Every finding on record at Tender Love Home Services LLC

An Emergency Preparedness Survey was conducted in accordance with 42 CFR 484.102 by the Indiana Department of Health. Survey Dates: 2/11/2025 to 2/14/2025 Census: 2

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 agency failed to ensure emergency preparedness training was provided and documented every 2 years in 5 out of 5 personnel records reviewed with direct patient care (CM, Alternate CM, HHA 1, HHA 2, HHA 3). Findings include: The emergency preparedness documentation provided by agency and the personnel record for CM, Alternate CM, HHA 1, HHA 2, and HHA 3 failed to evidence emergency preparedness training provided in the years 2022, 2023, and 2024. During an interview on 2/12/2025 beginning at 11:03 AM, a review of emergency preparedness training was conducted for the personnel records for CM, Alternate CM, HHA 1, HHA 2, and HHA 3. CM relayed emergency preparedness training had not been conducted with the reviewed personnel since prior to 2022.

This visit was for a Federal Recertification and State Re-licensure survey of a Home Health provider. Survey Dates: 2/11/2025 to 2/14/2025 Unduplicated skilled admissions: 0 This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Refer to State Form for additional State Findings. A partially Extended Survey was announced to the Administrator on 2/12/2025 at 12:25 PM. Abbreviations used in report: Home Health Aide [HHA], Clinical Manager [CM], Registered Nurse [RN], Plan of Care [POC], Start of Care [SOC], Skilled Nurse [SN], Physical Therapist (PT), Occupational Therapist (OT), Speech Therapist (ST), Masters social worker (MSW), Activities of daily living (ADL), Durable Medical Equipment (DME), Quality Assurance Performance Improvement (QAPI).

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure an initial assessment was conducted within 48 hours of referral or the practitioner ordered start of care dated in 1 of 1 active clinical record reviewed of a bedbound patient (Patient #1). Findings include: 1.The clinical record for Patient #1 included an Intake Referral form dated 2/5/2024 for requested HHA services eight hours a day, Monday through Friday. The clinical record included a start of care dated 2/20/2024. The clinical record failed to evidence an initial assessment within 48 hours of referral, nor a physician ordered start of care date. During an interview on 2/12/2025 beginning at 11:03 AM, CM relayed services were started when Patient’s benefits were active and did not provide documentation that the physician was aware of the delay. 410 IAC 17-14-1(a)(1)(A)

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 content of the comprehensive assessment accurately reflected the patient’s health, psychosocial, functional, and cognitive status in 2 of 2 active clinical records reviewed (Patients #1, 2). Findings include: 1.The clinical record for Patient #1 included a comprehensive reassessment dated 12/11/2024 that indicated Patient had wounds and a wound vac (negative pressure wound therapy). The comprehensive reassessment failed to evidence the location, measurement, nor assessment of wounds and wound vac. During an interview on 2/12/2025 beginning at 11:03 AM, CM revealed the wound assessment was not completed on the comprehensive assessment because another agency was managing the wound. 2. The clinical record for Patient #2 included a start of care on 9/28/2024 and a comprehensive reassessment documented on 1/21/2025 that failed to evidence a pain assessment. During an interview on 2/12/2025 beginning at 11:03 AM, the administrator revealed a pain assessment should be a part of the comprehensive assessment. 410 IAC 17-14-1(a)(1)(B)

