living aides, glucometer, hospital bed, incentive spirometer, podis boot, trapeze, powered wheelchair, gauzes/dressings, gloves, incontinent care disposables, specialty dressings, syringes/needles/infusion, tape, and urologicals". During a phone interview on 09/13/21 at 1 pm with patient’s family member L, confirming patient does have a baclofen pump. The plan of care failed to specifically identify the supplies used for treatment, the pain pump and the medication in the pain pump required for the patient. 11. During a home visit on 09/08/21 at 2 PM, it was observed that patient #6 had 2 rolling walkers, 1 with a seat and 1 without a seat. The clinical record review of patient #6 was completed on 09/10/21. The record contained a plan of care with a start of care date of 08/19/21. The patient’s diagnosis includes but not limited to: Type 2 Diabetes Mellitus, Hypertension (high blood pressure), Malignant neoplasm of left breast (breast cancer), Chronic pain, personal history of malignant neoplasm of brain (brain cancer), dependence on wheelchair, and history of falling. DME supplies listed on the plan of care were: "None". The clinical record contained a initial comprehensive assessment dated 08/19/21. The documented stated the patient checks her blood sugars three times a day, patient is incontinent, and uses a bedside commode. Under Equipment/Supplies the following items are listed: Multi-Wheeled Walker, rolling Walker, wheelchair, bed side commode, and shower chair. The plan of care failed to identify all DME supplies that was observed and in the comprehensive assessment.. 12. During a home visit on 09/08/21 at 3:40 PM, the patient was observed to have a grabber device(an aid so the patient could pick items up without bending over). The patient was also observed raising the back of their shirt up so the therapist could evaluate incision site. The clinical record of patient #7 was reviewed on 09/10/21 which contained a plan of care with a start of care date of 09/02/21 for a certification period of 09/02/21 to 10/31/21. The patient’s diagnoses are but not limited to: Other forms of Scoliosis (curvature of the spine), Encounter for other orthopedic aftercare (spinal surgery), Low Back Pain, Difficulty in walking. The plan of care indicated DME supplies were "walker-rolling; gauzes/dressings". A document in the clinical record of patient #7 identified as the initial comprehensive assessment dated 09/02/21 indicated the patient takes a daily blood sugar, has a back brace, with other DME supplies listed were a cane, multi-wheeled walker, bed rail, shower chair, and handheld shower. The plan of care failed to identify all the specific supplies for treatment and all DME supplies required for the patient. 13. The clinical record of patient #8 was reviewed on 09/10/21 which contained a plan of care with a start of care date of 08/09/21 for a certification period of 08/09/21 to 10/07/21. The patient’s diagnoses are but not limited to: Parkinson’s Disease (a chronic and progressive disorder that initially causes tremors in one hand, stiffness and slowing of movement), Fibromyalgia (A disorder that affects muscle and soft tissue characterized by chronic muscle pain, tenderness, fatigue, and sleep disturbances), Lupus (an autoimmune disease, with systemic manifestations including skin rash, erosion of joints or even kidney failure), and Chronic pain. The plan of care indicated the DME supply was a wheelchair. A document in the clinical record of patient #8 identified as the initial comprehensive assessment dated 08/09/21, indicated DME supplies as multi-wheeled walker, elevated toilet seat, and a shower chair. The plan of care failed to identify all DME supplies required for the patient. 14. The clinical record of patient #9 was reviewed on 09/10/21 which contained a plan of care with a start of care date of 08/18/21 for a certification period of 08/18/21 to 10/07/21. The patient’s diagnoses are but not limited to: Chronic Obstructive Pulmonary Disease (a disease that is characterized by persistent respiratory symptoms like progressive breathlessness and cough), Hypertension (high blood pressure), Type 2 Diabetes Mellitus, and Dependence on Supplemental Oxygen. The plan of care indicated DME supplies as Elevated toilet seat, cane, commode, glucometer, and walker. The medications listed on the plan of care were: Acetaminophen 325 mg tablet 2 tablets every 4 hours/prn (as needed) oral for pain, Albuterol Sulfate 2.5 mg/3 ml (0.083%) solution for nebulization 3 ml every 6 hours inhalation for difficulty breathing, Carvedilol 25 mg 1 tablet 2 times daily oral for heart rate control, Furosemide 40 mg tablet 1 tablet in the morning, 2 tablets at noon for water gain. A document in the clinical record of patient #9 identified as the initial comprehensive assessment dated 08/18/21, indicated the DME supplies as a cane, standard walker, elevated toilet seat, and oxygen. The plan of care failed to identify all DME supplies and medications required for the patient. 