Every finding on record at Sunrise Home Health Care Services Inc

An Emergency Preparedness survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102 of a home health provider. Census: 38 Facility ID: 157634 Survey dates: 01/21/2026 to 01/23/2026 QR: A1 Feb. 04, 2026

Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [facilities] 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 [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to include in its policies the use of volunteers in an emergency and the role for integration of State and Federally designated health care professionals to address needs during an emergency. The findings include: Review of the emergency preparedness plan and its policies failed to evidence the use of volunteers and the integration of State and Federally designated health care professionals to address needs during an emergency. On 01/23/2026 at 3:08 PM, the Administrator indicated the use for emergency staffing was a hypothetical situation and the use of the phone tree was the plan to activate emergency staffing. The Administrator indicated there was no emergency staff included in the phone tree.

EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to maintain an emergency training program. The findings include: An undated policy titled “Emergency Disaster Plan Orientation and Training” indicated the agency would provide emergency preparedness training to all staff initially and then annually. Review of the emergency preparedness binder, training binder, and personnel files failed to evidence emergency preparedness training for staff. On 01/23/2026 at 3:19 PM, the Administrator indicated there was no training offered for emergency preparedness.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to conduct a community or facilty -wide exercise to test the emergency plan at least every 2 years. The findings include: Review of the emergency preparedness plan failed to evidence a community or facility-wide exercise since the last recertification survey of 02/02/2023. On 01/23/2026 at 3:08 PM, the Administrator indicated the agency had not conducted a community or facility-wide exercise as the agency was informed they did not have to conduct a facility-wide exercise if the agency was not allowed to be included in the community-wide exercise.

This visit was for a Federal Recertification and State Re-licensure survey of a Home Health Provider. Survey Dates: 01/21/2026 to 01/23/2026 Unduplicated 12 month skilled admissions: 77 A partially extended survey was announced to the Administrator on 01/23/2026 at 2:45 PM. This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Abbreviations used in this survey include RN for Registered Nurse and HHA for Home Health Aide

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the following information: (1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment included a complete patient’s health status in 1 of 1 active clinical records reviewed of a patient with a suprapubic catheter (Patient #1). Findings include: An undated policy, titled, “Comprehensive Client Assessment,” indicated the comprehensive assessment would include but not limited to a general health status and system assessment, and integumentary (skin) status. A Comprehensive Assessment, dated 01/14/2026, indicated Patient #1 had a suprapubic catheter (device used to drain urine from the bladder through an incision in the abdominal wall), and required skilled nursing visits to assess urine output, evaluate catheter patency and stoma (skin opening) site, and monitor for signs and symptoms of infection. The Comprehensive Assessment failed to include an assessment of the suprapubic catheter stoma site. During an interview on 01/23/2026, beginning at 1:45 PM, the Administrator indicated there was not an assessment of the suprapubic catheter stoma site on the comprehensive assessment and should have been assessed and documented. 410 IAC 17-14-1(a)(1)(B)

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure all treatments were included on the plan of care in 1 of 3 active clinical records reviewed with a diagnosis of diabetes (Patient #3). Findings include: A policy, revised 01/26/2024, titled, “Plan of Care,” indicated the plan of care should include the care and services necessary to meet patient’s specific needs as identified in the comprehensive assessment. A Start of Care Comprehensive Assessment, dated 12/12/2025, indicated Patient #3, start of care 12/12/2025, had a diagnosis of type 2 diabetes with hyperglycemia (elevated blood sugar), Patient was not on hypoglycemic medications, and Patient and caregiver required instruction on use of the glucometer (device to check blood sugar).The Comprehensive Assessment indicated Patient’s fasting blood sugar was 111 at the time of the visit. A Plan of Care, for certification period 12/12/2025 to 02/09/2026, indicated skilled nursing once weekly for 9 weeks to instruct Patient and caregiver on use of glucometer and to record blood sugar readings. The Plan of Care indicated to notify the physician if fasting blood sugar was greater than 300 or less than 60. The Plan of Care was completed by the Alternate Director of Nursing. The Plan of Care failed to evidence a blood sugar testing frequency order. During an interview on 01/23/2026, beginning at 2:30 PM, the Alternate Director of Nursing indicated Patient was to have blood sugar checked weekly, the frequency of blood sugar monitoring should have been and was not on the plan of care. 410 IAC 17-13-1(a)(1)(D)(ix)

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure verbal orders for start of care or recertification were obtained or documented in the patient’s clinical record in 2 of 4 active clinical records reviewed with skilled nursing care ordered (Patient #3,Patient #8), and in 1 of 2 active clinical records reviewed with occupational therapy ordered (Patient #6). Findings include: 1.An undated policy, titled, “Verbal Order Policy,” indicated verbal orders would be documented by the clinician into the electronic medical record system on the day they were received and include date, time, name of ordering physician and clinician that received the order. 2.A Plan of Care, for certification period 12/12/2025 to 02/09/2026, indicated skilled nursing frequency was to be one time per week for 8 weeks to instruct Patient #3 on daily blood pressure monitoring and blood sugar monitoring device use. The Plan of Care physician signed the plan of care on 12/22/2025. The Plan of Care was completed by the Alternate Director of Nursing. A review of the clinical record failed to evidence a verbal order from the plan of care physician to start care on 12/12/2025. During an interview on 01/23/2026, beginning at 2:30 PM, the Alternate Director of Nursing indicated she did not obtain verbal orders to start care on Patient. 3.A Plan of Care, for certification period 12/03/2025 to 01/31/2026, indicated Patient #8, start of care 06/06/2025, was to have skilled nursing visits one time per week for 8 weeks to test fasting blood sugar and report results to the physician if blood sugar was less than 60 or greater than 250, and monitor for signs and symptoms of hypoglycemia (low blood sugar) or hyperglycemia (elevated blood sugar). The Plan of Care physician signed the plan of care on 12/04/2025. A Recertification Comprehensive Assessment, dated 12/01/2025, indicated Patient’s random blood sugar was tested with a result of 138, and the skilled nurse instructed Patient on symptoms of hyperglycemia, and to drink more water to remove excess sugar from the blood through urine, and the skilled nurse was to perform blood sugar testing due to Patient was unable to perform. A review of orders failed to evidence a verbal order from the plan of care physician to continue care for certification period 12/03/2025 to 01/31/2026. During an interview on 01/23/2026, beginning at 2:00 PM, the Administrator confirmed the agency did not obtain verbal orders to continue care for the certification period of 12/03/2025 to 01/31/2026. 4. A Plan of Care, for certification period 01/09/2026 to 03/09/2026, indicated Patient #6, start of care 01/09/2026, was to receive occupational therapy once per week for 8 weeks. The Plan of Care physician signed the plan of care on 01/15/2026. The Plan of Care was completed by RN 1. A Missed Visit Order Form, dated 01/13/2026, indicated the plan of care physician was notified Patient requested the initial occupational therapy evaluation for the week of 01/22/2026. A Referral, dated 01/07/2026, indicated disciplines ordered were physical therapy and occupational therapy. During an interview, on 01/23/2026, beginning at 12:45 PM, RN 1 indicated she completed the plan of care and included the occupational therapy frequency based on the referral received, the occupational therapist would complete the plan of care orders and frequency after the evaluation. RN 1 indicated she did not contact the plan of care physician to obtain verbal orders for the occupational therapy frequency. 410 IAC 17-14-1(a)(F)

Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This STANDARD is not met as evidenced by: Based on record review and interview, the agency’s Quality Assessment and Performance Improvement (QAPI) Program failed to track quality indicators to include all documented Patient infections in 1 of 1 active clinical records reviewed with a suprapubic catheter (Patient #1). Findings include: An undated policy, titled, “Quality Assurance and Performance Improvement,” indicated the QAPI Program Components would include infection prevention integration. The policy indicated the QAPI Committee would be responsible for identifying performance issues and reviewing data. The policy indicated the agency’s QAPI program would focus on improving clinical care and patient outcomes. A Plan of Care, for certification period 11/16/2025 to 01/14/2026, indicated Patient #1 had a suprapubic catheter (device used to drain urine from the bladder through an incision in the abdominal wall), and was sent to urgent care on 11/07/2025 for blood and sediment in the urine, a urinalysis and culture was performed and a new antibiotic cefpodoxime for 7 days was started on 11/10/2025 for the bacteria that the bacteria was sensitive to on the culture. A RN Skilled Nursing Visit Note, dated 01/07/2026, indicated Patient #1 was started on an antibiotic cefpodoxime on 01/02/2026 for a urinary tract infection. A review of the Infection Logs failed to include Patient #1’s urinary tract infections for 11/07/2025 and 01/02/2026. During an interview on 01/23/2026, beginning at 2:40 PM, the Alternate Administrator indicated the agency was tracking infections for quality indicators for their QAPI program. The Alternate Administrator indicated Patient #1’s urinary tract infections should have been and were not on the tracked infection logs. 410 IAC 17-12-2(a)

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure home health aide supervisory assessments were conducted onsite in 1 of 2 active clinical records reviewed with home health aide services (Patient #4). Findings include: A Plan of Care, for certification period 11/11/2025 to 01/09/2026, indicated Patient #4 had Physical Therapy once a week for 9 week, and Home Health Aide (HHA) services twice a week for 9 weeks. An Aide Care Plan, for certification period 11/11/2025 to 01/09/2026, indicated HHA was to complete pulse, respiration and temperature assessment every visit; provide incontinent care, record bowel movement every visit; assist with transfer and positioning every visit; perform shower and shampoo hair every visit. Aide Supervisory Visits, dated 11/21/2025, 12/05/2025, 12/19/2025, and 01/02/2026 indicated RN 1 completed supervisory visits on HHA 1, and HHA 1 was not present at time of visits. The Aide Supervisory Visits indicated HHA 1 demonstrated competency with assigned tasks, complied with infection prevention and control policies and procedures, followed plan of care as instructed and honored Patient’s Rights. During an interview on 01/23/2026, beginning at 12:45 PM, RN 1 indicated she completed HHA supervisory visits by calling Patient on the phone to assess Patient's satisfaction with care, did not complete the visits on site, and would only go to Patient's home for every 60 day recertifications.