Primary caregiver(s), if any CFR(s): 484.55(c)(6)(i,ii) The patient's primary caregiver(s), if any, and other available supports, including their: (i) Willingness and ability to provide care, and (ii) Availability and schedules; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment accurately reflected the patient’s primary caregiver, available support, and their willingness, ability, availability, and schedules to provide care in 1 of 1 active clinical record with a home visit (Patient #1). Findings include: During a home visit observation on 2/12/2024 beginning at 7:28 AM, HHA 2 relayed the availability of Patient #1’s caregiver, Other 1, was not often available on evenings and weekends. HHA 2 revealed Other 1 worked 24 hours shifts and Patient was often alone when HHA services were completed. The clinical record for Patient #1 included a comprehensive reassessment, dated 12/11/2024, which indicated Patient was dependent on others to complete ADL’s and to get out of bed. The assessment included Patient’s primary caregiver was Other 1, a family member, that was available on evenings and weekends, with notation Other 1 worked full time outside of the home. The clinical record failed to evidence an assessment of Other 1’s schedule, availability, and ability to care for Patient.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to ensure each patient received the home health services that are written in the individualized plan of care that identifies patient-specific measurable outcomes and goals in 1 of 1 skilled active clinical record (Patients #2) and one of one closed clinical record of a patient with input and and output measurements ordered (Patient #6). Findings include: 1. The clinical record for Patient #2 included a POC dated 1/26/2025 to 3/26/2025 for SN visits every two weeks and HHA services three times a week, on Monday, Wednesday, and Friday, for nine weeks for 2 hours per visit. The clinical record included missed visits dated 12/25/2024, 01/01/2025, and 2/20/2025 due to holidays. The clinical record failed to evidence the three HHA visits were made during the week of 12/25/2024, 1/1/2025, and 2/20/2025 nor were the agencies attempts to reschedule the services documented. During an interview on 2/12/2025 beginning at 11:03 AM, CM relayed the agency did not make attempts to make up the missed visits due to holidays. 2. The closed clinical record for Patient #6 included a POC dated 12/9/2021 to 2/6/2022 for SN services twice a week for one week then Monday through Friday for 3 hours per day for eight weeks to administer enteral (providing nutritional support directly into the gastrointestinal tract through a tube) nutrition, monitor vital signs, and monitor intake and output (measurement of fluids that enter and leave the body). The clinical record included SN visits documented on 2/4/2022, 2/1/2022, 1/31/2022, 1/28/2022, 1/27/2022, 1/26/2022, 1/25/2022, 1/24/2022, 1/21/2022, 1/20/2022, and 1/19/2022 that documented occurrence of diapers changed and failed to evidence documentation of fluid intake and fluid output by weighing diapers (1 gram weight equals 1 milliliter of fluid). The clinical record failed to evidence intake and output was recorded. During an interview on 2/14/2025 beginning at 8:40 AM, the CM revealed the intake and output was not recorded. 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 record review, observation, and interview the agency failed to ensure the individualized POC included patient’s psychosocial status, types of services, supplies and equipment required, nutritional requirements, and safety measures to protect against injury in 2 of 2 active clinical records reviewed (Patients #1, 2) and 2 of 4 closed clinical records reviewed (Patients #5, 6). Findings include: 1.During a home visit observation on 2/12/2025 beginning at 7:28 AM, HHA 2 provided personal care for Patient #1. Patient was on a hospital bed with an electric air mattress and a Hoyer lift (a mechanical lift to transfer a person) was in the home. The clinical record for Patient #1 included a POC dated 12/16/2024 to 2/12/2025 for SN and HHA services. The comprehensive assessment dated 12/11/2024 indicated Patient had a wound vac (negative pressure wound therapy) managed by another agency. The POC failed to include the wound vac nor air mattress as DME required for Patient care. During an interview on 2/12/2025 beginning at 11:03 AM, CM relayed Patient had a wound vac and an air mattress at the time of the 12/11/2024 comprehensive assessment. She revealed the wound vac nor the air mattress were included in the DME list for Patient’s 12/16/2024 to 2/12/2025 POC. 2. The clinical record for Patient #2 included a POC dated 1/26/2025 to 3/26/2025 for SN visits every two weeks and SN to change foley catheter (urinary catheter) every month. The DME and supplies list on the POC failed to evidence foley catheter supplies. The POC indicated Patient’s medication list included Aspirin daily and the safety precautions on the POC failed to evidence bleeding precautions. During an interview on 2/12/2025 beginning at 11:03 AM, the CM revealed the safety precautions should have included bleeding precautions due to Patient taking aspirin. 3. The closed clinical record for Patient #5 included a POC dated 5/24/2024 to 7/22/2024 for SN visits 1-2 times a month and HHA services four hours a day and seven days a week. The POC failed to evidence Patient’s diet nor nutritional requirements. During an interview on 2/14/2025 beginning at 8:40 AM, the CM relayed the Patient’s nutritional requirements were not included in the POC. 4. The closed clinical record for Patient #6 included a POC dated 12/9/2021 to 2/6/2022 for SN services twice a week for one week then Monday through Friday for 3 hours per day for eight weeks to administer enteral (providing nutritional support directly into the gastrointestinal tract through a tube) nutrition and Patient nutritional requirements included nothing by mouth with Natural food blend 27 ounces daily per peg tube(surgically placed tube in stomach to provide nutrition that requires flushing to prevent blockages). The POC failed to evidence the feeding schedule for the 27 ounces of nutrition nor an ordered amount and type of flush for peg tube. 410 IAC 17-13-1(a)(1)(D)(ii, xiii, x)

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on record review and interviews, the agency failed to ensure services and treatments were administered only as ordered by a physician in 1 of 2 active clinical records reviewed (Patient #1). Findings include: The clinical record for Patient #2 included a POC dated 1/26/2025 to 3/26/2025 for SN visits every two weeks and SN to change foley catheter (urinary catheter) every month. The clinical record included an order dated 11/26/2024 for SN to change foley catheter monthly and as needed. The SN visit note dated 01/06/2025 indicated foley catheter was changed, using an 18 French catheter. The physician order for a foley catheter procedure failed to evidence the size. During an interview on 2/12/2025 beginning at 11:03 AM, CM revealed the size of the urinary catheter was not included in the order. 410 IAC 17-13-1(a)