410 IAC 17-13-1(a)(1)(C)(ii, viii, ix, xiii) 1. Review of an agency policy revision date of 8/30/19 titled, "Plan of Care, Certification and Recertification" Policy 2.02 indicated, “Purpose, to provide guidance for the establishment of the physician plan of care, and for Medicare patients, the initial certification and subsequent recertification that the patient is eligible for the Medicare home health benefit. Procedure: …c. The types of services, supplies, and equipment required; d. Frequency and duration of visits to be made; …g. All medications and treatments; …” 2. During a home visit on 9/8/21 from 3:05 PM to 4:55 PM, patient #1 was observed sitting on blue barriers that were place in the seat of a recliner. Patient #1 was wearing a depend and t-shirt with bare feet on a blue barrier. A nebulizer, and air compression boots was observed sitting next to patient’s recliner. The clinical record of patient #1 was reviewed on 9/9/21 and indicated a start of care date of 9/1/20. The record contained a plan of care for the recertification period of 8/27/21 to 10/25/21 that indicated diagnoses, but not limited to, pressure ulcer of right buttocks, stage 2, pressure ulcer of other site stage 2, lymphedema, chronic obstructive pulmonary disease, venous insufficiency peripheral, morbid obesity, and unspecified urinary incontinence. The plan of care indicated Nutritional Requirements, "no diet specified." The plan of care further indicated DME and Supplies listed: Creams/Ointments, adaptive living aides, quad cane, scooter, shower and tub equipment, rolling walker, gauzes, dressings, specialty dressings, and urologicals. The POC (Plan of Care) failed to evidence a patient specific diet order, all specific DME that the patient requires, and specific wound care orders. 3. During a home visit on 9/8/21at 10:35 AM to 12:05PM, patient #2 was observed with legs contracted and arms in a fetal position in a large, motorized bed in the middle of the living area. The room was cluttered with stacks of boxes with multiple items surrounding the outer area of the room. The patient had multiple zip lock bags with different items in them, cups, paper towels, pill holders, ash tray, cigarettes and lighter, and towels surrounding patient in the bed. Observed multiple size pillows used to prop patient in the bed. At the end of the bed was 5 fans blowing towards the bed at different speeds. The patient was laying on chucks and had a condom catheter with catheter tube draining dark yellow urine into leading to a catheter bag sitting in a basin. The clinical record of patient #2 was reviewed on 9/9/21 and indicated a start of care date of 8/19/21. The record contained a plan of care for initial certification period 8/19/21 to 10/17/21 that indicated diagnoses, but not limited to, acute transverse myelitis in demyelinating disease, pressure ulcer of right lower back, stage 2, pressure ulcer of other site, stage 2, vitamin B 12 deficiency anemia due to intrinsic factor deficiency, essential hypertension, bed confinement status, and nicotine dependence. The plan of care indicated DME as the following: "creams/ointments, cushions/flotation air, adaptive living aides, gauzes/dressings, personal care, pharmaceutical /over the counter drugs, specialty dressings, and urologicals." The plan of care further indicated Advance directives "none." The plan of care listed safety measures as follows, adequate lighting, emergency plan, and med precautions. The plan of care failed to evidence specific DME that the patient requires for wound care, Vitamin B 12 syringes, needles, and condom catheters, incontinence supplies, and motorized bed. The plan of care failed to evidence safety measures with smoking in bed, confined to bed, and remove clutter. The clinical record contained a document titled “Patient Information Report” indicated patient has a Living Will with contents of comfort measures only. During an interview on 9/8/21 at 12:05 PM with the clinical manager confirmed there is a safety issue. 