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR §484.102 for Home Health Providers and Suppliers. Survey Dates: 01/26/2023-02/02/2023 Census: 43 At this Emergency Preparedness survey, Sunrise Home Health Care Services Inc., was found to be out of compliance with Conditions of Participation 42 CFR §484.102: Emergency Requirements for Medicare and Medicaid Participating Providers and Suppliers

Local, State, Tribal Collaboration Process CFR(s): 484.102(a)(4) §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility's needs in the event of an emergency. This STANDARD is not met as evidenced by: Based on record review and interview, the home health agency failed to include a process for cooperation and collaboration with local, tribal, regional, state, and federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. Findings include: Record review of an undated agency policy received on 02/01/2023, titled, “Communication Plan for Emergency Preparedness,” stated, “… The Incident Commander will verify contact information for local, State, Federal officials, community partners and resources on a quarterly basis. The agency will keep abreast of current information about emergency management via Methodist designated by local, regional, and state officials ….” Record review of an undated agency policy received on 02/01/2023, titled, “Emergency Preparedness Management Policy,” stated, “… The emergency plan will identify the links to local community organizations that may be needed to assist the agency in responding to clients needs ….” Review of the emergency preparedness binder on 01/27/2023, failed to evidence a process for collaboration with local, tribal, regional, state, and federal emergency preparedness officials. During an interview on 01/27/2023, at 3:30 PM, the administrator indicated he had contacted the local fire department regarding a local emergency plan, but the fire department was not interested in assisting the home health agency. During an interview on 01/31/2023, at 12:43 PM, the administrator indicated he had not collaborated with local, state, or federal emergency management officials regarding the home health agency’s emergency plan.

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 an individualized plan for each patient during a natural or man-made disaster was included in the patient’s comprehensive assessment in 8 of 8 clinical records reviewed. (#1, #2, #3, #4, #5, #6. #7. #8) Findings include: 1. Record review evidenced an undated agency policy received on 02/01/2023, titled, “Emergency Preparedness Management Policy,” which stated, “Agency will have an identified plan in place to ensure the safety and well-being of clients and employees during periods of an emergency or disaster that disrupts agency services … the agency conducts an analysis to identify potential emergencies and the direct and indirect effects these emergencies may have on agency operations and the demand for services. The agency will develop and maintain a written emergency management plan describe the process for disaster readiness and emergency management and implements it as appropriate …Clients dependent on medical equipment that is necessary for maintaining life support will have battery pack backup available ….” 2. Clinical record review on 01/27/2023, for patient #1, start of care 12/07/2022, evidenced an agency document titled, “OASIS [outcome assessment and information set] D-1 Start of Care,” identified as the comprehensive assessment, and indicated the patient lived alone, an emergency plan was developed, and patient was instructed on disaster/emergency plan. Review of the comprehensive assessment failed to evidence an individualized emergency plan. During an observation of a home visit on 01/27/2023, at 10:00 AM, an agency document titled, “Patient Emergency Preparedness Plan,” was evidenced and included blank lines for police, fire, ems, local red cross, local emergency management office, physician, pharmacy, neighbors, and relatives. Review of the document failed to evidence an individualized emergency plan. 3. Clinical record review on 01/27/2023, for patient #2, start of care 06/07/2022, evidenced an agency document dated 12/01/2022, titled, “OASIS-D1 Recertification,” and identified as the comprehensive assessment. This document indicated the patient was on dialysis, an emergency plan was developed, and the patient was instructed on disaster/emergency plan. Review of the comprehensive assessment failed to evidence an individualized emergency plan. During an observation of a home visit on 01/31/2023, at 9:00 AM, an undated agency document was evidenced titled, “Emergency Contact Information.” While reviewing the document the patient indicated she had filled in the emergency contact phone numbers. Review of the agency document failed to evidence an individualized emergency plan. 4. Clinical record review on 01/30/2023, for patient #3, start of care 06/20/2022, evidenced an agency document dated 12/13/2022, titled, “OASIS-D1 Recertification,” and identified as the comprehensive assessment. This document indicated the patient had a diagnosis of type 2 diabetes mellitus, an emergency plan was developed, and patient was instructed on disaster/emergency plan. Review of the comprehensive assessment failed to evidence an individualized emergency plan. During an observation of a home visit on 01/30/2023, at 7:30 AM, an undated agency emergency plan was evidenced and included blank lines for police, fire, ems, local red cross, local emergency management office, physician, pharmacy, neighbors and relatives. Review of the document failed to evidence an individualized emergency plan. 5. Clinical record review on 01/30/2023, for patient #4, start of care 12/19/2022, evidenced an agency document dated 01/17/2023, titled, “Oasis-E Resumption of Care,” and indicated the patient was on oxygen, an emergency plan was developed, and patient was instructed on disaster/emergency plan. Review of the comprehensive assessment failed to evidence an individualized emergency plan. During an observation of a home visit on 01/30/2023, at 9:50 AM, an undated agency emergency plan was evidenced with blank lines to be filled in. Review of the document failed to evidence an individualized emergency plan. 6. Clinical record review on 01/30/2023, for patient #5, start of care 06/20/2019, evidenced an agency document dated 11/29/2022, titled, “OASIS D-1 Recertification,” and identified as the comprehensive assessment. This document indicated the patient had a diagnosis of traumatic brain injury, had an emergency plan developed and was instructed on disaster/emergency plan. Review of the comprehensive assessment failed to evidence an individualized emergency plan. 7. Clinical record review on 01/30/2023, for patient #6, start of care 01/18/2022, evidenced an agency document dated 01/10/2023, titled, “OASIS-E Recertification,” and identified as the comprehensive assessment. This document indicated the patient was on oxygen, an emergency plan was developed, and was instructed on disaster/emergency plan. Review of the comprehensive assessment failed to evidence an individualized emergency plan. 8. Clinical record review on 01/30/2023, for patient #7, start of care 05/11/2022, evidenced an agency document dated 09/07/2022, titled, “OASIS-D1 Recertification,” and identified as the comprehensive assessment. This document indicated the patient lived in an assisted living facility, had an emergency plan developed and was instructed on disaster/emergency plan. Review of the comprehensive assessment failed to evidence an individualized emergency plan. 9. Clinical record review on 01/30/2023, for patient #8, start of care 05/17/2022, evidenced an agency document dated 11/11/2022, titled, “OASIS-D1 Recertification,” and identified as the comprehensive assessment. This document indicated the patient lived in a group home, had an emergency plan developed and was instructed on disaster/emergency plan. The comprehensive assessment indicated the group home had a disaster/emergency plan in place. Review of the comprehensive assessment failed to evidence an individualized emergency plan. During an interview on 02/01/2023, at 3:00 PM, the director of nursing indicated the group home had an emergency plan and the group home’s plan would supersede the home health emergency plan. The director of nursing indicated the home health agency did not document coordination of the group home’s emergency plan. 10. During an interview on 01/26/2023, at 3:40 PM, the director of nursing indicated the emergency plan in the patient’s home, provided by the agency, was the patient’s choice if they wanted to fill out the plan with information. 11. During an interview on 01/30/2023, at 3:40 PM, the administrator indicated the patient’s individualized emergency preparedness plan was for the patient to call 911 or 211 for emergencies.

Homebound HHA/Hospice Inform EP Officials CFR(s): 484.102(b)(2) §418.113(b)(2), §460.84(b)(4), §484.102(b)(2) [(b) Policies and procedures. The [facilities] 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:] *[For homebound Hospice at §418.113(b)(2), PACE at §460.84(b)(4), and HHAs at §484.102(b)(2):] The procedures to inform State and local emergency preparedness officials about [homebound Hospice, PACE or HHA] patients in need of evacuation from their residences at any time due to an emergency situation based on the patient's medical and psychiatric condition and home environment. This STANDARD is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure they included the procedures to inform State and local emergency preparedness officials about patients in need of evacuation from their residences at any time due to an emergency situation based on the patient’s medical, psychiatric, and home environment conditions. This had the potential to affect all agency patients. Findings include: Record review of an undated agency policy received on 02/01/2023, titled, “Emergency Preparedness Evacuation,” stated, “… The agency will orient agency staff upon hire and provide annual in service for staff on planning for evacuation during an emergent situation which includes: … Client assessment and evacuation planning … During the initial assessment, each client will be assessed for care needs and risk during a crisis situation. The assessment will include medical and psychiatric condition, the location of the client, the client’s transportation level, special needs, dependency on electricity or oxygen to sustain life, need for shelter, availability of assistance during a crisis and evacuation, and classification level. An individual client emergency plan will be documented as part of the comprehensive assessment to include: … Facilitate the registration of clients who are dependent upon electricity to sustain life with local fire department and electricity supplier … Facilitate the registration of those with shelter or evacuation needs with State and local emergency preparedness officials ….” Record review of an undated agency policy received on 02/01/2023, titled, “Communication Plan for Emergency Preparedness,” stated, “… A current roster with contact information for clients and their emergency contact will be maintained ….” Review of the emergency preparedness binder evidenced an agency document titled, “Master Patient Triage/Disaster Code List,” received on 01/27/2023, which failed to evidence the specific location of the patient or patient’s/emergency contact phone numbers. The emergency preparedness binder failed to evidence the procedure to inform State and local emergency preparedness officials about patients in need of evacuation from their residences due to an emergency situation. During an interview on 01/31/2023, at 12:43 PM, the alternate administrator indicated the agency’s emergency preparedness policy doesn’t say specifically about patient’s evacuation plan.

HHA- Procedures for Follow up Staff/Pts. CFR(s): 484.102(b)(3) §484.102(b)(3) Condition of 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:] (3) The procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency. The HHA must inform State and local officials of any on-duty staff or patients that they are unable to contact. This STANDARD is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the procedures were included to inform the State and local officials of any on-duty staff or patients that the agency were unable to contact. Findings include: Record review of an undated agency document received on 02/01/2023, titled, “Communication Plan for Emergency Preparedness,” stated, “… The agency will maintain a Staff Notification Tree which list all personnel, including volunteers and will include: The staff member’s telephone number or cell phone number, home address and an alternate means of communication [i.e. emergency contact information] … The Incident Commander will maintain communication within the agency and also with local officials via the chain of command. The Incident Commander will be responsible for cooperation, collaboration and maintain communication with local officials, [Office of Emergency Management], regional, state, [State Department of Health] and Federal emergency preparedness officials and community health coalitions ...." The policy failed to address what actions would be required due to the inability to make contact with staff or patients and reporting capabilities to the local and State Emergency officials. During an interview on 01/31/2023, at 12:43 PM, the director of nursing indicated the policy doesn’t say specifically about notifying local and state authorities if patients or staff can’t be reached.