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observations and interviews, the agency failed to ensure accepted standards of practice to prevent the transmission of infections and diseases were followed in 1 of 1 active clinical record with a home visit (Patient #1). Findings include: During a home visit on 2/12/2025 beginning at 7:28 AM, HHA 2 provided care for Patient #1. HHA 2 washed her hands and reached in her supply bag and removed a thermometer and obtained a measurement on Patient. HHA 2 reached back into the supply bag and removed a blood pressure cuff, applied the cuff to Patient’s wrist and started the automated blood pressure measurement. HHA 2 failed to evidence sanitizing hands prior to entering supply bag. After obtaining vital signs, HHA 2 used hand sanitizer liquid on paper towel to wipe the vital signs supplies and returned the items back into her bag. During an interview, on 2/14/2025 beginning at 8:40 AM, the Administrator relayed all staff were trained on the type of disinfectant product to use on their supplies, used in patients home, and using hand sanitizer on a paper towel was not sufficient. 410 IAC 17-12-1(m)

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on record review and interviews, the agency failed to ensure the RN assigned tasks appropriate to the HHA in 2 of 2 active clinical records reviewed (Patients #1, 2) and 1 of 3 closed clinical records with HHA services (Patient #5). Findings include: 1. The clinical record for Patient #1 included a POC dated 12/16/2024 to 2/13/2025 for SN services once to twice a month and HHA services Monday through Friday for 8 hours per day and indicated Patient safety measures included bleeding precautions. The record included a comprehensive reassessment dated 12/11/2024 indicating Patient needed assistance for oral hygiene. The HHA POC, last reviewed for updated on 12/20/2024 by CM, indicated HHA to provided mouth or denture care when Patient requested, to prep meals, and to serve meals. The HHA POC failed to evidence Patient’s diet as ordered by a physician nor safety measures. During an interview on 2/12/2025 beginning at 11:03, the CM revealed Patient was able to do oral care and required assistance to complete the task. CM relayed oral care was not a task included in the HHA POC nor were safety precaution and Patient’s diet included in the HHA POC. 2. The clinical record for Patient #2 included a POC dated 1/26/2025 to 3/26/2025 for SN visits every two weeks and HHA visits Monday, Wednesday, and Friday for 2 hours per day. The POC revealed Patient safety measure included: fall precautions and seizure (convulsions) precautions and Patient’s was prescribed a diabetic diet. The clinical record included an HHA POC, last reviewed on 1/22/2025 by CM, revealed HHA tasks to include prepare meals and serve meals. The HHA POC failed to evidence safety precautions nor Patient’s diet. The clinical record included a comprehensive reassessment dated 1/21/2025 and documented by CM that indicated Patient was able to bathe in the shower or tub only with the assistance of another person. The HHA POC included the task “assist at sink” and failed to evidence the task of assistance with a shower or tub bath. During an interview on 2/12/2025 beginning at 11:03 AM, the CM relayed Patient needs assistance to bathe and the task to “assist at sink” was to assist Patient to “wash up”. 3. The closed clinical record for Patient #5 included a POC dated 5/24/2024 to 7/22/2024 for SN visits 1-2 times a month and HHA services four hours a day and seven days a week. The POC included safety measures including clear paths, infections control measures, fall prevention, and require assistance to ambulate safely. The HHA assignment sheet failed to include Patient safety measures. During an interview on 2/14/2025 beginning at 8:40 AM, the CM revealed Patient safety measures were not included on the HHA POC. 410 IAC 17-14-1(m)

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 record review and interviews, the agency failed to ensure the HHA provided services consistent with HHA training in 1 of 1 active clinical record of a patient that requires a mechanical lift to move patient (Patient #1). Findings include: The clinical record for Patient #1 included a POC dated 12/16/2024 to 2/13/2025 for SN services once to twice a month for two months and HHA services eight hours a day, Monday through Friday each week. The POC indicated a Hoyer life (mechanical lift using a sling to transfer a patient) was required to transfer or transport Patient. HHA visits were documented and dated January 13, 15, 17, 22, 24, 27, 29, and 31, of 2025 by HHA 2 which indicated Patient was assisted with a transfer out of bed and assisted with transfer back to bed. The personnel record for HHA 2 included a hire date of 5/24/2013 and failed to evidence Hoyer lift nor mechanical lift training. During an interview on 2/14/2025 beginning at 8:40 AM, CM relayed there was not documentation that HHA was trained to use a mechanical lift to move a patient.

This visit was a recertification, re-licensure, and emergency preparedness survey. The survey visit took place from 2/10/2022 to 2/15/2022. Facility ID: 012817 At this Emergency Preparedness survey, Tender Love Home Services LLC was found to be in compliance with 42 CFR 484.102 Emergency Preparedness Requirements for Medicare Participating Providers and Suppliers for Home Health Agencies.