4. During a home visit 9/8/21 at 1:46 PM to 2:45 PM, patient #3 was observed at the kitchen table sitting in a wheelchair playing solitaire with a caregiver. Employee J, the speech therapist, asked the caregiver about patient #3’s blood sugars. The caregiver indicated patient #3’s other caregiver checks the patient’s blood sugar. Person A, the home health aide from Entity B, stated, “It was 82 the day before yesterday.” The clinical record of patient #3 was reviewed on 9/9/21 and indicated a start of care date of 8/19/21. The record contained a plan of care for the initial certification period of 8/19/21 to 10/17/21 that indicated diagnoses, but not limited to, other speech/language deficits following cerebral infarction, hemiplegia following cerebral infarction affecting left non dominant side, type 2 diabetes mellitus without complications, and essential hypertension. The plan of care indicated DME and supplies as "none." The record contained an agency document dated 8/19/21 titled, “Visit Note PT (Physical Therapy) OASIS Admission. The comprehensive assessment indicated the patient #3 had DME available listed as the following: multi-wheeled walker, wheelchair, and shower chair. The plan of care failed to evidence specific DME that the patient requires, glucometer, glucometer strips, lancets, walker, wheelchair, and shower chair. 5. During a home visit on 9/8/21 at 12:25 PM, small oxygen cylinders was observed laying on their sides in a great room next to entry hallway. Further observation was of a running oxygen concentrator in the hallway which had tubing connected. The tubing led to living area and was connected to a nasal cannula that patient #5 had in her nose. The physical therapist asked patient #5 if the oxygen was still set at 2 liters and if patient had to increase it at all. The physical therapist further asked regarding patient #5’s blood sugars to the caregiver. The clinical record of patient #5 was reviewed on 9/9/21 and indicated a start of care date of 8/18/21. The record contained a plan of care for the initial certification period of 8/18/21 to 10/16/21 that indicated diagnoses, but not limited to, chronic obstructive pulmonary disease with acute lower respiratory infection, bronchopneumonia unspecified organism, chronic respiratory failure with hypoxia, heart failure, type 3 diabetes mellitus with diabetic chronic kidney disease, personal history of COVID-19, and unspecified atrial fibrillation. The plan of care listed DME and supplies as the following: "elevated toilet seat, commode, hospital bed, oxygen supplies, rails and grab bars, vital sign equipment, rolling walker, and wheelchair." The plan of care failed to evidence specific DME that the patient requires, glucometer, glucometer strips, lancets, nasal cannulas, oxygen concentrator, portable oxygen tank and cylinders. The plan of care failed to list oxygen, liter flow, continuous or intermittent and route, in the medication section. The record contained an agency document dated 8/20/21 titled, “Client Coordination Note Report” that indicated patient #5 is oxygen dependent and uses 2 liters of oxygen continuously. During an interview on 9/13/21 at 9:59 AM, the administrator confirmed that oxygen should be on the list of medication and listed on DME. 6. The clinical record of patient #10 was reviewed on 9/10/21 and indicated a start of care date of 7/30/21. The record contained a plan of care for the initial certification period of 7/30/21 to 9/27/21 that indicated diagnoses, but not limited to, hypertensive heart disease with heart failure, heart failure, chronic obstructive pulmonary disease, bipolar disorder, dependence on supplemental oxygen, and chronic pain. The plan of care indicated DME and supplies as the following: oxygen supplies and rolling walker. The plan of care failed to evidence specific DME that the patient requires, oxygen concentrator, tubing, and nasal cannulas. The plan of care failed to list oxygen amount, frequency, and route in the medication list. During a phone interview on 9/10/21 at 2:27 PM, patient #10 confirmed she was using oxygen from Entity P. During a phone interview on 9/10/21 at 2:36 PM, Person K, the medical assistant, for Entity J confirmed patient #10 had orders for oxygen. 7. The clinical record of patient #11 was reviewed on 9/14/21 and indicated a start of care date of 7/113/21. The record contained a plan of care for the initial certification period 7/13/21 to 9/10/21 that indicated the diagnoses of, but not limited to, malignant neoplasm of bladder, major depressive disorder, macular degeneration, other artificial openings of urinary tract status, and long term (current) use of oral hypoglycemic drugs. The plan of care indicated DME and supplies as the following: elevated toilet seat, hospital bed, rails and grab bars, shower/tub equipment, walker, and wheelchair. The plan of care failed to evidence specific DME that the patient requires urostomy type, size, and supplies needed. The record contained an agency document dated 7/13/21 titled, “Visit Note Report PT OASIS Admission.” The comprehensive assessment indicated patient #11 has a urostomy. 