Emergency Officials Contact Information CFR(s): 484.102(c)(2) §403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.542(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at §483.73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at §483.475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency. This STANDARD is not met as evidenced by: Based on record review and interview, the home health agency failed to develop and maintain an emergency preparedness communication plan that included contact information for the Federal, State, tribal, regional, and local emergency preparedness staff. Findings include: Record review of an undated agency policy received on 02/01/2023, titled, “Communication Plan for Emergency Preparedness,” stated, “… The Incident Commander will maintain communication within the agency and also with local officials via the chain of command. The Incident Commander will be responsible for cooperation, collaboration and maintaining communication with local officials, [Office of Emergency Management], regional, State, [State Department of Health] and Federal Emergency preparedness officials and community health coalitions ….” Review of the agency emergency preparedness binder on 01/26/2023, failed to evidence an emergency preparedness communication plan that included information for the Federal and State emergency preparedness staff. During an interview on 01/31/2023, at 12:43 PM, the administrator indicated there should be information for Federal and State emergency officials in the emergency binder. The administrator indicated there was no coordination process for the emergency plan with local or state officials and he had not attended any emergency management meetings.

Primary/Alternate Means for Communication CFR(s): 484.102(c)(3) §403.748(c)(3), §416.54(c)(3), §418.113(c)(3), §441.184(c)(3), §460.84(c)(3), §482.15(c)(3), §483.73(c)(3), §483.475(c)(3), §484.102(c)(3), §485.68(c)(3), §485.542(c)(3), §485.625(c)(3), §485.727(c)(3), §485.920(c)(3), §486.360(c)(3), §491.12(c)(3), §494.62(c)(3). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (3) Primary and alternate means for communicating with the following: (i) [Facility] staff. (ii) Federal, State, tribal, regional, and local emergency management agencies. *[For ICF/IIDs at §483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID's staff, Federal, State, tribal, regional, and local emergency management agencies. This STANDARD is not met as evidenced by: Based on record review and interview, the home health agency failed to develop and maintain an emergency preparedness communication plan that included primary and alternate means for communication with the facility, staff, federal, state, tribal, regional, and local emergency management. Findings include: Record review evidenced an undated agency policy received on 02/01/2023, titled, “Communication Plan for Emergency Preparedness,” which stated, “… In the event of down conventional telephone communication, cellular phones will be utilized by administration, nursing personnel and coordination services. If cellular phone systems are not adequately functioning, the agency will utilize backup communication systems that include: organized messenger services, GPS system, Walkie-Talkies, and/or CB/Amateur radio systems, satellite phone, text, email, Website, bulletin boards, fax or radio announcements ….” Review of the emergency preparedness binder on 01/26/2023, failed to evidence an alternate means for communication with the facility, staff, federal, state, tribal, regional, and local emergency management. During an interview on 01/31/2023, at 12:43 PM, the director of nursing indicated there was nothing specific in the policy regarding alternate means of communication. The administrator indicated CB radios are not used anymore for alternate means of communication. The alternate administrator indicated walkie talkies cannot be used due to they only work for short distances.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on record review and interview, the home health agency failed to provide emergency preparedness training at least every 2 years and failed to maintain documentation of all emergency preparedness training. Findings include: Record review of an undated agency policy received on 02/01/2023, titled, “ Emergency Disaster Plan Orientation and Training,” stated, “… Emergency Disaster Preparedness Training will be provided at least annually … the agency will maintain documentation of all Emergency Disaster Preparedness Training provided. Attendance and demonstration of staff knowledge of emergency procedures will be notated in the employee’s personnel file….” Review of the emergency preparedness binder on 01/26/2023, failed to evidence emergency preparedness training at least every 2 years. During an interview on 01/31/2023, at 12:43 PM, the director of nursing indicated there was not any emergency preparedness training with staff in the last 2 years only the tabletop exercise was done with staff.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on record review and interview, the home health agency failed to conduct or participate in a full-scale community drill every 2 years or conduct a facility-based functional exercise every 2 years. Findings include: Record review of an undated agency policy received on 02/01/2023, titled, “Emergency Preparedness Management Policy,” stated, “… Agency staff members will participate in an annual desktop drill to determine the effectiveness and efficiency of the current plan and any forms developed for use in a disaster….” Record review of an undated agency policy received on 02/01/2023, titled, “Environmental Safety,” which stated, “…Each year the Agency will participate in one community practice drill relevant to emergency preparedness in the community. These drills will evaluate the communicate, coordination and attention to “chain of command” structures in the agency and in the community ….” Review failed to evidence a full-scale community drill or facility-based exercise was conducted in the last 2 years. During an interview on 01/31/2023, at 12:43 PM, the director of nursing indicated only a tabletop exercise was completed in 2022. The administrator indicated there had been no full-scale community drill or facility-based exercise.

This survey was a Recertification and Emergency Preparedness survey for a home health agency. Survey Dates: 01/26/2023-02/02/2023 Facility ID: 012486 Census: 43 During this Federal Recertification Survey, Sunrise Home Health Care Services, Inc., was found to be out of compliance with Conditions of Participation 42 CFR §484.60 Care Planning, Coordination, Quality of Care and 42 CFR §484.102 Emergency Preparedness. This deficiency report reflect State Findings cited in accordance with 410 IAC 17. Based on the condition-level deficiencies during the 01/26/2023- 02/02/2023 survey, Sunrise Home Health Care Services, Inc. is precluded from providing its own home health aide training and competency evaluation for a period of two years which began on 02/02/2023-02/02/2025. Quality Review Completed 02/14/2023

Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient's status at the time of assessment. This STANDARD is not met as evidenced by: Based on record review and interview, the home health agency failed to transmit accurate OASIS (outcome and assessment information set) with the current status of the patient at the time the OASIS was completed in 3 of 4 clinical records reviewed with skilled nurse visits. (#2, #3, #6) Findings include: 1. Record review of an undated agency policy received 02/01/2023, titled, “Encoding and Reporting Oasis Data,” stated, “… the encoded OASIS must accurately reflect the client’s status at the time of assessment ….” 2. Clinical record review on 01/27/2023, for patient #2, start of care 06/7/2022, evidenced an agency document dated 06/07/2022, titled, “OASIS-D1 Start of Care,” identified as the comprehensive assessment. This document indicated the drug regimen review identified no issues, and failed to evidence documentation in management of injectable medications. Review of an agency document dated 06/09/2022, titled, “Patient Medication Record,” indicated the physician was contacted regarding medication discrepancies and the physician was notified of severe medication interactions. 3. Clinical record review on 01/30/2023, for patient #3, start of care 06/20/2022, evidenced an agency document dated 06/20/2022, titled, “OASIS-D1 Start of Care,” identified as the comprehensive assessment. This document indicated the drug regimen review identified no issues. Review of an agency document dated 06/21/2022, titled, “Patient Medication Record,” indicated physician was notified of severe medication interactions. 4. Clinical record review on 01/30/2023, for patient #6, start of care 01/18/2022, evidenced an agency document dated 01/18/2022, titled, “OASIS-D1 Start of Care,” identified as the comprehensive assessment. This document indicated the drug regimen review identified no issues. Review of an agency document dated 01/19/2022, titled, “Patient Medication Record,” indicated physician was contacted regarding medication discrepancies and severe medication interactions. 5. During an interview on 01/31/2023, at 2:54 PM, the director of nursing indicated the OASIS should be entirely completed unless a section was not applicable or marked N/A.

Patient's or legal representative's signature CFR(s): 484.50(a)(2) Obtain the patient's or legal representative's signature confirming that he or she has received a copy of the notice of rights and responsibilities. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to obtain the legal representative’s signature confirming that he or she had received a copy of the notice of rights and responsibilities in 2 of 2 discharged clinical records reviewed. (#7, #8) Findings include: 1. Record review of an agency policy dated 09/2019, titled, “Patient’s Bill of Rights,” stated, “… in the event that the client is unable to make decisions, the Patient’s Bill of Rights shall be given to the client’s legal guardian. The reason the client is unable to acknowledge receipt of the Patient’s Bill of Rights shall be documented ….” 2. Clinical record review on 01/30/2023, for patient #7, start of care 05/11/2022, evidenced an agency document dated 05/11/2022, titled, “Consent to Provide Home Health Care Services to Client,” which stated, “…I acknowledge that I have reviewed and read the Patient’s Bill of Rights ….” The consent was initialed by the patient. Record review of document dated 05/19/2017, titled, “Health Care Power of Attorney,” indicated 2 patient’s family members as the attorney-in-fact (the person granted power of attorney). Review failed to evidence the health care power of attorney signed the consent. Record review of an agency document dated 05/11/2022, titled, “OASIS [outcome and assessment information set]-D1 Start of Care,” identified as the comprehensive assessment, indicated a diagnosis of unspecified dementia (loss of cognitive function) without behavioral disturbance. 3. Clinical record review on 01/30/2023, for patient #8, start of care 05/17/2022, evidenced an agency document dated 05/17/2022, titled, “Consent to Provide Home Health Care Services to Client,” which stated, “… I acknowledge that I have reviewed and read the Patient’s Bill of Rights ….” The consent was signed by the patient. Record review of a document dated 12/15/2005, titled, Appointment of Health Care Representative,” indicated an appointment of a health care representative. Record review of an agency document dated 05/17/2022, titled, “OASIS-D1 Start of Care,” identified as the comprehensive assessment, indicated a diagnosis of moderate intellectual disabilities, down syndrome (condition associated with intellectual disabilities), and conduct disorder. Review failed to evidence the health care representative signed the consent. 4. During an interview on 02/01/2023, at 2:20 PM, the director of nursing indicated the patients should not have signed for themselves that they had received the Patient’s Bill of Rights. 410 IAC 17-12-3(a)(2)

