Every finding on record at The Center for Hospice and Palliative Care Inc

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR §484.102 Survey Dates: June 2, 3, 4, 5, 6, 9, 2025 Active Census: 0 At this Emergency Preparedness survey, The Center for Hospice and Palliative Care Inc was found to be in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR §484.102.

This visit was for a Federal Recertification and State Re-Licensure survey of a Home Health Provider. Survey Dates: June 2, 3, 4, 5, 6, 9, 2025 12-Month Unduplicated Skilled Admissions: 0 A Fully Extended Survey was announced to CM on 6/06/2025 at 3:05 PM. This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Refer to State Form for additional State Findings. Abbreviations: RN - Registered Nurse, LPN - Licensed Practical Nurse, CM - Clinical Manager, SN - Skilled Nurse, POC - Plan of Care, SOC - Start of Care, EMR - Electronic Medical Record, ROC - Resumption of Care QR 6/16/2025 A2

5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the start of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure an occupational therapy (OT) evaluation was conducted within 5 days of SOC for 1 of 1 records reviewed of a patient referred to the agency for OT (Patient #2). Findings include: 1. Patient #2’s clinical record indicated Patient was referred to the agency on 2/21/2024. A communication note, dated 2/21/2024, evidenced Patient was referred for SN, physical therapy, OT, and speech therapy. Patient’s SOC was 2/28/2024 and an OT evaluation was conducted on 3/08/2024, which was nine days after the SOC. The record failed to evidence Patient was notified and agreeable to the delay in OT evaluation. During an interview on 6/05/2025 beginning at 3:15 PM, RN 3 reported she thought there was a “miscommunication” among Entity F, a contracted outpatient therapy provider, staff regarding who was going to conduct the OT evaluation. The nurse stated Patient was aware and agreeable to delay in the evaluation, however the record failed to evidence this notification. During an interview on 6/09/2025 beginning at 9:42 AM, Person E, an employee of Entity F, reported the entity tried to see patients within “48 hours to 5 days” of receiving a referral for therapy services. Person E reported the agency received notification of an OT evaluation order on 3/01/2024. Person E was unsure of the reason Patient’s OT evaluation was not conducted until 3/08/2024 and was unsure if the entity had documentation that Patient was notified of the delay in evaluation. No further documentation was provided prior to the survey exit.

Patient's needs CFR(s): 484.55(c)(4) The patient's medical, nursing, rehabilitative, social, and discharge planning needs; This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the initial comprehensive assessment included a complete assessment of the patient’s health needs for 1 of 1 record reviewed of a patient with a left ventricular assist device and wounds (Patient #1). Findings include: 1. Patient #1’s clinical record evidenced a SOC date of 8/02/2024. Patient was discharged on 8/01/2024 by Entity C, a hospital. Discharge instructions from Entity C included to notify Patient’s physician if there was a greater than 2 change in Patient’s Left Ventricular Assist Device (LVAD, a pump surgically implanted into the heart to assist with pumping blood) parameter readings, including flow, power, and pulsatility index (PI, measures the native contractility of the heart). The discharge instructions also indicated Patient’s goal Mean Arterial Pressure (MAP, measurement of the average arterial pressure throughout one cardiac cycle, used to monitor LVAD patients as traditional blood pressure methods may not be accurate) was 65 – 90 millimeters mercury (mmHg). Former Employee D, an RN, documented an initial comprehensive assessment was completed on 8/02/2024. The visit note indicated Patient had a LVAD and two open wounds, one to the chest and one to the LVAD driveline (portion of the LVAD which connects the pump to the external battery). Both wounds required a wound Vacuum-Assisted Closure (VAC, negative pressure therapy used to help treat wounds). The note failed to evidence an assessment of Patient’s LVAD parameters, including the LVAD flow, power, and/or PI, failed to evidence a MAP was obtained, and failed to evidence an assessment of Patient’s wounds, including wound bed tissue, surrounding skin appearance, wound edges, and presence or absence of drainage, odor, etc. During an interview on 6/04/2025 beginning at 10:14 AM, Former Employee D reported when a patient was admitted to the home health agency with a wound, she would conduct a wound assessment including the “color” of the wound, presence or absence of slough (dead tissue), drainage, etc. The nurse stated her assessment of Patient’s LVAD consisted of listening to Patient’s heart and asking Patient if there were “any issues with it.” During an interview on 6/04/2025 beginning at 2:50 PM, CM reported on admission, the nurse assessment should include “all characteristics,” including the type of wound, wound “surface,” presence or absence of tunneling, etc. CM reported the nurse should be assess for LVAD parameters, including the LVAD flow, power, and PI. CM also stated a traditional blood pressure should not be obtained on an LVAD patient as it would not be accurate. 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 home health agency failed to ensure the POC included all nursing interventions for 1 of 2 records reviewed of patients who received more than one SN visit per week. (Patient #1) Findings include: 1. An agency policy “Plan of Care: Physician Certification,” revised 3/2024, indicated the POC should include “An assessment of the patient’s needs and identification of services. The scope … of services/disciplines needed in order to meet the patient’s/caregiver’s needs ….” 2. Patient #1’s clinical record included a POC for the initial certification period of 8/02/24 – 9/30/24. The POC included orders for SN visits three times per week. The record evidenced the SN conducted only a focused assessment of Patient’s wounds and/or midline IV on 8/16/25, 8/23/25, 8/28/25, 9/02/25, and 9/11/25. The POC failed to evidence a complete nursing head-to-toe assessment was to be completed only once per week. During an interview on 6/03/25 beginning at 1:38 PM, RN 1 reported she would conduct a head-to-toe physical assessment during the first visit of the week and a focused assessment on Patient’s wounds and/or IV during the other two visits. The nurse stated this was not indicated on the POC as the doctor had not sent an order indicating when to conduct a nurse assessment. During an interview on 6/04/25 beginning at 2:50 PM, CM reported the frequency of a full head-to-toe assessment depended on the physician order. The CM was unsure if the POC reflected a SN head-to-toe assessment was to only be completed once per week, and a focused assessment only was to be completed for the other two visits. 410 IAC 17-13-1(a)(1)(ix, xiii)