This visit was a recertification, re-licensure, and emergency preparedness survey. The survey visit took place from 2/10/2022 to 2/15/2022. Due to low patient census and patient refusals of home visits due to the Covid pandemic, 2 home visits were completed for this survey. Facility ID: 012817 These deficiencies reflect State Findings cited in accordance with 410 IAC 17. Refer to state form for additional state findings. Quality Review Completed 02/23/2022

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 home health agency failed to ensure the plan of care contained complete medication orders for all patient medications in 7 of 7 records reviewed (#1, #2, #3, #4, #5, #6, #7). The findings include: 1. Record review on 2/15/2022, evidenced an agency policy titled, "Care Planning, coordination, quality of care Policy", reviewed 4/2/2021, which stated, " ... The plan of care ... covers all pertinent Diagnoses, including mental status, types of services and equipment required ... medications and treatments ... Plan of care must include the following: ... All medications and treatments...." 2. Clinical record review for patient #1 on 2/11/2022, start of care 6/25/2018, certification period 2/4/2022 to 4/4/2022, primary diagnosis of Cerebral Vascular Accident (stroke), evidenced an untitled agency document identified by the clinical supervisor as the plan of care, signed by the physician on 2/4/2022. The plan of care had a subsection titled, "Medications;", which stated, " ... Prostat Liquid [a liquid protein] 30 ml (tues, thurs, sat) ... Probiotic 1 per peg tube [feeding tube] BID [twice a day], Miralax [a laxative] 30 mL [milliliter] Q [every] (tues, thurs, sun), Tylenol [a pain and fever reducing medication] 5 ml PRN [as needed] Q 6 hrs. ... Silvadene [a topical antibiotic used to treat burns] 1% cream topically prn, Tinactin [a topical anti-fungal] 1% powder under breast prn ... Multivitamin 10 mLs (Tue, Th, Sat) ... Guaifenesin [a cough and cold medication] 100 mg [milligram] / 5mL per peg tube q6hrs prn ... Flexeril [a muscle relaxant] 10 mg per peg tube BID prn ... Nystatin [an anti-fungal] ointment top [topical] prn, Prep H [preparation H] [ a hemorrhoid treatment] rectally prn, Loperamide [an anti-diarrheal] 2 mg per peg tube QID [four times a day] prn, Zofran [an anti-nausea medication] 5 mL per peg tube q8hr [every 8 hours] prn...." Review of the plan of care failed to evidence a route for taking Prostat, Tylenol, and Multivitamin. Review of the plan of care failed to evidence a frequency for taking Silvadene, Tinactin, Nystatin, and Preparation H. Review of the plan of care failed to evidence an amount/dosage for the Probiotic. Review of the plan of care failed to evidence the indication for use of the as needed medications: Tylenol, Silvadene, Guaifenesin, Flexeril, Nystatin, Preparation H, Loperamide, and Zofran. 3. Clinical record review for patient #2 on 2/11/2022, start of care 8/12/2014, certification period 1/2/2022 to 3/2/2022, primary diagnosis of Paraplegia (paralysis effecting the lower half of the body), evidenced an untitled agency document identified by the clinical supervisor as the plan of care, signed by the physician on 12/28/2022. The plan of care had a subsection titled, "Medications;", which stated, " ... Oxycodone [a narcotic pain reliever] 7.5 mg PO [by mouth] q 4 hrs prn ... Senna Lax [a laxative] 8.6 mg 2 tabs PO prn ... Zofran 4 mg PO Q 8 hr prn...." Review of the plan of care failed to evidence an indication for use of Oxycodone, Senna Lax, and Zofran. 4. Clinical record review for patient #3 on 2/11/2022, start of care 4/10/2013, certification period 12/24/2021 to 2/21/2022, primary diagnosis of Dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), evidenced an untitled agency document identified by the clinical supervisor as the plan of care, signed by the physician on 12/21/2022. The plan of care had a subsection titled, "Medications;", which stated, " ... Mucinex [a cough and cold medication] 600 mg PO BID PRN...." Review of the plan of care failed to evidence an indication for use of Mucinex. 5. Clinical record review for patient #4 on 2/11/2022, start of care 11/20/2019, certification period 1/8/2022 to 3/8/2022, primary diagnosis of Degenerative Joint Disease (a type of arthritis that occurs when flexible tissue at the ends of bones wears down), evidenced an untitled agency document identified by the clinical supervisor as the plan of care, signed by the physician on 1/19/2022. The plan of care had a subsection titled, "Medications;", which stated, " ... Vit [vitamin] B6 PO Daily, Multivitamin PO Daily, Bisacodyl [a laxative] PO Daily ... Loperamide [an anti-diarrheal] 2 mg PO PRN, Cyclobenzaprine [a muscle relaxant] 5 mg PO TID [three times a day] PRN ... Sennosides [a laxative] 15 mg 2 tabs PO 1-2x Daily [one to two times per day] PRN ... Hydrocodone / Acetaminophen [a narcotic pain medication] 5/325 mg PO PRN...." Review of the plan of care failed to evidence a dosage / amount for Vitamin B6, Multivitamin, and Bisacodyl. Review of the plan of care failed to evidence an indication for use of Loperamide, Cyclobenzaprine, Sennosides, and Hydrocodone / Acetaminophen. 6. Clinical record review for patient #5 on 2/11/2022, start of care 5/17/2015, certification period 12/10/2021 to 2/7/2022, primary diagnosis of Multiple Sclerosis (a disease in which the immune system eats away at the protective covering of nerves), evidenced an untitled agency document identified by the clinical supervisor as the plan of care, signed by the physician on 12/7/2021. The plan of care had a subsection titled, "Medications;", which stated, " ... Proventil HFA [a medication used for wheezing and shortness of breath] 108 mcg / ACT [micrograms per actuation] 2 puffs QID [four times a day] prn...." Review of the plan of care failed to evidence an indication for use of Proventil HFA. 7. Clinical record review for patient #6 on 2/11/2022, start of care 5/21/2021, certification period 1/16/2022 to 3/16/2022, primary diagnosis of Multiple Sclerosis, evidenced an untitled agency document identified by the clinical supervisor as the plan of care. The plan of care had a subsection titled, "Medications;", which stated, " ... Tylenol 325 mg PO Q4hrs [every 4 hours] prn ... Miralax [a laxative] 17 gm [grams] PO Daily prn." Review of the plan of care failed to evidence an indication for use of Tylenol and Miralax. 8. Clinical record review for patient #7 on 2/11/2022, start of care 10/17/2018, certification period 6/3/2021 to 8/1/2022, primary diagnosis of Multiple Sclerosis, evidenced an untitled agency document identified by the clinical supervisor as the plan of care, signed by the physician on 6/2/2021. The plan of care had a subsection titled, "Medications;", which stated, " ... Latanoprost Sol [a glaucoma medication] 0.005% 1 gtt [drop] HS [at bedtime], Alprazolam [an anti-anxiety medication] 0.25 mg PO BID [twice a day] prn, Clonazepam [a medication used to treat seizures, panic disorder, and anxiety] 0.5 mg PO BID prn...." Review of the plan of care failed to evidence in which eye(s) the Latanoprost was used. Review of the plan of care failed to evidence an indication for use of Alprazolam and Clonazepam. 9. During an interview on 2/14/2022, at 9:40 a.m., the clinical supervisor indicated the plan of care should contain complete orders for all medications taken by the patient. The clinical supervisor indicated a complete medication order contains the name of the drug, dosage, route, and frequency. When queried, the clinical supervisor indicated orders for PRN (as needed) medications should include the indication for use of the medication, and orders for eye drops should indicate in which eye(s) the drops are used. 17-13-1(a)(1)(D)(ix)