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to provide a comprehensive assessment that accurately reflected the patient’s status in 2 of 6 active clinical records reviewed (#2, #5) Findings include: 1. Record review evidenced an undated agency policy received on 02/01/2023, titled, “Comprehensive Client Assessment,” which stated, “… the initial assessment bridges the gap between the first client encounter until a plan of care can be implemented. These may include items such as … skilled treatments … nutritional needs … the comprehensive assessment must accurately reflect the client’s status ….” 2. Clinical record review on 01/27/2023, for patient #2, start of care 06/07/2022, evidenced an agency document dated 06/07/2022, titled, “OASIS [observation and assessment information set] D1 Start of Care,” identified as the comprehensive assessment. This document indicated the patient had an AV graft (access for dialysis) to the right upper arm. The comprehensive assessment failed to evidence assessment of the AV graft site. During an interview on 01/31/2023, at 2:25 PM, the director of nursing indicated the comprehensive assessment should include assessment for thrill and bruit to the AV graft site. 3. Clinical record review on 01/30/23, for patient #5, start of care 06/20/2019, evidenced an agency document dated 11/29/2022, titled, OASIS-D1 Recertification,” which was identified as the comprehensive assessment. This document indicated the patient had a peg tube (plastic feeding tube that goes into the stomach). The comprehensive assessment failed to evidence assessment of the peg tube site. During an interview on 02/01/2023, at 12:00 PM, the director of nursing indicated the peg tube site assessment should be included on the comprehensive assessment. 410 IAC 17-14-1(a)(1)(B)

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 home health agency failed to ensure all current patient medications were reviewed as part of the comprehensive assessment, to identify any potential adverse effects, drug reactions, significant drug interactions, and duplicate drug therapy in 2 of 4 clinical records reviewed with skilled nurse visits. (#2, #6) Findings include: 1. Record review evidenced an undated agency policy received 02/01/2023, titled, “Comprehensive Client Assessment,” which indicated the comprehensive assessment will include a review of all medications the patient was currently using in order to identify significant drug interactions and duplicate drug therapy. 2. Record review evidenced an undated agency policy received 02/01/2023, titled, “Medication Management,” which stated, “… Comprehensive client assessment performed at start of care and other defined points in time include review of all medications the client is taking [prescribed, samples, over the counter, herbal remedies, PRN medications] and records this in the client record ….” 3. Clinical record review on 01/27/2023, for patient #2, start of care 06/07/2022, evidenced an agency document titled, “OASIS [outcome and assessment information set] D1 Start of Care,” identified as the comprehensive assessment, which indicated no issues found during drug regimen review. Review of an agency document dated 06/09/2022, titled, “Patient Medication Record,” indicated the physician was faxed a record of medication discrepancies and severe medication interactions. Review of the paper chart faxed to the physician evidenced the medication list was faxed to the physician but failed to evidence the medication interaction list was faxed. Review of a web based source on 01/27/2023, https://drugs/com/interactions-check.php, evidenced the following 14 major drug to drug interactions between medications on patient #2’s medication list: cyclobenzaprine (muscle relaxer) and tramadol (pain reliever) -may cause central nervous system depression, respiratory distress, coma and death; cinacalcet (thyroid medication) and Rexulti (antipsychotic) may cause respiratory distress, coma and death; tramadol and Rexulti may cause respiratory distress, coma and death; hydrocodone (pain reliever) and Rexulti may cause respiratory distress, coma and death; sertraline (antidepressant) and Rexulti may cause abnormal muscle movements and low blood pressure (circulating blood against blood vessel walls), gabapentin (pain reliever) and tramadol may cause respiratory distress, coma and death; hydrocodone and tramadol may cause seizures, respiratory distress, coma and death; sertraline and tramadol may cause confusion, hallucination, seizures, tremor, nausea and vomiting; trazadone (depression medication) and tramadol may cause confusion, hallucination, seizures, change in blood pressure, elevated heart rate, nausea and vomiting; hydrocodone and gabapentin may cause respiratory distress, coma, and death; cyclobenzaprine and hydrocodone may cause respiratory distress, coma and death; trazadone and cyclobenzaprine may cause confusion, hallucinations, seizure, elevated heart rate, tremor, nausea and vomiting; trazadone and sertraline may cause confusion, hallucinations, seizure, elevated heart rate, fever, tremor, nausea and vomiting; and sertraline and cyclobenzaprine may cause confusion, hallucination, seizure, tremor, nausea and vomiting. During an interview on 01/31/2023, at 2:00 PM, the director of nursing indicated the medication interaction list should have been sent to the physician for review. 4. Clinical record review on 01/30/2023, for patient #3, start of care 06/20/2022, evidenced an agency document titled, “OASIS-D1 Start of Care,” identified as the comprehensive assessment. This document indicated no issues were found during drug regimen review. Record review of an agency document dated 06/21/2022, titled, “Patient Medication Record,” evidenced duplicate therapy of medication Diclofenac (pain relieving gel) 1% 4 grams apply 4 grams three times a day to the skin and Diclofenac 2 grams apply four times a day; and duplicate medications of hydrochlorathiazide (medication for fluid retention) 25 milligrams one tablet every day, 2nd note hydrochlorathiazide 25 milligrams one tablet every day and losartan hydrochlorathiazide (blood pressure medication) 100/25 milligrams one tablet daily. During an interview on 01/31/2023, at 2:40 PM, the director of nursing indicated she doesn’t know why diclofenac and hydrochlorathiazide are duplicated on the medication list she would need to check. The director of nursing indicated the medications should be reconciled at each nursing visit. 5. Clinical record review on 01/31/2023, for patient #6, start of care 01/18/22, evidenced an agency document titled, “OASIS-D1 Start of Care,” identified as the comprehensive assessment. This document indicated no issues found during drug regimen review. Review of an agency document dated, 01/19/2022, titled, “Patient Medication Record,” indicated a fax was sent to the physician regarding medication discrepancies and severe medication interactions. Review of the paper chart faxed to the physician evidenced the medication list was faxed but failed to evidence the medication interaction list was sent to the physician. Review of a web based source on 01/30/2023, http://www.drugs.com/interactions-check.php,” evidenced the following 4 major drug to drug interactions between medications on patient #6 medication list: sotalol (treat abnormal heart rhythm) and sertraline (antidepressant) may increase risk of irregular heart rhythm; sotalol and albuterol (inhaler used to treat narrowing of airways) may cause narrowing of airways; oxybutynin (medication for overactive bladder) and potassium may have irritant effects on the stomach causing ulcers and bleeding; and hydrocodone (pain reliever) and gabapentin (pain reliever) may cause respiratory distress, coma and death. During an interview on 02/01/2023, at 12:23 PM, the administrator indicated the medication interactions were not sent to the physician because of a computer glitch due to software issue that was corrected. 410 IAC 17-14-1(a)(1)(B)

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 home health agency failed to ensure they sent 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 in 2 of 2 clinical records reviewed of transferred patients. (#4, #8) Findings include: 1. Record review evidenced an agency policy dated 12/26/2019, titled, “Patient Transfer,” which stated, “… A transfer summary shall be completed … The original Transfer Summary form shall be sent to the new provider or facility … if a client transfers to another health facility or home health agency, a copy of the summary shall be sent with the client ….” 2. Clinical record review on 01/30/2023, for patient #4, start of care 12/19/2022, evidenced an agency document dated 01/11/2023, titled, “OASIS-E Transfer,” which indicated the patient was transferred to an inpatient facility. Review failed to evidence a transfer summary was sent to the inpatient facility. During an interview on 02/01/2023, at 11:40 AM, the director of nursing indicated a transfer summary was not sent to the inpatient facility. 3. Clinical record review on 01/30/2023, for patient #8, start of care 05/17/2022, evidenced an agency document dated 12/31/2022, titled, “Memo to Physician,” which indicated the patient had been hospitalized on 12/27/2022. Review failed to evidence a transfer summary was sent to the hospital. During an interview on 02/01/2023, at 3:00 PM, the director of nursing indicated a transfer summary was not sent to the hospital. The director of nursing indicated transfer and discharge summaries are not sent if patient was sent to the hospital.