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 record review and interview, the home health agency failed to ensure the physician was notified for a change in wound bed tissue and/or measurements for 2 of 2 records reviewed with worsening of wound bed tissue or measurements (Patient #1, 3). Findings include: 1. The policy “Physician and Care Team Review of Plan of Care,” dated 11/2021, indicated “Verbal communication will be given to the physician and documented accordingly in the patient’s record indicating the condition of the patient, the plan of care, and that the physician was notified as frequently as the patient’s conditions warrant.” 2. Patient #1’s clinical record included a POC for the initial certification period of 8/02/2024 – 9/30/2024, which indicated Patient was to receive SN visits three times a week for wound care to Patient’s wounds to the chest and Left Ventricular Assist Device (LVAD, a pump surgically implanted into the heart to assist with pumping blood for patients with advanced heart failure) driveline site. A SN visit dated 8/05/2024 evidenced the first documented assessment of Patient’s wounds. RN 1 noted slough (dead tissue which can impede wound healing) to 50% of Patient’s chest wound bed. The record failed to evidence the nurse notified Person A, Patient’s physician, of the slough. A SN visit dated 8/09/2024 evidenced RN 1 noted slough to 20% of Patient’s chest wound, which was a change from the 8/07/2024 assessment. The record failed to evidence the nurse notified Person A of the slough. A SN visit dated 8/12/2024 evidenced RN 1 noted slough to 20% of Patient’s LVAD driveline wound and measured the wound at 2.8 centimeters (cm) in length by 4.8 cm in width by 1.5 cm in depth (2.8 cm x 4.8 cm x 1.5 cm), which was an increase by 1.4 cm in width from the 8/09/24 assessment. The record failed to evidence the nurse notified Person A of the new slough or increase in wound width. During an interview on 6/03/2025 beginning at 1:38 PM, RN 1 stated she would report “any changes” to a wound, including new presence of slough and/or increase in wound measurement of “0.5 – 1 centimeter” or more, to the physician. When asked if the nurse reported any wound changes to Person A, RN 1 thought one of the wounds had “deepened” at one point, and she sent a photograph of the wound once a week to Person A. During an interview on 6/04/2025 beginning at 2:50 PM, CM stated “any change” to a wound should be reported to the physician, including new presence of slough and/or an increase in wound measurement. During an interview on 6/09/2025 beginning at 2:07 PM, Person B, an employee in Person A’s office, reported the first wound photographs received was on 8/23/2024. The physician office did not have record of receiving notification of the slough in wounds or change in wound measurement until 9/26/2024. 3. Patient #3’s clinical record included a POC for the initial certification period of 2/16/2024 – 4/15/2024 with a primary diagnosis of osteomyelitis (infection to the bone) in the ankle and foot. SN visits were to be done once a week for five weeks. Patient was admitted to the agency on 2/16/2024 with a non-removable dressing to the right foot. A photograph of Patient’s right foot, dated 2/17/2024, evidenced a diabetic ulcer wound to the right lateral (outside) foot below the fifth toe with scabbing over the wound. A SN visit, dated 3/13/2024, evidenced the dressing covering Patient’s diabetic ulcer wound had been removed. RN 4 failed to document an assessment of the wound bed tissue. A photograph of the wound, dated 3/13/2024, evidenced black eschar (dead tissue which can impede wound healing) to the wound bed. The record failed to evidence the nurse notified Person G, the physician managing Patient’s wounds, of the presence of eschar. A SN visit, dated 3/14/2024, evidenced RN 4 noted Patient’s diabetic ulcer wound bed was “dusky.” A SN discharge visit, dated 3/22/2024, failed to evidence an assessment of Patient’s diabetic ulcer wound. The visit note indicated Patient had a follow-up visit with their physician on 4/12/2024. The review of Person G’s office visit notes evidenced Patient went to the office on 3/29/2024 due to the diabetic ulcer wound worsening. Patient’s diabetic ulcer was debrided (procedure where dead or damaged tissue is removed) during the visit. During an interview on 6/06/2025 beginning at 1:35 PM, RN 4 stated a change in wound bed tissue to eschar would be reported to the physician. The nurse was unsure if Patient had any changes in his/her wound while on services. During an interview on 6/06/2025 beginning at 1:22 PM, Person H, an employee of Person G’s office, reported the office had no record it was notified by the home health agency of a change in Patient’s diabetic ulcer wound. During an interview on 6/06/2025 beginning at 2:25 PM, CM agreed the 3/13/2024 picture of the diabetic ulcer appeared to have eschar in the wound bed, which was a change from the previous photograph. CM stated this change should be reported to the physician. 410 IAC 17-13-1(a)(2)