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure all staff followed standard precautions to prevent the transmission of infections and communicable diseases in 1 of 2 home visits observed (#6). The findings include: Record review on 2/15/2022 evidenced an agency policy titled, "Infection prevention and control policy", reviewed 4/2/2021, which stated, "TLHS [Tender Love Home Services] will follow accepted standards of practice, including the use of standard precautions to prevent the transmission of infections and communicable diseases ... Staff should follow the organization's standards precautions, including: A. Hand hygiene: Wash hands before and after patient contact, after contact with any potentially infectious material, and before and after donning protective equipment, including gloves and masks...." Record review on 2/15/2021, evidenced an agency document titled, "HOME HEALTH AIDE SKILLS CHECKLIST", dated 5/21/2021, signed by the clinical supervisor and HHA E. The evaluation indicated HHA could safely perform basic infection control procedures without supervision. Observation of a home visit for patient #6 took place on 2/11/2022, at 8:53 a.m. At 8:58 a.m., HHA [home health aide] E was observed removing a stethoscope and blood pressure cuff from their bag, then removing the patient's folder from a dresser drawer. At 8:59 a.m., HHA E was observed placing the blood pressure cuff on the patient's left arm, then checking the patient's blood pressure using their stethoscope on the patient's arm. At 9:00 a.m., HHA E was observed removing the blood pressure cuff from the patient's arm, placing it back in their bag, and removing their gloves. HHA E then placed the stethoscope in their bag. HHA E failed to clean the blood pressure cuff and stethoscope before returning them to their bag. At 9:04 a.m., HHA was observed applying new gloves. HHA E failed to perform hand hygiene after removing used gloves and before applying new gloves. At 9:05 a.m., HHA E was observed emptying the urine collection bag. After emptying & cleaning the basin used, HHA E was observed removing their gloves and applying new gloves. HHA E failed to perform hand hygiene after removing used gloves and before applying new gloves. During an interview on 2/14/2022, at 9:52 a.m., the clinical supervisor indicated hand hygiene should be performed after removing gloves and before applying new gloves. The clinical supervisor indicated only clean items and clean hands should enter the supply bag. When queried, the clinical supervisor indicated the HHA infection control training included hand hygiene and bag technique. When informed of the findings, the clinical supervisor indicated HHA E was a seasoned HHA who knew better, but was nervous being observed during the visit. 17-12-1(m)