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on observation, record review and interview, the home health agency failed to include in the individualized plan of care the types of services, supplies, equipment required, nutritional requirements, all medications and treatments, and patient specific interventions and safety measures ( see tag G574); failed to have the physician review and revise the plan of care as frequently as the patient’s condition requires (see tag G588); failed to promptly alert the physician to any changes in the patient’s condition or needs that suggest the outcomes are not being achieved and/or the plan of care should be altered (see tag G590); failed to integrate services to assure the identification of patients needs that could affect patient safety and treatment effectiveness (see tag G606); failed to provide a written visit schedule consistent with the patient’s most current plan of care (see tag G614); and failed to provide the patient written information regarding the patient’s medication regimen in plan language (see tag G616). Findings: The cumulative effect of these systemic problems resulted in the home health agency’s inability to ensure the provision of quality health care in a safety environment for the Condition of Participation 42 CFR §484.60: Care Planning, Coordination of Services, and Quality of Care. 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 home health agency failed to ensure the individualized plan of care included the types of services, supplies, and equipment required; nutritional requirements, all medications and treatments, patient specific interventions and safety measures in 8 of 8 clinical records reviewed. (#1, #2, #3, #4, #5, #6, #7, #8) Findings include: 1. Record review of an undated agency policy received on 02/01/2023, titled, “Plan of Care,” stated, “… The Plan of Care shall be completed in full to include … diagnostic tests, including laboratory … specific dietary or nutritional requirements … medications, treatments, and procedures … medical supplies and equipment required, and any safety measures to protect against injury ….” 2. Record review of an undated agency policy received on 02/01/2023, titled, “Care Plans,” stated, “… a Care Plan shall be developed with the client and/or caregiver. The interventions shall correspond to the problems identified, services needed and the client goals for the episode of care … The Care Plan shall include, but not limited to … a list of specific interventions with plans for implementations ….” 3. Record review of an undated agency policy received on 02/01/2023, titled, “Medication Orders,” stated, “… Orders for PRN [as needed] Medications must include name, dose, reason for use ….” 4. Clinical record review on 01/27/2023, for patient #1, start of care 12/07/2022, evidenced an agency document titled, “Home Health Certification and Plan of Care,” for certification period 12/07/2022-02/04/2023, which indicated the patient was taking Digoxin (medication for abnormal heart rhythms), and the patient was home bound. Review failed to evidence monitoring/intervals of a digoxin level blood test. During an interview on 01/31/2023, at 2:00 PM, the administrator indicated monitoring of the digoxin level should be included on the plan of care and the administrator would check with the physician. Record review indicated the patient was on Aspirin (medication to reduce pain and to reduce formation of blood clots) 325 mg [milligram] 2 tablets daily. Review failed to evidence safety instructions regarding bleeding precautions. During an interview on 01/31/2023, at 1:10 PM, the director of nursing indicated bleeding precautions are included on the plan of care for patients taking regular aspirin dose of 325 milligrams, but was not included on the plan of care if the patient was on aspirin dose of 81 milligrams. 5. Clinical record review on 01/27/2023, for patient #2, start of care 06/07/2022, evidenced an agency document titled, “Home Health Certification and Plan of Care, “for certification period 12/04/2022-02/01/2023, which indicated the patient received dialysis. Review of an agency document dated 01/10/2023, titled, “LPN (licensed practical nurse) Skilled Nursing Visit,” indicated the patient had a right arm AV Graft (access for dialysis) with an audible bruit (assessment by sound of AV graft site) and palpable thrill (assessment by palpation of AV graft site). Review failed to evidence the plan of care included the AV Graft site assessment and evaluation needs. Review failed to evidence the plan of care included safety measures related to the AV Graft site. During an interview on 01/31/2023, at 2:25 PM, the director of nursing indicated the plan of care should include assessment need of the AV Graft site to include assessing for thrill and bruit. The director of nursing indicated safety measures should be on plan of care to include bleeding precautions, lifting precautions, and no blood pressure assessment with cuff on the AV Graft arm. Review of an agency document dated 12/29/2022, titled, “LPN Skilled Nursing Visit,” indicated the patient utilized a medical alert device PRN (as needed). Review failed to evidence the plan of care safety measures included the medical alert device. During an interview on 01/31/2023, at 2:30 PM, the director of nursing indicated the medical alert device should be included in the patient’s safety measures and would only be included in the orders if the physician ordered the medical alert device. Review of the plan of care evidenced medications which stated, “… Nystatin external 10000 unit/GM [gram] apply to affected area as needed … Cyclobenzaprine HCL [hydrochloride] oral 10 mg 1 tab 3 times per day as needed ….” Review failed to evidence indications for as needed medication. During an interview on 01/31/2023, at 1:55 PM, the director of nursing indicated the reason for the as needed medication should be included on the plan of care medication list. 6. Clinical record review on 01/30/2023, for patient #3, start of care 06/20/2022, evidenced an agency document titled, “Home Health Certification and Plan of Care,” for certification period 12/17/2022-02/14/2023 which indicated skilled nurse to report fasting blood sugar of 60 or > 250. Review evidenced an agency document dated 12/13/2022, titled, “OASIS (outcome and assessment information set)-D1 Recertification,” which indicated the patient wore a continuous glucose monitor and the sensor was due to be changed in 12 days. Review of the plan of care failed to evidence the continuous glucose monitor or the sensor change frequency. During an interview on 01/31/2023, at 2:45 PM, the director of nursing indicated the plan of care should include the continuous glucose monitor and sensor change frequency. The director of nursing indicated the husband just knows when to change the sensor. Observation of a home visit for patient #3 on 01/30/2023, at 7:30 AM, evidenced the patient wore ted hose (stockings that help prevent swelling in the legs) to the legs for swelling. Review of the plan of care failed to evidence the use of ted hose. During an interview on 01/31/2023, at 3:30 PM, the director of nursing indicated the ted hose should be on the plan of care and should be included on the education narrative. 7. Clinical record review on 01/30/2023, for patient #4, start of care 12/19/2022, evidenced an agency document titled, “Home Health Certification and Plan of Care,” for certification period 12/19/2022-02/16/2023, which evidenced the medication Norco (pain medication). The plan of care stated, “… Norco oral 5-325 milligrams 1 tab by mouth as needed for pain ….” Review failed to evidence the frequency of the Norco medication. During an interview on 02/01/2023, at 11:42 AM, the director of nursing indicated the physician did not give a frequency to the Norco, but the patient only takes one per day. The director of nursing indicated she understood what the concern was regarding the frequency of the Norco but that she can’t make up the frequency if the physician did not indicate the frequency. 8. Clinical record review on 01/30/2023, for patient #5, start of care 06/20/2019, evidenced an agency document titled, “Home Health Certification and Plan of Care,” for certification period 01/30/2023-03/30/2023 which stated, “…Nutritional Requirements Other: Flush with 60 milliliters. Enteral Nutrition Kate Farms [formula] Amount 1300 cc [cubic centimeters] /day via Gravity Peg [feeding tube that goes into the stomach] Bolus [tube feeding given like a meal, a larger amount is given in a short period of time] ….” Review failed to evidence the plan of care included the frequency and amount of the peg tube formula. Review failed to evidence the plan of care included the frequency and schedule of the flush. During an interview on 02/01/2023, at 12:00 PM, the director of nursing indicated the peg tube formula should be on the medication list of the plan of care. The director of nursing indicated the peg tube frequency, amount and interval of formula; and the flushing frequency, if it was before the formula after the formula or in between feedings, the flush should be included on the plan of care. 9. Clinical record review on 01/30/2023, for patient #6, start of care 01/18/2022, evidenced an agency document titled, “Home Health Certification and Plan of Care,” for certification period 01/13/2023-03/13/2023, which indicated the orders were for the skilled nurse to notify the physician if the patient's weight was greater than 5 pounds or less than 5 pounds. Review of agency documents dated 12/27/2022, 01/05/2023, 01/19/2023, titled, “LPN [licensed practical nurse] Skilled Nursing Visit" failed to evidence the weight of the patient. During an interview on 02/01/2023, at 12:23 PM, the administrator indicated the patient was unable to be weighed and was unable to get on the scale. The administrator indicated he would need to remove the weight assessment from the plan of care. Review failed to evidence the plan of care was individualized. 10. Clinical record review on 01/30/2023, for patient #7, start of care 05/11/2022, evidenced an agency document titled, “Home Health Certification and Plan of Care,” for certification period 09/08/2022-11/06/2022, which indicated the patient had type 2 diabetes mellitus, and dementia (loss of cognitive functioning). Review failed to evidence the plan of care included the frequency of blood sugar testing or the caregiver responsible for testing the blood sugar. During an interview on 02/01/2023, at 2:30 PM, the director of nursing indicated the blood sugars were being checked at the patient’s assisted living facility and the plan of care should include the blood sugar testing and frequency. 11. Clinical record review on 01/30/2023, for patient #8, start of care 05/17/2022, evidenced an agency document titled “Home Health Certification and Plan of Care,” for certification period 11/13/2022-01/11/2023, which indicated the patient primary diagnosis of type 2 diabetes mellitus and moderate intellectual disabilities and lived in a 24 hour supportive living services facility. Review failed to evidence the plan of care included the frequency of the blood sugar testing or the caregiver responsible for testing the blood sugar. During an interview on 02/01/2023, at 3:10 PM, the director of nursing indicated the group home was testing her blood sugars and should be included on the plan of care. Review of an agency document titled, “Home Health Certification and Plan of Care,” for certification period 11/13/2022-01/11/2023, evidenced medications which stated, “… A&D External Dime size use daily as needed … Triple Antibiotic External Dime Size use daily as needed to affected area ….” The review failed to evidence an indication for as needed medication. During an interview on 02/1/2023, at 3:00 PM, the director of nursing indicated the reason for the as needed medication should be included on the plan of care medication list. 410 IAC 17-13-1(a)(1)(D)(ii, viii, ix, x, xiii)

Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient's condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the physician reviewed and revised the plan of care as frequently as the patient’s conditions required in 1 of 3 transferred/discharged clinical charts reviewed. (#4) Findings include: Record review evidenced an undated agency policy received on 02/01/2023, titled, “Care Plans,” which stated, “… The Care Plan shall be reviewed, evaluated, and revised (minimally every 60 days and as needed) based upon the client’s health status and/or environment, ongoing client assessments ….” Clinical record review on 01/30/2023, for patient #4, start of care 12/19/2022, evidenced an agency document titled, “OASIS [outcome assessment and information set]-E Resumption of Care,” which indicated the patient was admitted to the hospital from 01/11/2023-01/16/2023 and was discharged with a urinary catheter (a flexible tube that collects urine from the bladder and leads to a drainage bag). Review of an agency document titled, “Home Health Certification and Plan of Care,” for certification period 12/19/2022-02/16/2023, failed to evidence instructions for the urinary catheter. During an interview on 02/01/2023, at 11:45 AM, the director of nursing indicated there were no new orders for the urinary catheter so did not update the plan of care. The director of nursing indicated the urinary catheter was removed by the urologist on 01/26/2023. 410 IAC 17-13-1(a)(2)