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on record review and interview, the skilled nurse failed to conduct a complete and thorough assessment of the patient for 3 of 7 records reviewed (Patient #1, 3, 7). Findings include: 1. An agency policy “Skin and Wound Care,” revised 11/2021, indicated wounds should be assessed “at a minimum of every seven days by a nurse and measurement documented in the EMR.” 2. Patient #1’s clinical record evidenced a SOC date of 8/02/24. Patient was discharged on 8/01/24 by Entity C, a hospital. Discharge instructions from Entity C included to notify Patient’s physician if there was a greater than 2 change in Patient’s Left Ventricular Assist Device (LVAD, a pump surgically implanted into the heart to assist with pumping blood) parameter readings, including flow, power, and pulsatility index (PI, measures the native contractility of the heart). The discharge instructions also indicated Patient’s goal Mean Arterial Pressure (MAP, measurement of the average arterial pressure throughout one cardiac cycle, used to monitor LVAD patients as traditional blood pressure methods may not be accurate) was 65 – 90 millimeters mercury (mmHg). A POC for the initial certification period of 8/02/2024 – 9/30/2024 and recertification period of 10/01/2024 – 11/29/2024 included orders for the home health agency to call Person A, Patient’s physician, for “… swelling of extremities … weight gain of 2-4 pounds over 1-3 days …” SN visits to be done three times a week until 9/23/24, when a new order was obtained for SN visits once per week. A SN visit note, dated 08/05/2024, indicated RN 1 documented a BP of “120/62.” The record failed to evidence an assessment of Patient’s LVAD parameters and for the presence or absence of edema and weight gain. A SN visit note, dated 08/07/2024, indicated RN 1 documented a BP of “95/61.” The record failed to evidence an assessment of Patient’s LVAD parameters and for the presence or absence of edema and weight gain. A SN visit note, dated 8/09/2024, indicated RN 1 documented a BP of “99/64.” The record failed to evidence an assessment of Patient’s LVAD parameters and for the presence or absence of edema and weight gain. A SN visit note, dated 8/12/2024, indicated RN 1 documented a BP of “96/66.” The record failed to evidence an assessment of Patient’s LVAD parameters and for the presence or absence of edema and weight gain A SN visit note, dated 8/14/2024, indicated RN 1 documented a BP of “98/66.” The record failed to evidence an assessment of Patient’s LVAD parameters and for the presence or absence of edema and weight gain. SN visit notes, dated 8/16/2024, 8/19/2024, 8/21/2024, 8/23/2024, 8/26/2024, 8/28/2024, 8/30/2024, 9/02/2024, 9/04/2024, 9/06/2024, 9/09/2024, 9/11/2024, 9/13/2024, 9/16/2024, 9/18/2024, 9/23/2024, and 10/08/2024 failed to evidence an assessment of Patient’s LVAD parameters and for the presence or absence of edema and weight gain. A SN recertification visit note, dated 9/30/2024, failed to evidence an assessment of Patient’s LVAD parameters and for the presence or absence of edema and weight gain. A SN discharge visit note, dated 10/15/2024, failed to evidence an assessment of Patient’s LVAD parameters and for the presence or absence of edema and weight gain. During an interview on 6/03/2025 beginning at 1:38 PM, RN 1 reported she would use an automatic BP cuff to obtain a BP on Patient. The nurse stated she would sometimes need to repeat the BP a few times due to an error in the reading. RN 1 reported she would not assess Patient’s LVAD parameters, including power, flow, or PI, as it was not within the physician orders. RN 1 reported Patient had “issues” with “peripheral swelling,” but she would only document if the swelling was present. RN 1 stated she did not attempt to obtain Patient’s weight. During an interview on 6/04/2025 beginning at 2:50 PM, CM reported the nurse should assess Patient’s LVAD parameters, including the LVAD flow, power, and PI. CM stated a blood pressure should not be obtained on an LVAD patient as it would not be accurate. CM stated the nurse should document the presence or absence of edema, but agency staff were able to chart by exception. CM reported Patient’s weight was only noted on admission. 3. Patient #3’s clinical record included a POC for the initial certification period of 2/16/2024 – 4/15/2024 with a primary diagnosis of osteomyelitis (infection to the bone) in the ankle and foot. SN visits were to be done once a week for five weeks. Patient was admitted to the agency on 2/16/2024 with a non-removable dressing to the right foot. A photograph of Patient’s right foot, dated 2/17/2024, evidenced a diabetic ulcer wound to the right lateral (outside) foot below the fifth toe with scabbing over the wound bed. A SN visit, dated 3/13/2024, evidenced the dressing covering Patient’s diabetic ulcer wound had been removed. RN 4 failed to document an assessment of the wound bed tissue nor measurement of the wound. A photograph of the wound, dated 3/13/2024, evidenced black eschar (dead tissue which can impede wound healing) to the wound bed. A SN visit, dated 3/14/2024, evidenced RN 4 noted Patient’s diabetic ulcer wound bed was “dusky.” The nurse failed to document an assessment of the wound which included measurements. A SN discharge visit, dated 3/22/2024, failed to evidence an assessment of Patient’s diabetic ulcer wound. The visit note indicated Patient had a follow-up visit with their physician on 4/12/2024. The review of office visit notes from Person G, a physician managing Patient’s wounds, evidenced Patient went to the office on 3/29/2024 due to the diabetic ulcer wound worsening. The wound was debrided (dead tissue removed) during the visit. During an interview on 6/06/2025 beginning at 1:35 PM, RN 4 reported a wound assessment included measurement and wound bed tissue/appearance. The nurse was unsure if she measured Patient’s diabetic ulcer wound after the dressing was removed. During an interview on 6/06/2025 beginning at 2:25 PM, CM reported there was no record of measurements for Patient’s diabetic ulcer wound after the dressing was removed. 4. Patient #7’s clinical record included a POC for the initial certification period of 3/23/2022 – 5/21/2022. The POC indicated Patient was to receive two SN visits per week, with SN interventions to include “Assess current pain management regimen including: effectiveness, relief measures, and side effects at each visit … Assess pain including: pain level, frequency, location, quality, precipitating factors, and side effects at each visit ….” The record evidenced Patient was hospitalized 3/24/2022 – 3/31/2022. Former Employee N, an RN, conducted a resumption of care visit on 4/01/2022. The nurse failed to document an assessment of Patient’s pain and pain management regimen. During an interview on 6/09/2025 beginning at 3:45 PM, CM reported a pain assessment should be completed at every SN visit.

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 agency failed to ensure discharge or transfer summary contained sufficient information about current course of illness and treatment, post-discharge goals of care, and treatment preferences to ensure continuity of care in 4 of 4 patients who were transferred or discharged, from a total sample of 5 clinical records reviewed. (#1, #2, #3, #5) The findings include: .Clinical record review on 1/7/22, for patient #1, start of care 11/11/21, diagnosis of Congestive Heart Failure (CHF; a chronic condition where the heart does not pump blood adequately), evidenced a discharge date of 12/21/21. Record review evidenced an agency document titled "Discharge Summary" signed by Registered Nurse (RN) G. This document had areas subtitled "Allergies" and "Reason for Admission" which remained blank. Another area subtitled "Discharge Condition" stated "Alive ...." Review failed to evidenced the document contained all pertinent information for a smooth patient discharge/transfer. Review failed to evidence a complete discharge summary. .Clinical record review on 1/7/22, for patient #2, start of care 10/25/21, diagnosis of Chronic Obstructive Pulmonary Disorder (COPD; a progressive lung disease that progressively worsens with everyday activities), evidenced a discharge date of 12/23/21. Record review of an agency document titled "Discharge Summary" signed by RN J. This document had areas subtitled "Reason for Admission" and "Discipline Orders" which remained blank. Review failed to evidenced the document contained all pertinent information for a smooth patient discharge/transfer. Review failed to evidence a complete discharge summary. The findings include: Review of agency policy, obtained 1/7/2022, titled “Hospitalizations” stated, “Purpose: To assure continuity of care in all settings, to determine the appropriate location for patient care, and to retain professional management responsibilities through the care team… Procedure: Notify the attending physician, Patient Care Coordinator, and pertinent team members of the patient’s hospitalization… Complete the transfer OASIS”. Review of agency policy, revised November 2021 and obtained 1/7/2022, titled “Discharge Criteria” stated, “…After the decision is made for discharge, the patient/caregiver will be notified. At the time of discharge, a Discharge Summary Note is completed, and if applicable a Discharge OASIS”. Clinical record review on 1/6/2022 for patient #5, start of care 10/11/2021, evidenced an agency document titled “Transfer OASIS-D1” which indicated that patient #5 was transferred to an inpatient hospital on 11/26/2021. Record review evidenced resumption of care with home health agency 12/1/2021. No transfer summary was evidenced. During an interview on 1/7/2022 at 1:43 PM, clinical manager B indicated that the transfer summary for patient #5 who transferred 11/26/2021 did not get sent to the hospital before resumption of care 12/1/2021. Clinical record review on 1/6/2022 for patient # 3, start of care 11/3/2021, certification period 11/3/2021 – 1/1/2022, discharge date 12/28/2021, evidenced an agency document titled “Discharge Summary” which failed to evidence current labs, reason for admission, discharge condition, patient/family discharge instructions, and discipline orders. During an interview on 1/7/2022 at 1:55pm, clinical manager B was in agreeance that a complete discharge summary should have included labs, reason for admission, discharge condition, discharge instructions, and discipline orders.