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 record review and interview, the home health aide failed to provide services as ordered in the aide care plan in 5 of 7 clinical records reviewed with home health aide services (#3, #4, #5, #6, #7). The findings include: 1. Record review on 2/15/2022, evidenced an agency policy titled, "Home Health Aide Services", reviewed 4/2/2021, which stated, " ... A HHA [home health aide] provides services that are: ... Ordered by the physician ... Included in the plan of care ... Home health aide supervision must ensure that aides furnish care in a safe and effective manner, including ... Following the patient's plan of care for completion of tasks assigned to a home health aide by the registered nurse or other appropriate skilled professional...." 2. Clinical record review for patient #3 on 2/11/2022, start of care 4/10/2013, certification period 12/24/2021 to 2/21/2022, primary diagnosis of Dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), evidenced a group of agency documents titled, "HHA / CNA [certified nurse's assistant] WEEKLY NOTE", which stated, " ... CHECK ALL BOXES FOR CARE PROVIDED ... VERIFY THAT CARE HAS BEEN ASSIGNED PER AIDE CARE PLAN....". Review of the HHA notes indicated mouth / denture care was performed by HHA F on 12/20/2021, 12/21/2021, 12/22/2021, 12/23/2021, 12/24/2021, 12/27/2021, 12/28/2021, 12/29/2021, 12/30/2021, 12/31/2021, 1/3/2022, 1/4/2022, 1/5/2022, 1/6/2022, 1/7/2022, 1/10/2022, 1/11/2022, 1/12/2022, 1/13/2022, and 1/14/2022. Clinical record review evidenced an agency document titled, "HHA / CNA ASSIGNMENT SHEET", identified by the clinical supervisor as the aide care plan, reviewed and signed by the clinical supervisor on 12/21/2021. Review of the aide care plan failed to evidence the HHA was assigned to provide mouth / denture care to the patient. 3. Clinical record review for patient #4 on 2/11/2022, start of care 11/20/2019, certification period 1/8/2022 to 3/8/2022, primary diagnosis of Degenerative Joint Disease (a type of arthritis that occurs when flexible tissue at the ends of bones wears down), evidenced a group of agency documents titled, "HHA / CNA [certified nurse's assistant] WEEKLY NOTE", which stated, " ... CHECK ALL BOXES FOR CARE PROVIDED ... VERIFY THAT CARE HAS BEEN ASSIGNED PER AIDE CARE PLAN....". Review of the HHA notes indicated, "Assist In and out of bed" was performed by HHA G on 1/4/2022, 1/5/2022, 1/6/2022, 1/7/2022, 1/8/2022, 1/9/2022, 1/10/2022, 1/11/2022, 1/12/2022, 1/13/2022, 1/14/2022, 1/15/2022, 1/16/2022, 1/18/2022, 1/19/2022, 1/20/2022, 1/21/2022, 1/22/2022, 1/23/2022, 1/24/2022, 1/25/2022, 1/26/2022, 1/27/2022, 1/28/2022, 1/29/2022, 1/30/2022, 1/31/2022, and 2/1/2022. Clinical record review evidenced an agency document titled, "HHA / CNA ASSIGNMENT SHEET", identified by the clinical supervisor as the aide care plan, reviewed and signed by the clinical supervisor on 11/4/2021 and 1/7/2022. Review of the aide care plan failed to evidence the HHA was assigned to assist the patient in and out of bed. 4. Clinical record review for patient #5 on 2/11/2022, start of care 5/17/2015, certification period 12/10/2021 to 2/7/2022, primary diagnosis of Multiple Sclerosis (a disease in which the immune system eats away at the protective covering of nerves), evidenced an agency document titled, "HHA / CNA ASSIGNMENT SHEET", identified by the clinical supervisor as the aide care plan, reviewed and signed by the clinical supervisor on 12/6/2022. Review of the care plan evidenced a list of tasks assigned for the aide to complete at each visit. The list included, but was not limited to: hair care, mouth care, skin care, assist with ambulation, passive