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview the home health agency failed to ensure they promptly alerted the physician to any changes in the patient’s condition or needs that suggest the outcomes were not being achieved and/or the plan of care should be altered in 4 of 6 active clinical records reviewed. (#1, #2, #3, #4) Findings include: 1. Record review of an undated agency policy received on 02/01/2023, titled, “Plan of Care,” stated, “Home care services are furnished under the supervision and direction of the client’s physician. The plan of care is based on a comprehensive assessment and information provided by the client/family and health team members … The plan will be consistently reviewed to ensure the client needs are met, and will be updated as necessary … Professional staff shall promptly alert the physician to any changes that suggest a need to alter the Plan of Care …” 2. Clinical record review on 01/27/2023, for patient #1, start of care 12/07/2022, evidenced an agency document titled, “Home Health Certification and Plan of Care,” for certification period 12/07/2022-02/04/2023, which indicated the patient had diagnoses of hypertension (elevated blood pressure), heart murmur, heart valve replacement and was on Digoxin (a medication to treat irregular heartbeat). Record review of an agency document dated 01/09/2023, titled, “PTA [physical therapy assistant] Visit,” indicated the patient had an episode of rapid heart rate on 01/08/2023, with feeling of fatigue which lasted a few hours. Record review of an agency document dated 01/11/2023, titled, “PTA Visit,” indicated the patient had a squeezing feeling in her chest and that it lasted less than 30 minutes on 01/10/2023. Record review of an agency document dated 01/27/2023, titled, “PTA Visit,” stated, "... Patient said that on Wednesday she had another heart episode ...." Record review failed to evidence physician notification of patient’s symptoms documented on 01/09/2023, 01/11/2023, and 01/27/2023. Observation during a home visit on 01/27/2023, at 10:00 AM, the patient indicated she had what was described as a "heart episode" on Wednesday. During an interview on 01/31/2023, at 1:10 PM, the director of nursing indicated the PTA should notify the agency case manager and physician. The director of nursing indicated the physician should be notified of any patient concerns. During an interview on 01/31/2023, at 1:15 PM, the administrator indicated the patient should be evaluated and vitals signs done prior to continuing physical therapy. 3. Clinical record review on 01/27/2023, for patient #2, start of care 06/07/2022, evidenced an agency document titled, “Home Health Certification and Plan of Care,” for certification period 12/04/2022-02/01/2023, which indicated the patient had peripheral vascular disease (narrowed arteries reduce flow to legs). Review evidenced an agency document dated 12/29/2022, titled, “LPN [licensed practical nurse] Skilled Nursing Visit,” which indicated the patient had an excoriated area 2 cm [centimeter] x 2 cm to abdominal fold. During an observation of a home visit on 01/31/2023, at 9:00 AM, the patient was observed to have 2 scabbed areas on right front anterior leg surrounded by pink skin. The patient indicated the area was opened and was being covered with a bandage and she had left it open to air now that it had closed. Review failed to evidence documentation of physician notification of the abdominal excoriation or the leg skin change in condition. During an interview on 01/31/2023, at 2:00 PM, the director of nursing indicated the physician should be notified if there was new skin breakdown. 4. Clinical record review on 01/30/2023, for patient #3, start of care 06/20/2022, evidenced an agency document titled, “Home Health Certification and Plan of Care,” for certification period 12/17/2022-02/14/2023, which indicated the skilled nurse should report a fasting blood sugar of less than 60 or greater than 250. Review evidenced the plan of care updated on 12/13/2022, by the director of nursing, stated, "... her waking AM glucose today was 59 upon waking at 6am and then 135 after meal ...." Review failed to evidence the physician was notified of the fasting blood sugar of 59. During an interview on 01/31/2023, at 2:48 PM, the director of nursing indicated she left a message with the physician’s office regarding the blood sugar but doesn’t remember if the office called back, and should have been documented in the communication notes. Record review evidenced an agency document dated, 01/02/2023, titled, “LPN Skilled Nursing Visit,” which indicated the patient had a blister on the left ankle of 2 centimeters by 2 centimeters. The patient was instructed on skin care, avoid bursting blister, signs and symptoms of infection, keep skin clean, dry and moisturized and when to notify the skilled nurse/medical doctor. Review failed to evidence the physician was notified of the blister. During an interview on 01/31/2023, at 2:50 PM, the director of nursing indicated a nurse practitioner visit was scheduled to see the patient regarding the left ankle blister and should have been documented in the chart of the physician notification. 5. Clinical record review on 01/30/2023, for patient #4, start of care 12/19/2022, evidenced an agency document dated 01/10/2023, titled, “PTA Visit,” which indicated the patient was received by the PTA sitting in the recliner with knees up due to stomachache. The PTA indicated poor endurance and complaints of stomach pain limited therapy activity. The PTA noted the patient did not feel well and stomach hurt. Record review evidenced an agency document titled, “OASIS [outcome and assessment information set] E Transfer,” dated, 01/11/2023, which indicated the patient was very weak and taken to emergency room via ambulance for concern of possible gastrointestinal bleed Review failed to evidence the PTA promptly notified the home health agency's clinical manager or the physician of the patient's complaints on 01/10/2023. During an interview on 02/1/2023, at 11:50 AM, the director of nursing indicated the PTA notified the agency of the patient’s complaints on 01/11/2023, and the agency nurse saw patient for an evaluation the day of notification. 410 IAC 17-13-1(a)(2)

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure integrated services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines in 2 of 6 active clinical records reviewed. (#2, #5) Findings include: 1. Record review of an undated agency policy received on 02/01/2023, titled, “Coordination of Client Services,” stated, “… The agency will integrate services, whether they are provided directly or under contract, to assure the identification of client needs and factors that could affect client safety and the effectiveness of treatment. The coordination of care is provided by all disciplines and included communication with physicians … Coordination of care means assuring that the client needs are continually assessed, addressed in the Plan of Care, that care is delivered in a timely and effective manner, and that goals are achieved. The agency will coordinate the nursing, therapy, aide and social work services ….” 2. Record review of an undated agency policy received on 02/01/2023, titled, “Plan of Care,” stated, “… The Plan of Care is based on a comprehensive assessment and information provided by the client/family and health team members. The plan will be consistently reviewed to ensure that client needs are met … 3. Clinical record review on 01/27/2023, for patient #2, start of care 06/07/22, evidenced an agency document titled, “Home Health Certification and Plan of Care,” for certification period 12/04/2022-02/01/2023, indicated patient’s skilled nursing goals was to keep all scheduled dialysis days with a target date of 02/01/2023. Review of an agency document dated 12/01/2022, titled, “OASIS [outcome and assessment information set]-D1 Recertification,” indicated patient was unable to get to dialysis due to medical transportation was not available due to holiday schedule. Review failed to evidence coordination with the patient’s dialysis center to ensure transportation to dialysis. During an interview on 01/31/2023, at 10:00 AM, the patient indicated she scheduled the medical transportation to dialysis herself and was picked up at the corner of her street. The patient indicated there was always difficulty around the holidays scheduling transportation to dialysis due to the dialysis change in schedule. During an interview on 01/31/2023, at 2:54 PM, the director of nursing indicated care had not been coordinated with dialysis center to address transportation. The director of nursing indicated if the patient missed dialysis the physician should be notified, and the agency should call the dialysis center to see why the patient missed the visit. During an interview on 01/31/2023, at 2:54 PM, the alternate administrator indicated the home health agency’s social worker also worked for a dialysis center and the dialysis social worker should work to ensure patient transportation. 4. Clinical record review on 01/30/2023, for patient #5, start of care 06/20/2019, evidenced an agency document titled, “Home Health and Plan of Care,” for certification period 01/30/2023-03/30/2023 indicated the patient required 24-hour dependent care due to traumatic brain injury and indicated the patient had a home health aide from another agency that just started that week. The plan of care indicated the caregiver had a difficult time finding an agency and caregiver had been providing all care and was grateful for the assistance. Review evidenced agency documents titled, “Coordination of Care,” which indicated patient had several different home health agencies providing skilled nursing or home health aide services on 06/03/022, 08/01/2022, 09/28/2022, and 01/28/2023. Review evidenced an agency document dated 12/21/2022, titled, “ST [speech therapy] Re-Evaluation,” which indicated other discipline recommended: occupational therapy but there were none available for traumatic brain injury in the area. During an interview on 02/01/2023, at 12:07 PM, the alternate administrator indicated their agency did not offer a home health aide because the caregiver didn’t need help bathing the patient. The alternate administrator indicated the caregiver had problems getting help during the pandemic. Review failed to evidence the home health agency coordinated services to assist caregiver with finding a home health aide or staff to assist the patient's primary caregiver. 410 IAC 17-12-2(h)

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the home health agency failed to provide a written visit schedule to the patient consistent with the patient’s most current plan of care in 2 of 4 home visits. (#1, #4) Findings include: 1. Record review evidenced an undated agency policy received 02/01/2023, titled, “Plan of Care,” which stated, “… The Plan of Care shall be completed in full to include: … Type, frequency, and duration of all visits/services …” 2. Clinical record review on 1/27/2023, for patient #1, start of care 12/07/2022, evidenced an agency document titled, “Home Health Certification and Plan of Care,” for certification period 12/07/2022-02/04/2023, which indicated the physical therapy was ordered for 2 times a week for 8 weeks. During an observation of a home visit on 01/27/2023, at 10:00 AM, there was not a therapy home visit schedule in the patient’s binder or home. During an interview on 01/27/2023, at 10:40 AM, PTA (physical therapy assistant) #2 indicated the visit schedule was done verbally with the patient. During an interview on 01/31/2023, at 1:45 PM, the director of nursing indicated the physical therapist should put a visit schedule in the patient’s home agency binder. 2. Clinical record review on 01/30/2023, for patient #4, start of care 12/19/2022, evidenced an agency document titled, “Home Health Certification and Plan of Care,” for certification period 12/19/2022-02/16/2023, which indicated physical therapy visits twice a week for 9 weeks and home health aide twice a week for 7 weeks. During an observation of a home visit on 01/30/2023, at 9:30 AM, two home health agency binders were reviewed with no evidence of agency visit schedule available. During an interview on 01/30/2023, at 10:04 AM, home health aide #1 was unable to locate the visit schedule. During an interview on 02/01/2023, at 11:44 AM, the alternate administrator indicated the staff was supposed to write out visit schedule for patient.