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 agency failed to ensure coordination of care between therapy services and home health agency staff to ensure treatment effectiveness in 1 of 5 clinical records reviewed. (#4) The findings include: Review of agency policy, revised November 2021 and obtained 1/7/2022, titled “Therapy Services” stated, “Purpose: To ensure that necessary therapies for patients care are available to patients… Policy: The Agency will make available physical therapy, occupational therapy, and speech language pathology services in a manner consistent with accepted standards of practice. Contracted agencies will be used. … The plan of care will be obtained from the specific therapist and the Agency will show incorporation it into ours … The initial evaluation will be received by the therapist within 5 business days of initial evaluation … QA [quality assurance] department will upload these reports to the patient’s EMR [electronic medical record] … The therapist will be responsible for obtaining all orders and forwarding to QA to add to EMR”. Clinical record review on 1/6/2022 for patient #4, start of care 12/30/2021, evidenced an agency document titled “Communication Notes” which contained a note created by registered nurse E, on 1/5/2021 at 3:06 PM. The note indicated that patient was evaluated for physical therapy on 12/31/2021, but notes had not yet been submitted. The note stated that physical therapy notes would be received in the next couple of days “roughly”. Record review on 1/6/2022 of an agency document titled “Physical Therapy Evaluation” signed by physical therapist F, indicated that date of physical therapy evaluation was 12/30/2021. Record review on 1/6/2022 of agency document titled “Communication Notes” indicated that on 1/6/2022 at 8:27 AM physical and occupational plan of care and notes were received by agency. Record review on 1/6/2022 of electronic medical record failed to evidence physical or occupational therapy frequency orders in the patient’s medical record. During an interview on 1/7/2022 at 1:35 PM, alternate administrator A indicated that the contracted physical and occupational therapy services drop off the therapy notes and plans of care to the home health agency every Tuesday to ensure coordination of care. Alternate administrator A stated that the therapy agency failed to drop off the notes by Tuesday 1/4/2022, which resulted in a delay of ordering physical therapy and updating the patient’s plan of care. Alternate administrator A indicated the contracted agency failed to follow agency policy for coordination of therapy services

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure completed transfer summary was sent within 2 business days of becoming aware of unplanned transfer in 1 of 4 clinical records reviewed. (#5) The findings include: Review of an undated agency policy, obtained 1/7/2022, titled “Hospitalizations” stated, “Purpose: To assure continuity of care in all settings, to determine the appropriate location for patient care, and to retain professional management responsibilities through the care team… Procedure: Notify the attending physician, Patient Care Coordinator, and pertinent team members of the patient’s hospitalization… Complete the transfer OASIS”. Review of agency policy, revised November 2021 and obtained 1/7/2022, titled “Discharge Criteria” stated, “… After the decision is made for discharge, the patient/caregiver will be notified. At the time of discharge, a Discharge Summary Note is completed, and if applicable a Discharge OASIS”. Clinical record review on 1/6/2022 for patient #5, start of care 10/11/2021, evidenced an agency document titled “Transfer OASIS-D1” which indicated that patient #5 was transferred to an inpatient hospital on 11/26/2021. No transfer summary was evidenced as being sent to ensure continuity of patient care. During an interview on 1/7/2022 at 1:43 PM, clinical manager B indicated the transfer summary for patient #5 who transferred 11/26/2021 did not get sent to the hospital within 2 business days of becoming aware of transfer.

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with Condition of Participation for Home Health Agencies (HHAs): 42 CFR §484.102. Survey Dates: 10/20, 10/21, 10/22, 10/25, 10/26, 10/27/2021. Facility Number: IN005279 Provider Number: 157067 Current Census: 22 At this Emergency Preparedness survey, Center for Hospice and Palliative Care Inc., The, was found not in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR §484.102.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure its Emergency Preparedness Plan included agency specific strategies for addressing emergency events. Findings include: A policy with reviewed date 5/20/2021, titled “Maintain and Annual Emergency Preparedness Updates (E-0006)” stated “... development of the Emergency Preparedness Plan ... Identification of all business functions essential to the agency’s operations that should be continued during an emergency ... Identification of all risks ... Identification of all contingencies ... Consideration of the ... location ... Determination of what arrangements may be necessary ... will discuss emergency preparedness concerns with the landlord of its rented facilities ... will develop strategies for addressing emergency events ....” During an interview on 10/27/2021 at 10:53 AM, the alternate administrator, clinical director, and director of quality assurance C indicated the policy failed to evidence the agency’s business functions essential to the agency’s operations that would be continued during an emergency, identified all risks, identified all contingencies, considered the location of all facilities, determined arrangements that would be necessary, emergency preparedness concerns with the landlord of its rented facilities, or strategies which addressed emergency events.

EP Program Patient Population CFR(s): 484.102(a)(3) §403.748(a)(3), §416.54(a)(3), §418.113(a)(3), §441.184(a)(3), §460.84(a)(3), §482.15(a)(3), §483.73(a)(3), §483.475(a)(3), §484.102(a)(3), §485.68(a)(3), §485.625(a)(3), §485.727(a)(3), §485.920(a)(3), §491.12(a)(3), §494.62(a)(3). [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (3) Address [patient/client] population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.** *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do all of the following: (3) Address resident population, including, but not limited to, persons at-risk; the type of services the LTC facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. *NOTE: ["Persons at risk" does not apply to: ASC, hospice, PACE, HHA, CORF, CMCH, RHC/FQHC, or ESRD facilities.] This STANDARD is not met as evidenced by: Based on record review and interview, the home health agency (HHA) failed to ensure its Emergency Preparedness Plan addressed its patient population and the type of services the HHA provided during an emergency. Findings include: A policy with review date 5/20/2021, titled “Emergency Preparedness Program Patient Population (E-0007)” stated “... will implement an emergency operation plan to continue essential patient care ....”, but failed to evidence the types of patients the HHA provided services to, or essential services the HHA would provide during an emergency. During an interview on 10/20/2021 at 10:12 AM, the clinical director indicated the HHA had patients who received (but not limited to) infusion therapy (medications administered via a catheter inserted into a vein), tracheostomy care (an opening in the windpipe made to relieve an obstruction to breathing), wound care, urinary catheter care (a tube inserted into the bladder to drain urine), enteral feeding (a tube inserted into the stomach for administration of nutrition, fluids, and/or medications), and patients who received dialysis at outpatient facilities. During an interview on 10/27/2021 at 10:53 AM, the alternate administrator, clinical director, and director of quality assurance C indicated the HHA’s patient population was not addressed in the Emergency Preparedness Plan, or services the HHA would provide during an emergency.

Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [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. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility 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 annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization 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 address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility 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. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility's geographic area. This STANDARD is not met as evidenced by: Based on record review and interview, the home health agency (HHA) failed to develop Emergency Preparedness policies and procedures specific to the HHA. Findings include: A policy with review date 5/20/2021, titled “Development of Emergency Preparedness Program Policies and Procedures (E-0013)” stated “... Emergency Preparedness policies and procedures will be based on the Emergency Preparedness Plan ....” During an interview on 10/27/2021 at 10:53 AM, the alternate administrator, clinical director, and director of quality assurance C indicated the HHA was part of an integrated healthcare system, agreed the HHA’s Emergency Preparedness Program policies and procedures was based largely on the corporation’s hospice program, and several elements required in the policies and procedures for the HHA’s compliance with the program were missing.