8. The clinical record of patient #12 was reviewed on 9/14/21 and indicated a start of care date of 6/4/21, with a resumption of care date of 8/20/21. The record contained a plan of care for the recertification period of 8/3/21 to 10/1/21 that indicated the diagnoses of, but not limited to, chronic diastolic (congestive) heart failure, chronic kidney disease, stage 4, chronic obstructive pulmonary disease, paroxysmal atrial fibrillation, left bundle-branch block, sick sinus syndrome, and presence of cardiac pacemaker. The plan of care indicated the following: Advance Directives, “None,” Allergies, “NKA (No Known Allergies),” DME and Supplies, “rails/grab bars, rolling walker, wheelchair, and powered wheelchair.” The record contained an agency document dated 8/20/21 titled, “Visit Note Report RN Resumption of Care.” The comprehensive assessment indicated patient #12 had a shower chair, rolling walker. The record contained an Entity R document dated 8/17/21 titled, “Entity R Discharge Report” indicating patient #12 has severe allergies to Azithromycin, Levaquin, and Keflex. The document further indicated patient #12 has advance directives. The plan of care failed to evidence specific DME, allergies, and advance directives specific to the patient. 9. During an interview on 9/13/21 at 9:59 AM, the administrator confirmed DME is anything that is specific to the patient’s care needs.

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on observation, record review and interview, the agency failed to ensure coordination of care with outside providers was documented to effectively coordinate care to support the care planning objectives of the patient for 3 of 12 patients with outside service providers. (Patient #1, 3, 4) Findings include: 5. During a home visit on 09/08/21 at 10 AM with patient #4, it was observed the patient was receiving personal care from another agency, the personal care attendant assisted the nurse with repositioning patient. The clinical record review of patient #4 was reviewed on 09/10/21 which indicated a start of care date of 04/23/21. The record contained a plan of care for a recertification period of 08/22/21 to 10/20/21. Patient’s diagnosis is but not limited to: Disruption of Internal Operation (Surgical Wound), Encounter for attention to Cystostomy (surgical creation of an opening into the bladder; creating a stoma for bladder drainage), Multiple Sclerosis, quadriplegia, Type 2 Diabetes. The patient did not have orders for personal care nor were there coordination notes in record to indicate patient was receiving services from another agencies. During a phone interview on 09/13/21 at 1 PM with person L, family member to patient #4 confirmed the patient does have a baclofen pump but couldn’t remember name of company that oversees the pump. During a phone interview on 09/10/21 at 12:46 PM with employee E, when queried about coordination of care, employee E stated I usually talk to the aide in the home of patient #4. When queried about what company was providing the personal care services, they stated they didn’t know for sure, but thought entity I, but did know the case manager’s name and number. When queried about patient’s Baclofen pump, employee E didn’t know about the pump. During a phone interview 09/10/21 at 1 PM with person H with entity I, when queried regarding coordination of care, person H stated, "I never hear from employee E". The agency failed to ensure coordination of care with outside providers was documented to effectively coordinate care to support the care planning of the patient. 410 IAC 17-14-1(a)(1)(F) 1. Review of an agency policy revision date of 11/19 titled, "Coordination of Patient Care," Policy 2.005 indicated, "Purpose: To provide guidance on the importance of interdisciplinary care coordination to assure appropriate continuity of care and services from admission to discharge…Procedure:..2.c.Integrate services, whether provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety, treatment effectiveness and the coordination of care provided by all disciplines." 2. The clinical record of patient #1 was reviewed on 9/9/21 and indicated a start of care date of 9/1/20. The record contained a plan of care for the recertification period of 8/27/21 to 10/25/21 that indicated diagnoses, but not limited to, pressure ulcer of right buttocks, stage 2, pressure ulcer of other site stage 2, lymphedema, chronic obstructive pulmonary disease, venous insufficiency peripheral, morbid obesity, and unspecified urinary incontinence. The plan of care further indicated, “Frequency/Duration of Visits” skilled nursing for 1 time a week for 1 week, 3 times a week for 8 weeks, and 1 time a week for 1 week. The clinical record failed to evidence any coordination of care notes with Entity C, that was providing home health aide services for patient #1. During a home visit on 9/8/21 at 4:05 PM patient #1 confirmed she had a home health aide from Entity C. Employee H, RN (Registered Nurse) for patient #1 inquired how the new home health aide was doing. Employee H confirmed patient had been without an aide form the other agency for 2 weeks. Patient #1 confirmed home health aide was providing hand on care with showers. 