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on observation and interview, the home health agency failed to ensure they provided the patient written information regarding the patient’s medication regimen in plain language that does not include medical abbreviations in 4 of 4 home visits. (#1, #2, #3, #4) Findings include: 1. Observation of patient #1, start of care 12/07/2022, during a home visit on 01//27/2023, at 10:00 AM, failed to evidence a medication list provided by the home health agency. During an interview on 1/27/2023, at 10:37 AM, patient #1 indicated no medication list was available. Patient #1 indicated when the nurse came out one time may have reviewed the medications, but no medication list was left by the agency. During an interview on 1/31/2023, at 1:50 PM, the director of nursing indicated the therapist should have put a medication list in the patient’s home binder. The director of nursing indicated the home health agency provides the medication list to the therapist to bring to the patient’s home. 2. Observation of patient #2 during a home visit on 1/31/2023, at 9:00 AM, evidenced a medication list, identified by the patient as the medication list provided by the home health agency. The medication list stated, “… Tramadol [pain medication] 50mg [milligrams] every 6 hours PRN [as needed] ….” Review failed to evidence a medication list written in plain language without medical abbreviations. During an interview on 2/01/2023, at 11:58 AM, the director of nursing indicated the patient’s medication provided by the agency for the patient’s home was the same medication list that was sent to the physician. The director of nursing indicated the prescription “lingo” on the medication list for PRN medication should be changed to as needed for the patient. 3. Observation of patient #3 during a home visit on 1/30/2023, at 7:30 AM, failed to evidence a medication list provided by the home health agency. During an interview on 1/31/2023, at 3:35 PM, the director of nursing indicated a medication list provided by the home health agency should be put into the patient’s home health binder. During an interview on 1/31/2023, at 7:40 AM, patient #3 indicated she does not have a written medication list. 4. Observation of patient #4 during a home visit on 1/30/2023, at 9:30 AM, failed to evidence a medication list in the patient’s 2 home health binders provided by the agency. During an interview on 2/01/2023, at 11:44 AM, the alternate administrator indicated the patient’s medication list should be in the patient’s home health binder agency provided to patient.

Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA's governing body. This STANDARD is not met as evidenced by: Based on record review and interview, the home health agency’s governing body failed to approve the frequency and detail of the data collection for Quality Assessment Performance Improvement (QAPI) program. Findings include: Record review of an undated agency policy received on 02/01/2023, titled, “Quality Assessment and Performance Improvement,” stated, “… The governing body is responsible for ensuring the following: An ongoing program for quality improvement and patient safety is defined, implemented, and maintained ….” Record review of an undated agency policy received on 02/01/2023, titled, “Governing Body,” stated, “… The Governing Body shall assume full legal authority and responsibility for the overall management and operation of Agency. This includes the provision of home health services … the Quality Assessment and Performance Improvement Program ...." Review of the agency's QAPI binder on 02/01/2023, failed to evidence the governing body had approved the frequency and detail of the data collection. During an interview on 02/02/2023, at 10:45 AM, the director of nursing indicated the governing body should approve the frequency and detail of the data collection for the QAPI program, and there was no governing body meeting minutes regarding QAPI. 410 IAC 17-12-2(a)

Activities lead to an immediate correction CFR(s): 484.65(c)(1)(iii) (iii) Lead to an immediate correction of any identified problem that directly or potentially threaten the health and safety of patients. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the performance improvement activities led to an immediate correction of any identified problems that directly or potentially threaten the health and safety of patients. Findings include: Record review of an undated agency policy received on 02/01/2023, titled, “Quality Assessment and Performance Improvement (QAPI),” stated, “… QAPI … Purpose to use performance improvement activities to track adverse client events, analyze their causes and implement preventive actions ….” Review of the agency QAPI binder on 02/01/2023, failed to evidence the QAPI activities led to immediate corrective action of any identified problems that directly or potentially threaten the health and safety of patients. During an interview on 02/02/2023, at 10:50 AM, the director of nursing indicated education and staff training should be implemented when problems are identified on the performance improvement activities.

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on record review and interview, the home health agency failed to conduct at least one performance improvement project yearly. Findings include: Record review evidenced an undated agency policy received on 02/01/2023, titled, “Quality Assessment and Performance Improvement,” stated, “… Performance Improvement Projects … must conduct performance improvement projects. The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the agency services and operations ….” Record review of the agency QAPI (quality assessment performance improvement) binder on 02/01/2023, failed to evidence a performance improvement project. During an interview on 02/02/2023, at 10:36 AM, the director of nursing indicated there was not a performance improvement project and didn’t realize the agency needed to have a performance improvement project.

Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This STANDARD is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure they provided infection control education to all staff annually. Findings include: Record review evidenced an undated agency policy received on 02/01/2023, titled, “Infection Control Education/Training,” which stated, “For each 12 months of employment, all employees and contractors who have contact with the clients in the clients’ resident shall complete in-service training about infection control practices to be used in the home … Employee education shall occur at the time of employment … and annually … Training records will include dates, contents of the training sessions, names and qualifications of instructors, and the names and job titles of attendees….” Record review evidenced an undated agency policy received on 02/01/2023, titled, “In-Service Education/Staff Development,” which stated, “… All staff members must attend … mandatory in-service programs. The mandatory in-service training programs include: OSHA [occupational safety and health administration]/Bloodborne Pathogens and infection control ….” Record review on 02/01/2023, failed to evidence the administrative staff #2, #3, #4, and Registered Nurse #1 received annual infection control training. During an interview on 02/01/2023, at 11:50 AM, the director of nursing indicated she didn’t know infection control training had to be done annually.

COVID-19 Vaccination of Home Health Agency staff CFR(s): 484.70 (d)-(d)(3)(i-x) § 484.70 Condition of Participation: Infection Prevention and Control. (d) Standard: COVID-19 Vaccination of Home Health Agency staff. The home health agency (HHA) must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. For purposes of this section, staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for COVID-19 is defined here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine. (1) Regardless of clinical responsibility or patient contact, the policies and procedures must apply to the following HHA staff, who provide any care, treatment, or other services for the HHA and/or its patients: (i) HHA employees; (ii) Licensed practitioners; (iii) Students, trainees, and volunteers; and (iv) Individuals who provide care, treatment, or other services for the HHA and/or its patients, under contract or by other arrangement. (2) The policies and procedures of this section do not apply to the following HHA staff: (i) Staff who exclusively provide telehealth or telemedicine services outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section; and (ii) Staff who provide support services for the HHA that are performed exclusively outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section. (3) The policies and procedures must include, at a minimum, the following components: (i) A process for ensuring all staff specified in paragraph (d)(1) of this section (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the HHA and/or its patients; (ii) A process for ensuring that all staff specified in paragraph (d)(1) of this section are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations; (iii) A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19; (iv) A process for tracking and securely documenting the COVID-19 vaccination status of all staff specified in paragraph (d)(1) of this section; (v) A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC; (vi) A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law; (vii) A process for tracking and securely documenting information provided by those staff who have requested, and for whom the HHA has granted, an exemption from the staff COVID-19 vaccination requirements; (viii) A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws, and for further ensuring that such documentation contains (A) All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and (B) A statement by the authenticating practitioner recommending that the staff member be exempted from the HHA's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications; (ix) A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and (x) Contingency plans for staff who are not fully vaccinated for COVID-19. This STANDARD is not met as evidenced by: Based on observation, record review and interview, the home health agency failed to implement policies and procedures to ensure the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who were not fully vaccinated. Findings include: Record review of an agency policy dated 11/09/2021, titled, “Mandatory COVID-19 Vaccine Policy and Procedure,” stated, “… Covered Staff Members who are granted exemptions … will be required to take the following steps as a reasonable accommodation in place of becoming Fully Vaccinated. If Staff members, clinical or clerical, have been in direct contact with a person that is actively symptomatic and/or tested positive for COVID-19 they are to monitor for any signs and symptoms for 72 hours, using proper general precautions around patients … If a staff member, clinical or clerical, is symptomatic [fever chills, body aches, etc.] they are not to see patients in the field or be present in the office without testing ….” Review failed to evidence a contingency plan developed to mitigate the spread of COVID-19 infections that may include: requiring unvaccinated staff to follow additional CDC (center for disease control) recommended precautions, such as adhering to universal source control and physical distancing measures in areas that are restricted from patient access, reassigning unvaccinated staff to non-patient areas, or to duties which limit exposure to those most at risk, requiring at least weekly testing for unvaccinated staff, or requiring unvaccinated staff to use a NIOSH (National Institute for Occupational Safety and Health) N95 (filtering facepiece respirator) or equivalent or higher-level respirator for source control, regardless of whether they are providing direct care to or otherwise interacting with patients. Review of an untitled agency document, dated 01/21/2022, identified as the COVID-19 vaccination exemption stated, “… Employees understand that they may be required to take additional steps to protect themselves and other from contracting and spreading COVID-19 when in the field or office … Employee has been given a copy of the Additional Precautions that all unvaccinated staff members are required to follow ….” During an observation on 01/26/2023, at 10:38 AM, unvaccinated administrative staff #2, #3, and governing body member A were observed without a face mask. During an observation on 01/26/2023, at 1:00 PM, unvaccinated administrative staff #1 was observed without a face mask after arriving to the agency office. During an observation on 01/30/2023, at 9:42 AM, unvaccinated home health aide #1 entered the patient’s home without a mask. Home health aide #1 put on a surgical mask at 9:50 AM. During an interview on 01/26/2023, at 3:30 PM, the administrator indicated the home health agency doesn’t have a COVID-19 policy related to unvaccinated staff. The administrator indicated there are no additional precautions to mitigate transmission of COVID-19 for staff not fully vaccinated. The administrator indicated the agency used standard precautions. During an interview on 01/26/2023, at 3:45 PM, the administrator indicated governing body member A was the owner of the home where the home health agency was located in and provided maintenance for the home. The administrator indicated governing body member A doesn’t believe in the vaccine. During an interview on 01/26/2023, at 3:45 PM, the alternate administrator indicated governing body member A was not a direct employee, and the home health agency does not have documentation of governing body member A vaccine status. During an interview on 02/01/2023, at 11:48 AM, the director of nursing indicated no masking in the patient’s home was required for the staff that was vaccinated or unvaccinated for COVID-19. The director of nursing indicated she thought the additional precautions related to COVID-19 were up to the individual agency. The director of nursing indicated the agency was not tracking the status of governing body member A, and indicated it was an oversight and they would begin tracking governing body member A vaccination status. During an observation on 02/02/2023, at 10:25 AM, administrative staff #1, #2, #3, and #4 were observed not wearing masks.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure they provided services ordered by the physician as indicated in the plan of care in 4 of 5 clinical records reviewed with physical therapy services. (#1, #4, #7, #8) Findings include: 1. Record review of an undated agency policy received on 02/01/2023, titled, “Care Plans,” stated, “… Each client will have a care plan on file that address their identified needs and the agency’s plan to respond to those needs. This plan is developed with the client and family, as indicated, and is based on services needed to achieve specific measurable goals … The interventions shall correspond to the problems identified, services needed and the client goals for the episode of care … The Care plan shall include … Reasonable, measurable, and realistic goals as determined by the assessment and client expectations. A list of specific interventions with plans for implementation ….” 2. Record review of an undated agency policy received on 02/01/2023, titled, “Skilled Professional Services,” stated, “… Skilled professional services include skilled nursing services, physical therapy … Skilled professionals who provide services to home health agency clients … must participate in the coordination of care … Skilled professionals must assume responsibility for … ongoing interdisciplinary assessment of the client. Development and evaluation of the plan of care in partnership with the client … Providing services that are ordered by the physician as indicated in the plan of care ….” 3. Record review of an undated agency policy received on 02/01/2023, titled, “Pain Assessment/Management,” stated, “… The Agency will work with the client … to establish a goal for pain relief and develop and implement a plan to achieve that goal … Pain is assessed on every home visit and documented on a pain or symptom flow sheets. Documentation will include the effectiveness of all pain interventions … The documentation will include what interventions were used and describe response/effectiveness of care … The nurse/therapist will use a standardized agency accepted pain assessment tool that evaluates the location, duration, severity (rating scale), alleviating factors, exacerbating factors, current treatments (medication and non-medication) and response to treatment ….” 4. Clinical record review on 01/27/2023, for patient #1, start of care 12/07/2022, evidenced an agency document titled, “Home Health Certification and Plan of Care,” for certification period 12/07/2022-02/04/2023, which indicated the patient was oriented and lived alone. The plan of care indicated physical therapist to determine the patient’s condition, plans and rehab. Review evidenced an agency document dated 12/07/2022, titled, “OASIS [outcome and assessment information set]-D1 Start of Care,” identified as the comprehensive assessment, which indicated intensity of pain at level 5 [on a scale of 0 - 10 with 0 being no pain and 10 the most severe], pain level at 3 after medication. The comprehensive assessment indicated the patient’s pain goal was to lessen pain through physical therapy. Review evidenced agency documents titled, “PTA [physical therapist assistant] Visit,” for 12/16/2022, 01/09/2023, 01/11/2023, 01/18/2023, 01/23/2023, and 01/27/2023 which failed to evidence pre and post therapy pain intensity scale documentation. The PTA Visits indicated pain to the knees increased by movement, relieved by rest and medication, and interferes with walking. 5. Clinical record review on 01/30/2023, for patient #4, start of care 12/19/2022, evidenced an agency document titled, “Home Health Certification and Plan of Care,” for certification period 12/19/2022-02/16/2023, which indicated the physical therapist was to determine the patient’s condition, plans and rehab. Review of agency documents titled, “PTA Visit,” dated 12/28/2022, indicated pain level at intensity 6 pre and post therapy; dated 12/28/2022, indicated pain level at intensity 7 pre and post therapy; dated 01/03/2023, indicated pain level at intensity 6 pre and post therapy; dated 01/05/2023, indicated pain level at intensity 7 pre and post therapy; dated 01/10/2023, indicated pain level at intensity 6 pre and post therapy; and 1/26/2023, indicated pain level at intensity 5 pre and post therapy. 6. Clinical record review on 01/30/2022, for patient #7, start of care 05/11/2022, evidenced an agency document titled, “Home Health Certification and Plan of Care,” for certification period 09/08/2022-11/06/2022, which stated, “... Maintenance physical therapy to determine the patient’s condition, plans and rehab ...." Review of an agency document dated 09/07/2022, titled, “OASIS-D1 Recertification,” identified as the comprehensive assessment, indicated the patient’s pain intensity at 4 through the day and night indicating movement and sitting up makes pain worse. The patient’s pain goal was the patient will have comfort while in bed. Review of an agency document dated 10/03/2022, titled, “PT [physical therapy] Re-Evaluation,” failed to evidence pain assessment. Review of an agency document dated 10/31/2022, titled, “PT Discharge,” failed to evidence pain assessment. Review failed to evidence services were provided as indicated in the plan of care. 7. Clinical record review on 01/30/2023, for patient #8, start of care 05/17/2022, evidenced an agency document titled, “Home Health Certification and Plan of Care,” for certification period 11/13/2022-01/11/2023, which indicated physical therapy to determine the patient’s condition, plans and rehab. Review of an agency document dated 11/11/2022, titled, “OASIS-D1 Recertification,” identified as the comprehensive assessment, indicated the patient’s pain intensity to be at 8, and the patient’s pain goal was to be 1-2. Review of an agency document dated 11/14/2022, titled, “PTA Maintenance,” indicated the patient’s pain intensity to be at 4 to the knee, the document failed to indicate the post therapy intensity. Review of an agency document dated 11/23/2022, titled, “PTA Maintenance,” indicated pre-therapy pain intensity at 4 to the knee. The document failed to indicate the post therapy intensity. 8. During an interview on 01/31/2023, at 1:10 PM, the director of nursing indicated pain level should be documented at each physical therapy visit. 9. During an interview on 01/31/2023, at 1:48 PM, the administrator indicated clinicians should utilize pain scale to document frequency, duration, medication, and pain relief at each visit. 10. During an interview on 02/01/2023, at 11:40 AM, the director of nursing indicated patient’s pain level should be reported to the skilled nurse if not meeting the patient’s pain goals. 410 IAC 17-14-1(a)(1)(H)