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 (HHA) failed to ensure the registered nurse developed an individualized emergency preparedness plan for all agency patients during the completion of the comprehensive assessment, and failed to ensure all patients received a copy of their individualized emergency plan for 3 of 3 home visits completed. Findings include: 1. A policy with review date 5/20/2021, titled “Comprehensive Patient Assessment in Disaster (E-0017)” stated “... will ensure all patients have an individualized plan of care in the event of an emergency ... included as a part of the patient’s comprehensive assessment ... keep a copy of the individualized emergency plan in the patient’s file, as well as provide a copy to the patient and/or caregiver.” 2. A document with copyright date 2019 by 5 Star Consultants, LLC titled “Patient Emergency Plan” evidenced a section which stated “... [HHA] clinician reviewed this Emergency Plan with patient/caregiver and I [patient/caregiver] received a copy ....” The document included a space for dates and signatures for the patient/representative and clinician. 3. A policy with revised date 10/2021 titled “Initial Assessment of Patient, Family, Caregiver” stated “... the nurse will gather the following baseline data at the time of admission ....” The document failed to evidence completion of the patient’s comprehensive assessment included the development of the patient’s individualized emergency preparedness plan. 4. A home visit observation was conducted with patient #7 on 10/21/2021 at 9:00 AM. During this time, the home folder was reviewed, which failed to evidence documentation of a patient specific emergency plan. 5. A home visit observation was conducted with patient #6 on 10/22/2021 at 10:30 AM. During this time, the home folder was reviewed, which failed to evidence documentation of a patient specific emergency plan. 6. A home visit observation was conducted with patient #5 on 10/22/2021 at 1:00 PM. During this time, the patient’s caregiver indicated there were no HHA documents or folder present in the home. 7. During an interview on 10/26/2021 at 10:00 AM, the director of quality assurance indicated the policy titled “Initial Assessment of Patient, Family, Caregiver” also represented the policy for comprehensive assessment. 8. During an interview on 10/27/2021 at 10:53 AM, the alternate administrator, clinical director, and director of quality assurance C indicated they could not confirm if there were copies of patient individualized emergency plans in the patients’ homes, there were not copies in the HHA clinical records, and the patient handbooks contained general emergency instructions, not patient specific plans.

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 (HHA) failed to ensure its Emergency Preparedness Plan policies included the agency’s specific procedures to follow up with on-duty staff and patients. Findings include: A policy with review date 5/20/2021, titled “Procedure for Follow Up (E-0021)” stated “... will follow-up with on duty staff and patients ... will address what actions would be required due to the inability to make contact with staff or patients ....” The policy failed to evidence the specific procedure on how the agency would follow up, or specific actions required as a result of inability to contact staff or patients. During an interview on 10/27/2021 at 10:53 AM, the alternate administrator, clinical director, and director of quality assurance C indicated the emergency preparedness plan should have indicated specific procedures and actions required, not simply broad statements such as “will develop ... will follow-up ... will determine ....”

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), §485.625(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 home health agency (HHA) failed to ensure its Emergency Preparedness Plan policies included a process for the use of volunteers during an emergency, or other agency specific emergency staffing strategies. Findings include: A policy with review date 5/20/2021, titled “Policies and Procedures for Volunteers (E-0024)” stated “... will determine the use of ... volunteers in an emergency or other staffing strategies, including the process and role for integration of State and Federally designated health care professionals ....” The policy failed to evidence the specific procedure on how and/or when the use of volunteers was determined, or the process for integration of State and Federally designated health care professionals. During an interview on 10/27/2021 at 10:53 AM, the alternate administrator, clinical director, and director of quality assurance C indicated they were unaware HHAs utilized volunteers during an emergency, thought the policy referred to hospice volunteers, and the plan was largely geared to the hospice component of the organization.

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(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:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: Based on observation, record review and interview, the home health agency (HHA) failed to ensure its Emergency Preparedness Communication Plan required contact information for the HHA employees, and failed to include names and contact information for entities who provided services under arrangement, all patients’ physicians, or volunteers. Findings include: A policy with review date 5/20/2021, titled “Names and Contact Information (E-0030)” stated “... will maintain contact information for ... entities providing services under arrangement, patients’ physicians, and other hospices and health care providers ... The communication plan must include the name and contact information for the following ... Hospice employees ... Entities providing services under agreement ... Patients’ physicians ... Other hospices ....” The policy failed to evidence the plan must include contact information for the HHA’s employees. During an interview on 10/20/2021 at 10:12 AM, the clinical director indicated physical therapy (PT), occupational therapy (OT), and speech therapy (SLP) was provided to the HHA under arrangement (contracted services). During a visit with HHA branch C on 10/27/2021 at 9:30 AM, patient care coordinator (PCC) O indicated they did not have a list of all patients’ physicians because they served such a broad geographic area. During this time, staff also provided other documents associated with the emergency preparedness plan, which failed to evidence contact information for entities who provided services under arrangement (therapies), or volunteers utilized during an emergency. During an interview on 10/27/2021 at 10:53 AM, the alternate administrator, clinical director, and director of quality assurance C indicated the emergency preparedness communication plan failed to include the name and contact information for HHA staff was required, failed to evidence contact information for entities who provided services under arrangement (therapies), volunteers utilized during an emergency, and the plan was largely geared to the hospice component of the organization.

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), §485.625(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 (HHA) failed to ensure its Emergency Preparedness Communication Plan contained contact information for Federal, State, tribal, regional, local emergency preparedness staff, or other sources of assistance. Findings include: A policy with review date 5/20/2021, titled “Emergency Officials Contact Information (E-0031)” stated “... will maintain contact information of Federal, State, tribal, regional, and local emergency officials ....” The policy evidenced a list of officials, but failed to evidence the contact information for the listed officials. During an interview on 10/27/2021 at 10:53 AM, the alternate administrator, clinical director, and director of quality assurance C indicated the emergency preparedness communication plan submitted failed to include contact information for Federal, State, tribal, regional, local emergency preparedness staff, or other sources of assistance.