3. The clinical record of patient #3 was reviewed on 9/9/21 and indicated a start of care date of 8/19/21. The record contained a plan of care for the initial certification period of 8/19/21 to 10/17/21 that indicated diagnoses, but not limited to, other speech/language deficits following cerebral infarction, hemiplegia following cerebral infarction affecting left non dominant side, type 2 diabetes mellitus without complications, and essential hypertension. The plan of care further indicated, “Frequency/Duration of Visits:” PT(Physical Therapy) 1 time a week for 1 week, 2 times a week for 6 weeks, and 1 time a week for 2 weeks., OT (Occupational Therapy) 3 times a week for 1 week, 2 times a week for 3 weeks, and ST (Speech Therapy) 1 time a week for 1 week, 2 times a week for 3 weeks, and 1 time a week for 4 weeks. The clinical record failed to evidence any coordination of care notes with Entity B, that was providing home health aide services for patient #1. During a phone interview on 9/9/21 at 2:09 PM Person E, the clinical manager, for Entity B, confirmed patient #3 was receiving home health aide services 7:00 AM to 3:00 PM attendant care services form 3:00 PM to 8:00 PM daily. Person E further confirmed that patient#3 has no documentation in the chart of notification of another agency being in patient #3’s home. Person E with have patient #3’s nurse call me. During a phone interview on 9/10/21 at 8:15 AM Person F, a nurse case manager with Entity B, confirmed no one coordinated care and made Person F aware person #3 was receiving therapy services again. Person F confirmed that patient #3 was receiving daily home health aide services and attendant care services in the evening. 4. During an interview on 9/10/21 at 2:11 PM, the clinical manager confirmed there was no client coordination care notes that coordinated care with the other agency that was providing care to the patients in their clinical records.

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, record review, and interview, the RNs (Registered Nurses) failed to ensure they practiced proper hand hygiene while providing wound care to a patient for 2 of 3 patient's observed receiving wound care services by the agency. (Patient #1, 2) Findings Include: 1. Review of a revised policy dated 7/2019 titled, “Infection Prevention and Control” Policy no. 2.022 indicated, “Purpose: To provide guidance on the agency’s infection prevention and control plan, personal safety, and security guidelines and OASHA mandated regulations in the workplace…Procedure: Infection Control:…(a)Personal hygiene including adherence to standard blood and body precautions: handwashing techniques, and appropriate use and disposal of personal protective equipment…” 2. Centers for Disease Control last updated January 2021. When to Perform Hand Hygiene. Retrieved from cdc.gov/hand hygiene/providers/index.html indicated "Use an Alcohol-Based Hand Sanitizer: Immediately before touching a patient. Before performing an aseptic task [e.g., placing an indwelling device] or handling invasive medical devices. Before moving from work on a soiled body site to a clean body site on the same patient. After touching a patient or the patient's immediate environment. After contact with blood, body fluids or contaminated surfaces. Immediately after glove removal. Wash with Soap and Water: When hands are visibly soiled...After known or suspected exposure to spores....When using alcohol-based hand sanitizer: Put product on hands and rub hands together. Cover all surfaces until hands feel dry. This should take around 20 seconds...The CDC Guideline for Hand Hygiene in Healthcare Settings recommends: When cleaning your hands with soap and water, wet your hands first with water, apply the amount of product...and rub your hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse your hands with water and use disposable towels to dry. Use towel to turn off the faucet...Other entities have recommended that cleaning your hands with soap and water should take around 20 seconds. Either time is acceptable. The focus should be on cleaning your hands at the right time...When and How to Wear Gloves: Wear gloves...when...contact with blood or other potentially infectious materials, mucous membranes, non-intact skin, potentially contaminated skin or contaminated equipment could occur...Change gloves and perform hand hygiene during patient care, if gloves become damaged, gloves become visibly soiled...moving from work on a soiled body site to a clean body site on the same patient or in another..." 