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure communication with all physicians involved in the current plan of care for 1 of 1 clinical records reviewed of patients receiving warfarin (blood thinning medication). (#6) Findings include: Record review of an undated agency policy received on 02/01/2023, titled, “Coordination of Client Services,” stated, “… Agency will communicate with ALL physicians who are writing orders regarding the plan of care ….” Clinical record review on 01/30/2023, for patient #6, start of care 01/18/2022, evidenced an agency document titled,” Home Health Certification and Plan of Care,” for certification period 01/13/2023-03/13/2023, which indicated the patient was receiving warfarin. The plan of care indicated the skilled nurse will check the INR (blood level to monitor bleeding time) and call results to the physician. Review of an agency document dated 01/19/2023, titled, “LPN [licensed practical nurse] Skilled Nursing Visit,” indicated doctor B was notified of INR results. The plan of care was signed by doctor C. Review failed to evidence the home health agency coordinated doctor C’s warfarin orders for patient #6 with doctor B. During an interview on 02/01/2023, at 12:15 PM, the administrator indicated doctor C monitors the INR level. The administrator indicated doctor B and doctor C are aware of each other. 410 IAC 17-14-1(a)(1)(G)

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 provides services that were included in the plan of care in 1 of 2 home visits with a home health aide. (#2) Findings include: Record review evidenced an undated agency policy received on 02/01/2023, titled, “Home Health Aide Care Plan,” which stated, “… All home health aide staff will follow the identified plan. The Care Plan will be available to all persons involved in the client care ….” Record review evidenced an undated agency policy received on 02/01/2023, titled, “Home Health Aide: Documentation,” which stated, “… Home Health Aides will document care/services provided on the home health aide chart form. Care/services provided should be in accordance with direction provided in the Home Health Aide Care Plan ….” Clinical record review on 01/27/2023, for patient #2, start of care 06/07/2022, evidenced an agency document titled, “Aide Care Plan,” for dates 12/04/2022-02/01/2023, which indicated home health aide duties to perform included, but not limited to, change linens every visit, make bed every visit, and oral hygiene every visit. Observation of a home health aide visit on 01/31/2023, at 9:00 AM, evidenced the bed linens were not changed, the bed was not made, and oral hygiene was not performed. During an interview on 01/31/2022, at 10:04 AM, patient #2 indicated the home health aide does not ever change the bed linens or make the bed. During an interview on 02/02/2023, at 10:29 AM, the director of nursing indicated the home health aide knows what care was to be provided based on the aide care plan. The director of nursing indicated if care or tasks were not performed by the home health aide it should be documented what was not performed and the home health agency should be notified.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure they provided a supervisory aide visit no less frequently than every 14 days for patients receiving home health aide services in 1 of 3 active patients who received home health aide services. (#4) Findings include: Record review evidenced an undated agency policy received on 02/01/2023, titled, “Home Health Aide Supervision,” which stated, “… Supervisory visits of Home Health Aides shall be according to the following frequency: When skilled services are being provided to a client, a Registered Nurse/Therapist must make a supervisory visit to the client’s resident no later than every 14 days [either when the Home Health Aide is present to observe and assess care delivery, or when the Home Health Aide is absent] to assess relationships and determine whether goals are being met … Supervisory visits are to be documented in the client’s chart on the Home Health Aide Supervision Form … The aide visit record is reviewed by the supervising nurse/therapist to assure services are being provided according to the care plan….” Clinical record review on 01/30/2023, for patient #4, start of care 12/19/2022, evidenced an agency document titled, “Home Health Certification and Plan of Care,” for certification period 12/19/2022-02/16/2023, which indicated an order for home health aide services 2 times per week for 7 weeks. Review indicated patient had visits by the home health aide 12/26/2022, 12/30/2022, 01/02/2023, 01/06/2023, 01/09/2023, 01/20/2023, 01/23/2023, 01/27/2023, and 01/30/2023. Record review failed to evidence any supervisory visits. During an interview on 02/01/2023, at 11:30 AM, the director of nursing indicated there were no supervisory aide visits documented and she would check to see why the supervisory visits were not in the chart.

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on observation, record review and interview, the home health agency failed to ensure services were provided in accordance with current clinical practice guidelines and accepted professional standards of practice. Findings include: Record review evidenced an undated agency policy received on 02/01/2023, titled, “Equipment and Supplies Management,” which stated, “…Equipment and/or supplies will be properly stored, cleaned, and maintained by Agency staff before client usage … All agency staff is required to read packaging labels for directions regarding temperature effect on items. Manufacturer’s direction will be adhered to ...." During an observation on 01/27/2023, at 12:30 PM, an agency refrigerator was evidenced with Sanofi Tuberculin Purified Protein (a skin test to check for an infectious lung disease) . The Tuberculin Purified Protein vial was opened and in the manufacturer’s box. The manufacturer’s box indicated discard open product after 30 days. There was no date documented when vial was opened on the manufacturer box or the vial. During an interview on 01/27/2023, at 12:30 PM, the administrator indicated he did not know the Tuberculin Purified Protein had to be discarded 30 days after opening of the vial.