Every finding on record at Star Home Health Inc

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR §484.102 Survey Dates: 03/25/2025, 03/26/2025, and 03/27/2025 Active Census: 69 At this Emergency Preparedness survey, Star Home Health Incorporated was found to be in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR §484.102. QR: A 1 3/31/2025

This visit was for a Federal Recertification and State Re-Licensure survey of a Home Health Provider. Survey Dates: March 25, 26, and 27, 2025. 12-Month Unduplicated Skilled Admissions: 156 Partially Extended on 03/26/2025 at 2:55 PM This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Refer to State Form for additional State Findings. Abbreviations used in report: Home Health Aide [HHA], Physical Therapy [PT], Registered Nurse [RN], Occupational Therapy [OT], Clinical Manager [CM], Plan of Care [POC], Start of Care [SOC], and Skilled Nursing [SN]. QR: A1, 3/31/2025

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 agency failed to ensure an initial assessment was conducted within 48 hours of referral or the practitioner ordered start of care dated in 2 of 4 active records reviewed (Patients: #2 and 5) and 2 of 4 focused active records reviewed (Patients: #9 and 11). Findings Include: A review of the clinical record for Patient #2, with a start of care date of 02/19/2025 evidenced a physician order for home health care services for nursing and therapy signed by Physician 4 and a Fax from Entity 5, a skilled nursing facility, dated 02/12/2025 reporting Patient #2 would be discharged to home on 02/14/2025. A review of the initial start of care comprehensive assessment visit was dated 02/19/2025 and signed by Alternate Administrator, RN. During an interview on 03/26/2025 at 2:51 PM, Patient #2 reported being discharged from Entity 5 on 02/14/2025 and was contacted by the Alternate Administrator, RN, on 02/19/2025 and a visit was made that day. During an interview on 03/26/2025 at 4:08 PM, Alternate Administrator, RN, indicated they had not completed an initial assessment on Patient #2 until 02/19/2025 because they were unable to contact them. When queried what the agency process for referrals and initial assessments were, they reported the process was to do the initial assessment within 48 hours of the referral and contact the physician if this was not completed. When asked if there was documentation of contact with the physician or attempts to contact the Patient, they reported writing a note related to contacting the Patient after they started care on 02/19/2024. The Alternate Administrator, RN failed to complete an initial assessment 48 hours after receiving an order for a referral to home health care. 410 IAC 17-14-1(a)(1)(A) 1. A review of undated Star Home Health policy titled “Initial Assessment” indicated but was not limited to “ … 1. The initial visit shall be made within 48 hours of referral from a physician or from discharge from an inpatient facility, or on the physician-ordered start of care date. If the initial visit is delayed for reasons such as and inability to contact the patient or at the patient’s request, the physician shall be notified, and documentation shall be completed reflecting the physician’s approval … ” 2. A review of the clinical record for Patient #5 start of care date 10/24/2024, contained a physician order dated 10/17/2024 for Patient #5 to receive PT, OT, HHA for bathing to eval and treat. A review of the initial start of care comprehensive assessment visit dated 10/24/2024, had been completed and signed by the CM. A review of the communication notes dated 10/17/2024 through 03/25/2025 evidenced a communication note dated 10/24/2024 electronically signed by the CM. The communication note indicated the CM had spoken to the caregiver for Patient #5 on 10/18/2024 and scheduled appointment to see the patient on 10/22/2024, due to Patient #5’s dialysis schedule. The note further confirmed the SOC was set up for 10/24/2024 due to a family emergency. The communication notes failed to evidence documentation of the physician being notified of the delay in the SOC. During an interview on 03/25/2025 at 2:45 PM, when requested the new order for the new start of care and documentation of the physician being notified of the delay in Patient #5’s SOC, the CM confirmed they did not obtain a new order for the SOC, nor did they notify the physician of the delay in the SOC. 3. A focused review of the clinical record for Patient #9 start of care date 02/24/2025, contained a physician order dated 02/20/2025 for Patient #9 to receive PT, OT, and Skilled Nursing. A review of the initial start of care comprehensive assessment visit dated 02/24/2025, had been completed and signed by the CM. A review of the communication notes dated 02/20/2025 through 03/25/2025 failed to evidence documentation of the physician being notified of the delay in the SOC. During an interview on 03/26/2025 at 2:00 PM, when requested the new order for the new start of care and documentation of the physician being notified of the delay in Patient #9’s SOC, the CM stated, “No. I did not call the physician to obtain a new order for the SOC or notify the physician of the delay in the SOC.” 4. A focused review of the clinical record for Patient #11 start of care date 02/24/2025, contained a physician order dated 11/14/2024 for Patient #11 to receive PT, OT, Skilled Nursing, and HHA. A review of the initial start of care comprehensive assessment visit dated 11/20/2024, had been completed and signed by RN 2. A review of the communication notes dated 11/20/2024 through 03/25/2025 failed to evidence documentation of the physician being notified of the delay in the SOC. During an interview on 03/26/2025 at 3:29 PM, when asked regarding the referral date for Patient #11 and the SOC date, RN 2 confirmed the SOC initial assessment should had been completed in 48 hours of the receipt of referral, and if unable to complete a communication note with the physician notification should had been completed. RN 2 further communicated they were unaware of the reason the SOC was delayed.