3. During a home visit at patient #1’s 9/8/21 from 3:05 PM to 4:55 PM, Employee H, a registered nurse (RN), was observed providing wound care to the patient. Employee H performed hand hygiene donned gloves and sat on the stool in front of the patient. Employee H picked up her tablet off the floor and then after sat it back down on the floor. Employee H removed bilateral lower extremity dressings discarded dressings in the trash and washed patient’s bilateral lower extremities with wash clothes and soap and water without hand hygiene or changed gloves between dressing removal and washing the lower extremities. Employee H performed hand hygiene and donned gloves after washing the patient’s lower extremities then picked up the tablet off the floor read the orders for wound care then placed the tablet on the floor. Employee H went to the bathroom came back with a tube of lidocaine and an open package of cotton tip applicators. Employee H removed a band aide from patient #1’s left upper leg and discarding the band aide in the trash. Employ H removed the cap off the tube of lidocaine and applied gel to the cotton tip applicator then applied the tip to open areas on patient’s left lower extremity wounds without hand hygiene or changed gloves after removing the soiled band aide. Employee H performed hand hygiene and donned gloves, opened two abdominal pads packets and placed the dressings on the blue barrier. Employee H picked up the tablet read the order to the surveyor and clinical manager sat the tablet down on the floor. Employee H placed the abdominal pads on the patient’s right lower extremity then reach for the gauze roll. The abdominal pads fell on the blue chuck on the floor that the patient keeps her feet on. Employee H placed the abdominal pads back on the patient’s extremity then wrapped gauze around the right extremity without obtaining new abdominal pads that fell on a contaminated area. The gauze roll fell on the floor and rolled across the room. Employee H picked the gauze roll off the floor, placed it on the blue barrier and asked the clinical manager to obtain a new gauze roll. Employee H picked up the tablet off the floor after wrapping patient leg and stated, “I need to verify orders again, they were just changed this week.” Employee H place the tablet on the floor obtained scissors out of the equipment bag cleansed the scissors with a wipe without performing hand hygiene before reaching in the equipment bag. During an interview on 9/8/21 at 4:55 PM, when leaving patient #1’s apartment building, the clinical manager stated, “We have infection control issues.” 4. During a home visit at patient #2’s on 9/8/21 from 10:25 AM to12:05 PM, Employee A, a registered nurse (RN), was observed providing wound care to the patient. The home health aide and the RN performed hand hygiene and donned gloves. Employee A took the patient’s vital signs, heart auscultation and anterior lung sounds, completed a wrist blood pressure reading, pulse oximeter to obtain pulse and oxygen saturation. Home health aide turned patient to the left show Employee A dressings on right side midline shoulder area. Employee A removed the dressing without performing hand hygiene and donning gloves. Employee A placed the old dressings removed on the end table next to the bed and failed to discard the soiled dressings in the trash. Employee A removed wrapper from 4x4guaze placing the wrappers on the end table and cleansed the superficial area with wound cleanser applied a new border adhesive foam dressing. Employee A placed the used gauze on the end table and discarded gloves placing them on the end table and wrapper from new dressing failing to throw soiled dressings and gloves in the trash. Home health aide put a blue barrier at the end of the bed with a fleets enema and glycerin suppository on the barrier. Employee A performed hand hygiene and donned new gloves and removed old soiled adhesive foam dressing and cleansed area with wound cleanser and 4x4 gauze without performing hand hygiene or changed gloves between dressing removal and cleansing wound. Employee A performed hand hygiene and donned gloves then applied purcol dressing and 4x4 gauze and adhesive foam dressing. Employee A removed right buttock dressing patient had soiled self on pad and dressing discarding the soiled dressing in the trash. Employee A cleansed area with wipes, the cleansed area with wound cleanser spraying area, and wiping with 4x4 gauze, applied prizma dressing and adhesive border foam dressing without hand hygiene or changed gloves between cleaning patient who had an incontinent episode and cleansing the patient’s wound. Employee A applied sacral colloid dressing and continued to cleanse patient who soiled the chuck and area of dressing was soiled. Employee A used wipes to continue to clean area and reinforced sacral dressing without performing hand hygiene or change gloves between cleaning patient from incontinent episode and reinforcing sacral dressing. During an interview on 9/8/21 at 12:05 PM, the clinical manager confirmed infection control issues with dressings and hand hygiene during the dressing changes. The clinical manager also confirmed that she saw Employee A, registered nurse, place soiled gloves and dressings on the end table of patient #2 without a barrier being placed on the table. 410 IAC 17-12-1(m)