range of motion (stretching or movement of a part of the body, done by another person), and empty catheter bag (urine collection bag). Clinical record review evidenced a group of agency documents titled, "HHA / CNA [certified nurse's assistant] WEEKLY NOTE", which stated, " ... CHECK ALL BOXES FOR CARE PROVIDED ... VERIFY THAT CARE HAS BEEN ASSIGNED PER AIDE CARE PLAN....". Review of the HHA notes failed to evidence the HHA provided hair care on 12/13/2021, 12/14/2021, 12/15/2021, 12/16/2021, 12/17/2021, 12/18/2021, 12/19/2021, 12/20/2021, 12/21/2021, 12/22/2021, 12/23/2021, 12/24/2021, 12/27/2021, 12/29/2021, 12/30/2021, 12/31/2021, 1/3/2022, 1/4/2022, 1/5/2022, 1/6/2022, 1/7/2022, 1/10/2022, 1/11/2022, 1/11/2022, 1/12/2022, 1/13/2022, 1/14/2022, 1/15/2022, 1/16/2022, 1/18/2022, 1/19/2022, 1/20/2022, 1/21/2022, 1/24/2022, 1/25/2022, 1/26/2022, 1/28/2022, 1/29/2022, 1/30/2022, 1/31/2022, and 2/1/2022. Review of the HHA notes failed to evidence the HHA provided mouth care on 12/13/2021, 12/14/2021, 12/15/2021, 12/16/2021, 12/17/2021, 12/18/2021, 12/19/2021, 12/20/2021, 12/21/2021, 12/22/2021, 12/23/2021, 12/24/2021, 12/27/2021, 12/29/2021, 12/30/2021, 12/31/2021, 1/3/2022, 1/4/2022, 1/5/2022, 1/6/2022, 1/7/2022, 1/10/2022, 1/11/2022, 1/11/2022, 1/12/2022, 1/13/2022, 1/14/2022, 1/15/2022, 1/16/2022, 1/18/2022, 1/19/2022, 1/20/2022, 1/21/2022, 1/24/2022, 1/25/2022, 1/26/2022, 1/28/2022, 1/29/2022, 1/30/2022, 1/31/2022, and 2/1/2022. Review of the HHA notes failed to evidence the HHA provided skin care on 12/13/2021, 12/14/2021, 12/15/2021, 12/16/2021, 12/17/2021, 12/18/2021, 12/19/2021, 12/20/2021, 12/21/2021, 12/22/2021, 12/23/2021, 12/24/2021, 12/27/2021, 12/29/2021, 12/30/2021, 12/31/2021, 1/3/2022, 1/4/2022, 1/5/2022, 1/6/2022, 1/7/2022, 1/10/2022, 1/11/2022, 1/11/2022, 1/12/2022, 1/13/2022, 1/14/2022, 1/15/2022, 1/16/2022, 1/18/2022, 1/19/2022, 1/20/2022, 1/21/2022, 1/24/2022, 1/25/2022, 1/26/2022, 1/28/2022, 1/29/2022, 1/30/2022, 1/31/2022, and 2/1/2022. Review of the HHA notes failed to evidence the HHA assisted with ambulation on 12/13/2021, 12/14/2021, 12/15/2021, 12/16/2021, 12/17/2021, 12/18/2021, 12/19/2021, 12/20/2021, 12/21/2021, 12/22/2021, 12/23/2021, 12/24/2021, 12/27/2021, 12/29/2021, 12/30/2021, 12/31/2021, 1/3/2022, 1/4/2022, 1/5/2022, 1/6/2022, 1/7/2022, 1/10/2022, 1/11/2022, 1/11/2022, 1/12/2022, 1/13/2022, 1/14/2022, 1/15/2022, 1/16/2022, 1/18/2022, 1/19/2022, 1/20/2022, 1/21/2022, 1/24/2022, 1/25/2022, 1/26/2022, 1/28/2022, 1/29/2022, 1/30/2022, 1/31/2022, and 2/1/2022. Review of the HHA notes failed to evidence the HHA provided passive range of motion on 12/12/2021, 12/13/2021, 12/14/2021, 12/15/2021, 12/16/2021, 12/17/2021, 12/18/2021, 12/19/2021, 12/20/2021, 12/21/2021, 12/22/2021, 12/23/2021, 12/24/2021, 12/26/2021, 12/27/2021, 12/29/2021, 12/30/2021, 12/31/2021, 1/3/2022, 1/4/2022, 1/5/2022, 1/6/2022, 1/7/2022, 1/8/2022, 1/9/2022, 1/10/2022, 1/11/2022, 1/11/2022, 1/12/2022, 1/13/2022, 1/14/2022, 1/15/2022, 1/16/2022, 1/18/2022, 1/19/2022, 1/20/2022, 1/21/2022, 1/22/2022, 1/23/2022, 1/24/2022, 1/25/2022, 1/26/2022, 1/28/2022, 1/29/2022, 1/30/2022, 1/31/2022, and 2/1/2022. Review of the HHA notes failed to evidence the HHA emptied the catheter bag on 1/3/2022, 1/4/2022, 1/5/2022, 1/6/2022, 1/7/2022, 1/10/2022, 1/11/2022, 1/11/2022, 1/12/2022, 1/13/2022, 1/14/2022, 1/15/2022, 1/16/2022, 1/18/2022, 1/19/2022, 1/20/2022, 1/21/2022, 1/24/2022, 1/25/2022, 1/26/2022, 1/28/2022, 1/29/2022, 1/30/2022, 1/31/2022, and 2/1/2022. 