Methods for Sharing Information CFR(s): 484.102(c)(4)-(5) §403.748(c)(4)-(6), §416.54(c)(4)-(6), §418.113(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §482.15(c)(4)-(6), §483.73(c)(4)-(6), §483.475(c)(4)-(6), §484.102(c)(4)-(5), §485.68(c)(4), §485.625(c)(4)-(6), §485.727(c)(4), §485.920(c)(4)-(6), §491.12(c)(4), §494.62(c)(4)-(6). [(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: (4) A method for sharing information and medical documentation for patients under the [facility's] care, as necessary, with other health providers to maintain the continuity of care. (5) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii). [This provision is not required for HHAs under §484.102(c), CORFs under §485.68(c)] (6) [(4) or (5)]A means of providing information about the general condition and location of patients under the [facility's] care as permitted under 45 CFR 164.510(b)(4). *[For RNHCIs at §403.748(c):] (4) A method for sharing information and care documentation for patients under the RNHCI's care, as necessary, with care providers to maintain the continuity of care, based on the written election statement made by the patient or his or her legal representative. *[For RHCs/FQHCs at §491.12(c):] (4) A means of providing information about the general condition and location of patients under the facility's care as permitted under 45 CFR 164.510(b)(4). This STANDARD is not met as evidenced by: Based on observation, record review and interview, the home health agency (HHA) failed to ensure its Emergency Preparedness Communication Plan contained the detailed method for sharing information and medical documentation for patients under the HHA’s care, or how the HHA would provide information about the general condition and location of patients. Findings include: 1. A policy with review date 5/20/2021, titled “Methods for Sharing Information (E-0033)” stated “... will share general patient information ... a copy of the patient’s face sheet will be sent with an evacuated patient ... information will also be made readily available for patients being sheltered in place ....” 2. A home visit observation was conducted with patient #7 on 10/21/2021 at 9:00 AM. During this time, the home folder was reviewed, which failed to evidence documentation of a patient specific emergency plan, a current plan of treatment with medications, or a patient face sheet. 3. A home visit observation was conducted with patient #6 on 10/22/2021 at 10:30 AM. During this time, the home folder was reviewed, which failed to evidence documentation of a patient specific emergency plan, a current plan of treatment with medications, or a patient face sheet. 4. A home visit observation was conducted with patient #5 on 10/22/2021 at 1:00 PM. During this time, the patient’s caregiver indicated there were no HHA documents or folder present in the home. 5. During an interview on 10/27/2021 at 10:53 AM, the alternate administrator, clinical director, and director of quality assurance C indicated the emergency preparedness communication plan submitted failed to indicate the information that would be provided included the patients’ general condition or location.

Information on Occupancy/Needs CFR(s): 484.102(c)(6) §403.748(c)(7), §416.54(c)(7), §418.113(c)(7) §441.184(c)(7), §482.15(c)(7), §460.84(c)(7), §483.73(c)(7), §483.475(c)(7), §484.102(c)(6), §485.68(c)(5), §485.68(c)(5), §485.727(c)(5), §485.625(c)(7), §485.920(c)(7), §491.12(c)(5), §494.62(c)(7). [(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: (7) [(5) or (6)] A means of providing information about the [facility's] occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For ASCs at 416.54(c)]: (7) A means of providing information about the ASC's needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For Inpatient Hospice at §418.113(c):] (7) A means of providing information about the hospice's inpatient occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. This STANDARD is not met as evidenced by: Based on record review and interview, the home health agency (HHA) failed to ensure its Emergency Preparedness Communication Plan contained the means of providing information about the HHA’s occupancy, needs, or ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. Findings include: A policy with review date 5/20/2021, titled “Sharing Information on Occupancy/Needs (E-0034)” stated “... Hospice Inpatient Unit patient information will be printed ....” The policy failed to address anything about the HHA. During an interview on 10/27/2021 at 10:53 AM, the alternate administrator, clinical director, and director of quality assurance C indicated the policy titled “Sharing Information on Occupancy/Needs (E-0034)” included only information for the hospice, not the HHA component of the organization.

Integrated EP Program CFR(s): 484.102(e) §416.54(e), §418.113(e), §441.184(e), §460.84(e), §482.15(f), §483.73(f), §483.475(e), §484.102(e), §485.68(e), §485.625(f), §485.727(e), §485.920(e), §486.360(f), §491.12(e), §494.62(e). (e) [or (f)]Integrated healthcare systems. If a [facility] is part of a healthcare system consisting of multiple separately certified healthcare facilities that elects to have a unified and integrated emergency preparedness program, the [facility] may choose to participate in the healthcare system's coordinated emergency preparedness program. If elected, the unified and integrated emergency preparedness program must- [do all of the following:] (1) Demonstrate that each separately certified facility within the system actively participated in the development of the unified and integrated emergency preparedness program. (2) Be developed and maintained in a manner that takes into account each separately certified facility's unique circumstances, patient populations, and services offered. (3) Demonstrate that each separately certified facility is capable of actively using the unified and integrated emergency preparedness program and is in compliance [with the program]. (4) Include a unified and integrated emergency plan that meets the requirements of paragraphs (a)(2), (3), and (4) of this section. The unified and integrated emergency plan must also be based on and include the following: (i) A documented community-based risk assessment, utilizing an all-hazards approach. (ii) A documented individual facility-based risk assessment for each separately certified facility within the health system, utilizing an all-hazards approach. (5) Include integrated policies and procedures that meet the requirements set forth in paragraph (b) of this section, a coordinated communication plan, and training and testing programs that meet the requirements of paragraphs (c) and (d) of this section, respectively. This STANDARD is not met as evidenced by: Based on record review and interview, the home health agency (HHA) failed to ensure its Emergency Preparedness Program (EPP) designated itself as part of an integrated healthcare system, Findings include: A document updated October 2021, titled “Center for Hospice Care ... Emergency Preparedness Program” included all of the agency’s EPP policies and procedures. The document failed to evidence the HHA designated itself as part of an integrated healthcare system, demonstrated that each separately certified facility within the system actively participated in the development of the unified and integrated EPP, was developed and maintained in a manner that took into account each separately certified facility's unique circumstances, patient populations, and services offered, demonstrated that each separately certified facility was capable of actively using the unified and integrated EPP and was in compliance, or included integrated policies and procedures that met regulatory requirements. During an interview on 10/27/2021 at 10:53 AM, the alternate administrator, clinical director, and director of quality assurance C indicated the HHA was part of an integrated healthcare system, agreed the HHA’s EPP policies and procedures was based more on the corporation’s hospice program, and some elements required for the HHA’s compliance with the program were missing.

This was a partially extended State and Federal Home Health Agency (HHA) Re-Licensure Survey completed by the Indiana Department of Health (IDOH). Survey Dates: 10/20, 10/21, 10/22, 10/25, 10/26, 10/27/2021. Facility Number: IN005279 Provider Number: 157067 Current Census: 22 Based on the Condition-level deficiency during the October 27, 2021 survey, Center for Hospice and Palliative Care Inc., The, was subject to a partial or extended survey pursuant to section 1891(c)(2)(D) of the Social Security Act on 7/27/21. Therefore, and pursuant to section 1891(a)(3)(D)(iii) of the Act, Center for Hospice and Palliative Care Inc. is precluded from operating or being the site of a home health aide training and/or competency evaluation programs for the two years beginning October 27, 2021 and continuing through October 27, 2023 for being found out of compliance with the Condition of Participation 42 CFR §484.58: Discharge planning. This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Refer to State Form for additional State Findings.