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 record review and interview, the agency failed to ensure the comprehensive assessment included a review of all the medications, and allergies to include drug interactions in 1 of 1 active clinical record reviewed receiving in-center dialysis treatment. (Patient: #5) Findings Include: 1. A review of a Star Home Health policy titled “Drugs and Biologicals” indicated but was not limited to, “ … To maintain a standard for managing patient medications that serves to prevent errors and protect the patient from adverse reactions … At time of admission, the clinician shall document all current … and over the counter medications and allergies … The clinician shall assess, and document is a medication is long standing, new within the last 30 days, or changed with the last 60 days … The clinician shall document a drug regimen review … ” 2. A review of the clinical record for Patient #5 contained a recertification comprehensive assessment dated 02/20/2025, electronically signed by RN1. The recertification assessment indicated RN 1 completed medication review and assessed drug interactions. A review of a document from Entity 1, an ESRD provider [dialysis facility] for Patient #5, indicated Patient #5's medications included: Venofer, Mircera, Cinacalcet, and listed an allergy to Lidocaine. During an interview on 03/25/2025 at 3:12 PM, RN 1 communicated they were unaware of the dialysis prescriptions and Patient #5’s allergy to Lidocaine. RN 1 further confirmed they had not coordinated care with Entity 1 to obtain a complete and accurate list of Patient #5’s medications and allergies to reconcile Patient #5’s medication to check for medication interactions. The POC for the recertification period 02/21/2025- 04/21/2025 included a list of Patient’s medications; the POC failed to evidence Venofer (treats anemia), Mircera (treats anemia), and Cinacalcet (treats increased amounts of calcium), and Patient’s allergy to Lidocaine. 410-IAC 17-14-1(a)(1)(B)

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102. Survey Dates: 4/27/2022, 4/28/2022, 4/29/2022, 5/2/2022, 5/4/2022 Census: 82 At this Emergency Preparedness survey, Star Home Health was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 484.102.