5. Clinical record review for patient #6 on 2/11/2022, start of care 5/21/2021, certification period 1/16/2022 to 3/16/2022, primary diagnosis of Multiple Sclerosis, evidenced an agency document titled, "HHA / CNA ASSIGNMENT SHEET", identified by the clinical supervisor as the aide care plan, reviewed and signed by the clinical supervisor on 11/12/2021 and 1/11/2022. Review of the care plan evidenced a list of tasks assigned for the aide to complete at each visit. The list included, but was not limited to: hair care, mouth care, assist with transfer, assist in and out of bed, and encourage fluids. Clinical record review evidenced a group of agency documents titled, "HHA / CNA [certified nurse's assistant] WEEKLY NOTE", which stated, " ... CHECK ALL BOXES FOR CARE PROVIDED ... VERIFY THAT CARE HAS BEEN ASSIGNED PER AIDE CARE PLAN....". Review of the HHA notes failed to evidence the HHA provided hair care on 1/18/2022, 1/19/2022, 1/20/2022, 1/21/2022, 1/24/2022, 1/25/2022, 1/26/2022, 1/27/2022, 1/28/2022, 1/31/2022, and 2/1/2022. Review of the HHA notes failed to evidence the HHA provided mouth care on 1/24/2022, 1/25/2022, 1/26/2022, 1/27/2022, 1/28/2022, 1/31/2022, and 2/1/2022. Review of the HHA notes failed to evidence the HHA assisted the patient to transfer on 1/18/2022, 1/19/2022, 1/20/2022, 1/21/2022, 1/25/2022, 1/27/2022, 1/31/2022, and 2/1/2022. Review of the HHA notes failed to evidence the HHA assisted the patient in and out of bed on 1/18/2022, 1/19/2022, 1/20/2022, 1/21/2022, 1/24/2022, 1/25/2022, 1/26/2022, 1/27/2022, 1/28/2022, 1/31/2022, and 2/1/2022. Review of the HHA notes failed to evidence the HHA encouraged the patient to drink fluids on 1/31/2022, and 2/1/2022. 6. Clinical record review for patient #7 on 2/11/2022, start of care10/17/2018, certification period 6/3/2021 to 8/1/2022, primary diagnosis of Multiple Sclerosis, evidenced an agency document titled, "HHA / CNA ASSIGNMENT SHEET", identified by the clinical supervisor as the aide care plan, reviewed and signed by the clinical supervisor on 3/30/2021. Review of the care plan evidenced a list of tasks assigned for the aide to complete at each visit. The list included, but was not limited to: record vital signs, hair care, mouth care, skin care, assist with transfer, assist in and out of bed, and encourage fluids. Clinical record review evidenced a group of agency documents titled, "HHA / CNA [certified nurse's assistant] WEEKLY NOTE", which stated, " ... CHECK ALL BOXES FOR CARE PROVIDED ... VERIFY THAT CARE HAS BEEN ASSIGNED PER AIDE CARE PLAN....". Review of the HHA notes failed to evidence vital signs recorded on 6/17/2021, 6/18/2021, and 6/21/2021. Review of the HHA notes failed to evidence the HHA provided hair care on 6/17/2021, 6/18/2021, 6/21/2021, 6/22/2021 and 6/25/2021. Review of the HHA notes failed to evidence the HHA provided mouth care on 6/21/2021, 6/22/2021 and 6/25/2021. Review of the HHA notes failed to evidence the HHA provided skin care on 7/3/2021. Review of the HHA notes failed to evidence the HHA provided hair care on 6/17/2021, 6/18/2021, 6/21/2021, 6/22/2021 and 6/25/2021. Review of the HHA notes failed to evidence the HHA assisted the patient to transfer on 6/5/2021, 6/21/2021, 6/22/2021, 6/25/2021, 6/26/2021, 7/3/2021, and 7/10/2021. Review of the HHA notes failed to evidence the HHA assisted the patient in and out of bed on 6/5/2021, 6/21/2021, 6/22/2021, 6/25/2021 and 7/3/2021. Review of the HHA notes failed to evidence the HHA encouraged the patient to drink fluids on 6/5/2021, 6/21/2021, 6/22/2021 and 6/25/2021. 7. During an interview on 2/14/2022, at 9:43 a.m., the clinical supervisor indicated the nurse created the individualized HHA care plan for each patient and reviewed it with the HHA verbally as well as in writing. The clinical supervisor indicated the HHA should perform assigned tasks at each visit and document them on the HHA weekly note.