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 agency failed to accurately document the patient’s referral date and/or the physician’s ordered start of care date on the initial OASIS (outcome and assessment information set) Assessment form for 3 of 7 records reviewed (#1, 6, 7). Findings include: 1. A policy revised 3/2017 titled “Referral Intake Process” stated “... The patient should be scheduled within 48 hours ... Failure to admit within 48 hours ... will be documented as to the reason and that the doctor was notified ....” 2. A policy revised 7/2019 titled “Initial Assessment ....” stated “... An initial assessment is done within 48 hours ....” 3. Record review for patient #1 was completed on 10/27/2021, start of care date 9/27/2021, for certification period 9/27/2021-11/25/2021. The clinical record evidenced the agency received a physician referral for home health on 9/22/2021, did not admit the patient until 9/27/2021, and failed to evidence the physician ordered home health services to begin on 9/27/2021. A document dated 9/22/2021 titled “Referral Notes” evidenced the patient was referred to the agency for skilled nursing and skilled therapy by nurse practitioner J. A document titled “... [patient] ... Communication Notes” evidenced an entry dated 9/22/2021 which stated “... Received call back from Pt’s [patient’s] spouse ... offered Monday [9/27/2021, five days after referral] at 10:30 [for start of care assessment] ... which she accepted ....” A document dated 9/27/2021 titled “SOC [start of care] OASIS-D1 [outcome and assessment information set] ....” stated “... If the physician indicated a specific start of care ... date when the patient was referred for home health services, record the date specified ... 09/27/2021 ....” During an interview on 10/27/2021 at 4:50 PM, the clinical manager and alternate administrator agreed the OASIS document date was not accurate, and the physician did not order the start of care to occur on 9/27/2021. 4. Record review for patient #6 was completed on 10/26/2021, start of care date 8/26/2021, for certification period 8/26/2021-10/24/2021. The clinical record evidenced the agency received a physician referral for home health on 8/19/2021, did not admit the patient until 8/26/2021, and failed to evidence the physician ordered home health services to begin on 8/26/2021. A faxed document received by the agency on 8/19/2021, signed by certifying physician H on 8/19/2021 titled “Order” which stated “... [discharge] 8/21/21 home w/ HHC [home health care] ....” A document dated 8/26/2021 titled “SOC OASIS-D1 ....” stated “... If the physician indicated a specific start of care ... date when the patient was referred for home health services, record the date specified ... 8/26/2021 ....” During an interview on 10/26/2021 at 11:00 AM, the alternate administrator indicated the clinical record failed to evidence the certifying physician ordered the start of care to occur on 8/26/2021. 5. Record review for patient #7 was completed on 10/21/2021, start of care date 8/14/2021, for certification period 8/14/2021-10/12/2021. The clinical record evidenced the agency received a physician referral for home health on 8/10/2021, did not admit the patient until 8/14/2021, and failed to evidence the physician ordered home health services to begin on 8/14/2021. A document titled “... [patient] ... Communication Notes” evidenced an entry dated 8/10/2021 at 12:19 PM which stated “... I advised [certifying physician I] that we are booking about 1 week out for OT and maybe 2 for PT ... we can start for medication management right away ....” A document titled “... [patient] ... Communication Notes” evidenced an entry dated 8/10/2021 at 4:31 PM which stated “... offered first available [home health] admit on 8/14 [2021] ....” A document dated 8/14/2021 titled “SOC OASIS-D1 ....” stated “... If the physician indicated a specific start of care ... date when the patient was referred for home health services, record the date specified ... 8/14/2021 ....” During an interview on 10/21/2021 at 1:00 PM, the alternate administrator confirmed the clinical record did not evidence the certifying physician ordered the start of care to occur on 8/14/2021, and the OASIS entry made was incorrect.

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure the patient and/or caregiver participated in and consented to the development of the plan of care which included (but not limited to) the disciplines that would furnish the care, the frequency of visits, and/or the care that was furnished for 3 of 3 home visits observed (#5, 6, 7). Findings include: 1. A policy revised 09/2017 titled “Plan of Care: Physician Certification” stated “... Each patient’s needs should be continually assessed ... shall include ... frequency ... needed in order to meet the patient’s/caregiver’s needs ....” 2. A policy revised 07/2019 titled “Care Plan Establishment and Review” stated “... must provide a written individualized plan of care ... occurs with the collaboration of ... patient and family ... planning appropriate responses to patient and family needs ....” 3. A Centers for Disease Control and Prevention web-based site referenced on 10/27/2021, https://www.cdc.gov/diabetes/managing/managing-blood-sugar/a1c.html, stated “... The A1C test—also known as the hemoglobin A1C or HbA1c test—is a simple blood test that measures your average blood sugar levels over the past 3 months ... Higher A1C levels are linked to diabetes complications, so reaching and maintaining your individual A1C goal is really important if you have diabetes ... A normal A1C level is below 5.7% ... a level of 6.5% or more indicates diabetes ....” 4. A home visit observation was conducted with patient #7 on 10/21/2021 at 9:00 AM with home health aide (HHA) H. The patient’s spouse indicated the patient also received weekly nursing visits, physical therapy services, she never knew when they were coming, they did not leave schedules for how often they would visit, and she wished the HHA would come twice weekly instead of once. Clinical record review was completed on 10/21/2021, start of care date 8/14/2021, for certification periods 8/14/2021-10/12/2021 and 10/13/2021-12/11/2021. The clinical record evidenced a PT evaluation was completed on 9/8/2021 with goals for future visits, but no other PT (physical therapy) visits were documented, and no OT (occupational therapy) evaluation was completed. The record failed to evidence the patient/caregiver was made aware or approved the changes to the services or frequencies they were provided. A document signed by certifying physician I on 10/12/2021 titled “Home Health Care Certification and Plan of Care” for certification period 8/14/2021-10/12/2021 evidenced HHA weekly for 7 weeks, and PT and OT services were ordered. A document signed by certifying physician I on 10/20/2021 titled “Home Health Care Certification and Plan of Care” for certification period 10/13/2021-12/11/2021 evidenced HHA weekly for 9 weeks, nursing visits weekly, and PT and OT services were ordered. A document titled “[patient] Communication Notes” evidenced an entry dated 8/14/2021 which stated “... They [patient/family] were informed that the PT/OT will be ordered but it might take a few weeks to get started ....” The entry failed to evidence the patient/family approved of this delay in services ordered. An entry dated 10/18/2021 evidenced nursing visits changed to every other week, but failed to evidence the patient/family was notified or approved the change in nursing visit frequency. During an interview on 10/21/2021 at 1:00 PM, director of quality assurance C indicated she wasn’t sure why the aide was only ordered weekly if the family requested twice per week. 5. A home visit observation was conducted with patient #6 on 10/22/2021 at 10:30 AM. During the visit, the patient drank a bottle of mountain dew (soft drink high in sugar, contraindicated for people with diabetes), family indicated the patient’s blood sugar readings were out of control but getting better, she would like someone to teach the patient about diabetes management, diabetic diet, and how exercise affected blood sugar levels. When asked, RN (registered nurse) J indicated the visit was for recertification of services (review and modification of the plan of care) for the next 60-day period (10/25/2021-12/23/2021), she did not know what his most recent A1c level (a blood test to estimate average blood sugar levels over the past 2-3 months) was, and she would need to follow up with the patient’s physician. A document received from director of quality assurance C on 10/26/2021 titled “Discharge Summary” evidenced the patient’s A1c lab value was 12.4% (normal value is less than 7%) on 7/29/2021. A document signed by certifying physician H on 9/14/2021 titled “Home Health Care Certification and Plan of Care” for certification period 8/26/2021-10/24/2021 evidenced (but not limited to) the patient had diabetes with a foot ulcer (open wound), but was ordered a regular diet. A document signed/not dated by (the new) certifying physician K titled “Home Health Care Certification and Plan of Care” for certification period 10/25/2021-12/23/2021 evidenced (but not limited to) the patient had diabetes with a foot ulcer (open wound), and diet was “as tolerated”. The plan of care failed to evidence skilled nursing interventions that family requested for teaching of diabetes management, diabetic diet, or how exercise affects blood sugar levels. 5. A home visit observation was conducted with patient #5 on 10/22/2021 at 1:00 PM. When asked what his goal(s) for the services received from the home care agency was, the patient indicated he wanted physical therapy (PT) services, and his goal was to get out of bed. When asked, RN Q indicated PT wasn’t ordered upon start of care, and the quality assurance department took care of that. A document signed by certifying physician L on 10/13/2021 titled “Home Health Care Certification and Plan of Care” start of care date 10/7/2021, for certification period 10/7/2021-12/5/2021 failed to evidence PT was ordered, or the patient’s goal was to get out of bed. 17-12-3(b)(2)(D)(i)(AA) 17-12-3(b)(2)(D)(i)(BB) 17-12-3(b)(2)(D)(ii)(AA) 17-12-3(b)(2)(D)(ii)(BB)