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 RN (Registered Nurse) failed to assess and provide patient care according to professional standards for 2 of 3 skilled nurse observations. (Patient #1, 2) Findings Include: 1. Review of an agency policy with a revised date of 12/1/17 titled, “Scope of Services and Clinical Supervision” Policy 2.003 indicated, “Purpose: To provide guidance on the scope of services provided by the agency and the requirements for supervision…Scope of Services. Skilled Nursing Services. Skilled nursing services is rendered by a nurse (Registered Nurse [RN] or Licensed Practical Nurse/Licensed Vocational Nurse [LPN/LVN] under the supervision of a RN and in accordance with the plan of care. All nurses will be currently licensed in the state in which practicing, Nursing personnel must comply with all Practice Acts and other applicable regulatory requirements that govern the provision of nursing services in the state where the care is provided…The RN: 1) Evaluates the patient’s initial and ongoing nursing needs…5) Observes signs and symptoms, observes the patient’s response to treatments (including medications), and changes in the patient’s physical and emotional condition. Informs the physician and other agency personnel of changes in the patient’s condition and needs…” 2. Constantine, L., MSN, RN, C-FNP. (2004, June 15). Overview of Nursing Health Assessment. Retrieved January 16, 2019, from rn.com "... PULMONARY ASSESSMENT: When examining the pulmonary system... Inspect the thoracic cage, palpate the thoracic cage, Auscultate the anterior and posterior chest: Have patient breath slightly deeper than normal through their mouth, Auscultate from C-7 to approximately T-8, in a left to right comparative sequence. You should auscultate between every rib...Identify any adventitious breath sounds..... " 3. Nurse.org, dated April 7, 2020, indicated: "How to Conduct a Head-to-Toe Assessment :...LENGTH OF ASSESSMENT...the duration of the exam is directly in correlation to the patient's overall health status. Health patients with limited health histories may be completed in less than 30 minutes" The Order of a Head-to-Toe Assessment: 1. GENERAL STATUS: Vital signs;...Temperature;...Pain. 2. HEAD, EARS, EYES, NOSE, THROAT...3. NECK...4. RESPIRATORY: Listen to lung sounds front and back; Assess respiratory expansion level; Ask about coughing; Palpate thorax. 5. CARDIAC: Palpate the carotid and temporal pulses bilaterally; Listen to heartbeat. 6. ABDOMEN:... Ask about problems with bowel or bladder. 7. PULSES: Check pulses in arms/legs/feet including, Radial, Femora, Posterior tibial, Dorsalis pedis. 8. EXTREMITIES:...Check capillary refill on fingernails/toenails. 9. SKIN: Check skin turgor; Check for lesions, abrasions, rashes; Check for tenderness, lumps, lesions; Check if patient is pale, clammy, dry, cold, hot, flushed. 10. NEUROLOGICAL: Oriented x3; Assess gait; Check coordination; Assess reflexes; Check Glasgow Coma Scale." 2. During a home visit on 9/8/21 at 3:05 PM to 4:55 PM, Employee H, RN (Registered Nurse), was observed assessing patient #1's lung sounds to the upper posterior fields. Employee H failed to assess anterior lung sounds, and pedal pulses. 3. During a home visit on 9/8/21 at 10:35 AM to 12:05PM, Employee A, RN (Registered Nurse) was observed assessing patient #2's lung sounds to the anterior upper field. Employee A failed to listen to posterior lung sounds, failed to remove 10 4x4 adhesive foam dressings covering patient #2’s back, bilateral shoulder blades, bilateral hips, and bilateral legs and ankles to complete a skin assessment, failed to assess legs and pedal pulses. 4. During an interview on 9/9/21at 10:15 AM, the clinical manager confirmed, the nurses should complete a complete assessment including listening to all lung fields posterior and anterior, a total skin assessment removing any dressings to assess wounds and skin, and bilateral lower extremity assessments for edema and pedal pulses. 410 IAC 17-12-2(g)