HHA Comprehensive Assessment in Disaster CFR(s): 484.102(b)(1) §484.102(b)(1) Condition for Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (1) The plans for the HHA's patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. This STANDARD is not met as evidenced by: Based on observation, record review, and interview, the home health agency failed to ensure all patients had an emergency preparedness plan that was individualized in 7 of 7 clinical records reviewed. (#1, #2, #3, #4, #5, #6, #7) The findings include: 1. Record review of an undated agency policy retrieved on 5/4/2022, titled “Emergency Preparedness Plan” stated “Policy … STAR HOME HEALTH will have an identified plan in place to ensure safety and well being of patients and employees in the event of an emergency that results in interruption of patient care or services … Purpose To provide an organized plan for meeting patient needs in a manner in the event of emergency or environmental disaster … Policy Statement … 1. During the Start of Care assessment, the admitting clinician shall identify information specific to the patient’s needs including: … b. A minimum of one emergency contact person designated by the patient … 2. The admitting nurse shall discuss the emergency plans with the patient/family and provide oral and written instructions on the emergency preparedness and procedures. This information shall be included in the patient handbook and include specific steps to take in a variety of emergency situations, evacuation plans, medications, food/water, important documents, and care for pets ….” 2. An observation of a home visit was conducted on 5/2/2022, from 1:33 – 2:20 PM, for patient #3, start of care 9/29/2021, with licensed practical nurse (LPN) J. During the visit, the patient’s home folder was reviewed for the required emergency preparedness plan. Review of the home folder failed to evidence an individualized emergency preparedness plan to include but not limited to an emergency contact, relocation and/or transfer information, or the nearest shelter location. Clinical record review on 5/4/2022, evidenced an agency document titled “OASIS [Outcome and Assessment Information Set]-D1 Resumption of Care” from 4/24/2022, and electronically signed by RN I. This document had an area subtitled “Hospitalization Risk Assessment Tools and Emergency Preparedness” which stated, “Emergency Preparedness … Emergency Preparedness Performed ….” Record review failed to evidence an individualized emergency preparedness plan to include but not limited to emergency contacts who does not live in the same home, relocation or shelter information, and emergency contact information. 3. An observation of a home visit was conducted on 4/28/2022, from 10:00 - 10:30 AM, for patient #1, start of care 3/4/2022, with home health aide (HHA) G. During the visit, the patient’s home folder was reviewed for the required emergency preparedness plan. Review of the home folder failed to evidence an individualized emergency preparedness plan to include but not limited to an emergency contact, relocation and/or transfer information, or the nearest shelter location. 4. An observation of a home visit was conducted on 4/28/2022, from 3:35 – 4:18 PM, for patient #2, start of care 2/3/2022, with registered nurse (RN) I. During the visit, the patient’s home folder was reviewed for the required emergency preparedness plan. Review of the home folder failed to evidence an individualized emergency preparedness plan to include but not limited to an emergency contact, relocation and/or transfer information, or the nearest shelter location. 5. Clinical record review on 5/4/2022, for patient #4, start of care 3/8/2022, evidenced an agency document titled “OASIS-D1 Start of Care” from 3/8/2022, and electronically signed by RN C. This document had an area subtitled “Hospitalization Risk Assessment Tools and Emergency Preparedness” which stated, “Emergency Preparedness … Emergency Preparedness Performed ….” Record review failed to evidence an individualized emergency preparedness plan to include but not limited to emergency contacts who does not live in the same home, relocation or shelter information, and emergency contact information. 6. Clinical record review on 5/4/2022, for patient #5, start of care 11/21/2020, evidenced an agency document titled “OASIS-D1 Recertification” from 3/11/2022 and electronically signed by RN I. This document had an area subtitled “Hospitalization Risk Assessment Tools and Emergency Preparedness” which stated, “Emergency Preparedness … Emergency Preparedness Performed ….” Record review failed to evidence an individualized emergency preparedness plan to include but not limited to emergency contacts who does not live in the same home, relocation or shelter information, and emergency contact information. 7. Clinical record review on 5/4/2022, for patient #6, start of care 4/24/2021, evidenced an agency document titled “OASIS-D1 Recertification” from 2/17/2022, and electronically signed by RN C. This document had an area subtitled “Hospitalization Risk Assessment Tools and Emergency Preparedness” which stated, “Emergency Preparedness … Emergency Preparedness Performed ….” Record review failed to evidence an individualized emergency preparedness plan to include but not limited to emergency contacts who does not live in the same home, relocation or shelter information, and emergency contact information. 8. Clinical record review on 5/4/2022, for patient #7, start of care 4/19/2021, evidenced an agency document titled “OASIS-D1 Recertification” from 12/10/2021, and electronically signed by RN C. This document had an area subtitled “Hospitalization Risk Assessment Tools and Emergency Preparedness” which stated, “Emergency Preparedness … Emergency Preparedness Performed ….” Record review failed to evidence an individualized emergency preparedness plan to include but not limited to emergency contacts who does not live in the same home, relocation or shelter information, and emergency contact information. 9. During an interview on 5/2/2022, at 9:50 AM, clinical manager B indicated an individualized emergency preparedness plan should be discussed with the patient and documented at every comprehensive assessment. She indicated information collected should include evacuation information, medications, assistance needed, and medical equipment used by the patient.

This visit was for a Federal Recertification and State Relicensure survey of Star Home Health, Inc. Survey Dates: 4/27/2022, 4/28/2022, 4/29/2022, 5/2/2022, 5/4/2022 Census: 82 This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Refer to State Form for additional State Findings. Quality Review Completed 05/17/22

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the registered nurse prepared clinical notes in accordance with patient's current status in 1 of 5 active clinical records reviewed . (patient #5) The findings include: Record review of an undated agency policy titled “Documentation of Patient Services” retrieved on 5/4/2022, stated “Policy … Documentation shall be written on patient care, patient related communications, verbal orders, supervision, any other information related to the patient's home health services … Purpose … To establish a standard for clinical documentation … 4. Documentation should include the patient's functional status and eligibility for service, assessments, treatments, education, and the progress towards meeting the goals ….” Clinical record review on 5/4/2022, for patient #5, start of care 11/21/2020, pertinent diagnosis history of urinary tract infection (UTI), evidenced an agency document titled “Home Health Certification and Plan of Care” for certification period 3/16/2022 – 5/14/2022, and signed by the physician on 3/23/2022. This document had an area subtitled “Orders for Discipline and Treatment” that stated “SN [skilled nurse] to assess for signs and symptoms of genitourinary [pertaining to the genitals and urinary system] infection and instruct patient/ caregiver regarding care of the genitourinary system including indwelling catheter care, care of cystostomy, self-catheterization, appropriate equipment use, appropriate perineal hygiene, dietary and fluid needs ….” Record review evidenced an agency document titled “SN Teaching/Training Visit” from 4/11/2022, and electronically signed by registered nurse (RN) I. This document had an area subtitled “Genitourinary” which indicated the patient had abnormal urine appearance with sediment, and stated “Comment … had hx [history] of bladder tumor. Hx of UTI’s and dysuria [discomfort while urinating]. Pt has monthly suprapubic catheter changes by urologist. Next change will be 4/12 [2022] as stated by wife. Urine is yellow with a bit of sediment .…” Record review evidenced an agency document titled “SN Teaching/Training Visit” from 4/20/2022, electronically signed by licensed practical nurse (LPN) J. This document had an area subtitled “Genitourinary” which indicated the patient had an abnormal urine appearance which was dark with sediment. This area stated “Comment … had hx of bladder tumor. Hx of UTI’s and dysuria. Pt has monthly suprapubic catheter changes by urologist. Next change will be 4/12 [2022] as stated by wife. Urine is yellow with a bit of sediment .…” Review evidenced the next catheter change documented occurred 8 days prior to the visit. Review failed to evidence the SN documented consistently with the patient’s condition. Record review evidenced an agency document titled “SN Teaching/Training Visit” from 4/27/2022, electronically signed by LPN J. This document had an area subtitled “Genitourinary” which stated “Comment … had hx of bladder tumor. Hx of UTI’s and dysuria. Pt has monthly suprapubic catheter changes by urologist. Next change will be 4/12 [2022] as stated by wife. Urine is yellow with a bit of sediment .…” This document failed to indicate any abnormalities in the urine from the assessment on 4/27/2022. Review evidenced the next catheter change documented occurred 15 days prior to the visit. Review failed to evidence the SN documented consistently with the patient’s condition. During an interview on 5/4/2022, at 2:36 PM, clinical manager B indicated the comments repeatedly documented were not consistent with the assessments documented for each visit. IAC 410-17-14-1(a)(2)(B)

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the home health agency failed to ensure the home health aide provided services as directed on the care plan for 1 of 1 patient where a home visit was conducted with the home health aide. (employee G) The findings include: Record review of an undated agency policy titled “Home Health Aide Documentation” retrieved on 5/4/2022, stated “Policy … Home Health Aide will document all care/ services provided on the home health aide note ... Purpose ... To provide documentation of the Home Health Aide care and observations to provide data to assist the registered nurse/ therapist in identifying additional patient needs … Policy Statement ... 1. The Home Health Aide follow the care plan left in the patients home when providing all patient care services and observations … 4. If the patient refuses and ordered service, the Home Health Aide shall indicate this in the comment section. 5. If observations cannot fit onto the Home Health Aide note the case communication form will be completed by the Aide. 6. The Registered Nurse case manager and the Nursing supervisor will review the Home Health Aide documentation to assure that the care plan is being followed….” Record review of an undated agency policy titled “Home Health Aide Services” retrieved on 5/4/2022, stated “Policy … Home Health Aide (HHA) services will be provided to appropriate patients on an intermittent, part-time or full-time basis, under the direct supervision of a Registered Nurse/ Therapist in accordance with a medically approved plan of care...Policy Statement …1. Home Health Aide services may include: … l. Medication reminders … p. Light meal preparation … u. Light housekeeping … v. Changing bed linen … x. Documentation of findings and interventions according to agency policy … 3. The HHA shall provide patient services and direct care by following the care plan exactly as written by the registered nurse and may not make any changes to the plan of care. Any deviations from the plan of care must be reported to the case manager ….” An observation of a home visit was conducted on 4/28/2022, from 10:00 - 10:30 AM, for patient #1, start of care 3/4/2022, with HHA G. The visit took place in the living room, where the patient remained sitting in a chair. HHA G brought bath supplies to a tray next to the patient’s chair and performed a sponge bath combed the hair, applied lotion to body, and assisted the patient to get dressed. This home visit failed to evidence the HHA completed personal care tasks such shower, shave, and medication reminders as indicated in the care plan. Observation failed to evidence the HHA completed household tasks such as make bed, change linen, and light housekeeping as indicated in the care plan. Observation failed to evidence the HHA completed a meal set up for the patient as indicated in the care plan. Clinical record review on 5/4/2022, evidenced an agency document titled “HHA Care Plan” electronically signed by clinical manager B on 4/1/2022. This document had an area subtitled “Plan Details” which had a box checked to indicate the following tasks should be performed every visit, including but not limited to: Shower, shave, medication reminder, make bed, change linen, light housekeeping, and meal set up. Record review evidenced an agency document titled “HHA Visit” which was electronically signed by HHA G on 4/28/2022. This document had an area subtitled “Tasks” which had a box checked next to the following items indicating they had been performed, including but not limited to: Shower, shave, medication reminder, make bed, change linen, light housekeeping, and meal set up. Record review failed to evidence the HHA followed the care plan as prescribed on 4/1/2022. During an interview on 5/4/2022, at 2:31 PM, clinical manager B indicated tasks listed on the care plan selected to be performed at every visit should have all personal care, meal preparation, and housekeeping tasks listed as duties to be completed at each visit.