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure a discharge summary was written and sent to the primary care physician who is responsible for the patient's care after discharge within 5 business days of the patients discharge for 4 of 8 record review. (Patients #13, 14, 16, and18) 1. Review of an agency policy number 2.012, titled; "Patient Transfer and Discharge," dated 11/01/11 with last revision dated 02/24/21. "Purpose: To Provide guidance on the process for patient transfer to a new provider and/or discharging a patient from home health services. Policy: The agency will have a documented process to ensure prompt and orderly transfer of a patient to a new service provide (e.g., acute care hospital, hospice) if the agency is unable to meet their needs. When the patient is transferred to another health facility, a copy of the record or abstract of care and services provided shall be sent to the receiving facility." "...Patient Discharge...5. The agency shall provide a copy of the patient's discharge summary within 5 business days of patient discharge 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 agency (if any)"... 2. The clinical review of patient #13 revealed the patient was admitted on 04/30/21 with diagnoses of but not limited to Hemiplegia (paralysis of one side of the body) , disc degeneration (refers to symptoms of back or neck pain caused by wear-and-tear on a spinal disc) , and osteoarthritis (degenerative joint disease or wear and tear arthritis). The patient was to receive occupational, speech and physical therapy. A discharge-transfer summary report was written on 06/04/21 indicating the patient was discharged to home, however the occupational therapist wrote a note on 06/05/21, discharging patient, and speech therapist noted on 06/08/21, stating patient had been discharged on 06/03/21. During an interview on 09/13/21 at 9:21 AM with employee F, administrator, stated discharge summaries in the patients’ charts are written but not sent out to anyone. The agency failed to provide all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility and/or health care practitioner to ensure the safe and effective transition of care within 5 days of discharge. 3. The clinical record review of patient #14 revealed the patient was admitted on 04/22/21 with diagnoses of but not limited to infection, MRSA (Methicillin-resistant Staphylococcus aureus infection that is resistant to many antibiotics), and osteomyelitis (inflammation or swelling that occurs in the bone). The patient was to receive physical therapy. The clinical record evidenced a discharge-transfer summary report dated 07/19/21 with note written by physical therapist on 07/25/21. The record failed to evidence discharge summary with coordination of care. During an interview on 09/13/21 at 9:21 AM with employee F, administrator, stated discharge summaries in the patients’ charts are written but not sent out to anyone. Employee F stated there was no coordination of care. The agency failed to provide all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility and/or health care practitioner to ensure the safe and effective transition of care within 5 days of discharge. 4. The clinical record review of patient #16 revealed the patient was admitted on 02/24/21 with diagnoses of but not limited to pressure ulcer of right buttock, deficiency of B group vitamins, thrombocytopenia (a condition in which you have a low blood platelet count. Platelets (thrombocytes) are colorless blood cells that help blood clot), and long-term use of opiate analgesic. The patient was to receive skilled nursing services, physical therapy, occupational therapy, and home health aide services. The clinical record revealed a discharge-transfer summary report dated 03/19/21, stating patient was discharged to hospice/home. During an interview on 09/13/21 at 9:21 AM with employee F, administrator, stated discharge summaries in the patients’ charts are written but not sent out to anyone. The agency failed to provide all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility and/or health care practitioner to ensure the safe and effective transition of care within 5 days of discharge. 5. The clinical record review of patient #18 revealed the patient was admitted on 07/16/21 with diagnoses of but not limited to alzheimer’s ( a type of dementia that affect memory, thinking, and behaviors), dementia (a general term for the impaired ability to remember, think or make decisions that interferes with doing everyday activities), pulmonary fibrosis (a lung disease that occurs when lung tissues becomes damaged and scarred), and Type 2 diabetes mellitus (an impairment in the way the body regulates and uses sugar (glucose) as a fuel). The patient was to receive physical therapy. The clinical record revealed a discharge summary report with no coordination of care. During an interview on 09/13/21 at 9:21 AM with employee F, administrator, stated discharge summaries in the patients’ charts are written but not sent out to anyone. The agency failed to provide all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility and/or health care practitioner to ensure the safe and effective transition of care within 5 days of discharge. 410 IAC 17-15-1(a)(6)