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, record review and interview, the registered nurse (RN) failed to ensure the patient’s medication profile included all the medications the patient currently took, included indications for use, and/or correct dose for 5 of 7 records reviewed (#1, 2, 4, 6, 7). Findings include: 1. A policy revised 03/2017 titled “Medication Review” stated “... A Drug Regimen Review comprehensive assessment must include a review of all medications the patient is currently taking ... will include a listing of the medications that the patient is taking ... shall include over-the-counter and herbal medications ... shall be labeled with ... all applicable information ....” 2. A policy revised 07/2019 titled “Medication Orders” stated “... medications are documented in the patient’s medical record and include ... Purpose (if PRN [as needed] and/or antibiotic) ....” 3. A policy revised 10/2021 titled “Initial Assessment of Patient, Family, Caregiver” stated “... [RN] Instruct in actions, side effects, contraindications, and efficacy of current [medication] regime, examine any additional medications (prescribed or over-the-counter) which the patient may be taking ....” During an interview on 10/26/2021 at 10:00 AM, director of quality assurance C indicated the policy titled “Initial Assessment of Patient, Family, Caregiver” represented the agency’s policy for the comprehensive assessment. 4. An FDA (Federal Drug Administration) website, https://www.accessdata.fda.gov/drugsatfda_docs/label/2018/021134s010lbl.pdf, referenced on 10/27/2021, stated “... NITROSTAT ... At the onset of an attack, administer one tablet under the tongue ... One additional tablet may be administered every 5 minutes as needed. No more than 3 total tablets are recommended within a 15 minute period ... If chest pain persists after three tablets, seek prompt medical attention ....” 5. An FDA (Federal Drug Administration) website, https://www.accessdata.fda.gov/drugsatfda_docs/label/2013/017874s038lbl.pdf, referenced on 10/27/2021, stated “... For use longer than 3 days, remove current patch and place new patch behind other ear ....” 6. Record review for patient #1 was completed on 10/27/2021, start of care date 9/27/2021, for certification period 9/27/2021-11/25/2021. A document printed on 10/21/2021 titled “Medication Profile” stated “... Nitrostat [medication used to relieve chest pain] ... 1 tab ... [under the tongue] ... every 5 minutes as needed ... scopolamine ... Apply ... topically every 72 hours ....” During an interview on 10/27/2021 at 4:50 PM, the clinical manager indicated the medication profile should have included instructions to take no more than 3 doses for the nitrostat, to call “911” if chest pain was unrelieved, and the scopolamine should have included instructions to rotate sites for each new patch applied, and ensure old patch was removed. 7. Record review for patient #2 was completed on 10/27/2021, start of care date 5/1/2020, for certification period 8/24/2021-10/22/2021. A document printed on 10/21/2021 titled “Medication Profile” evidenced (but not limited to) the patient took 1mg (milligram) of warfarin (a blood thinner requiring routine lab monitoring for therapeutic blood levels) daily. During an interview on 10/27/2021 at 5:15 PM, the clinical manager and director of quality assurance C indicated 1mg was the default dose on the patient’s medication list, there were no lab results in the patient’s medical record, and the current dose of warfarin the patient took was unknown. 8. Record review for patient #4 was completed on 10/27/2021, start of care date 3/11/2020, for certification period 9/2/2021-10/31/2021, and discharge date 9/25/2021, evidenced a document titled “[patient] Communication Notes” evidenced an entry dated 7/21/2021 which stated “... A lot of teaching is done with ... [family] ... about treating with sliding scale [insulin] ....” A document titled “Home Health Care Certification and Plan of Care” for certification period 9/2/2021-10/31/2021 evidenced (but not limited to) a primary diagnosis of diabetes with hyperglycemia (high blood sugar), skilled nursing for symptom management and education of uncontrolled blood sugars, and failed to evidence sliding scale insulin in the medication section of the plan of care. 9. Record review for patient #6 was completed on 10/26/2021, start of care date 8/26/2021, for certification period 8/26/2021-10/24/2021. A document dated and signed by LPN (licensed practical nurse) S on 8/27/2021 stated “... 6 units of insulin was administered per sliding scale order ....” A home visit observation was conducted on 10/22/2021 at 10:30 AM with RN J. The surveyor and RN J both observed a hand-written post-it note in a plastic bag which evidenced sliding scale insulin instructions for administration. During this time, family confirmed the patient did take sliding scale insulin. A document printed on 10/20/2021 titled “Medication Profile” failed to evidence sliding scale insulin use or indications. During an interview on 10/26/2021 at 11:00 AM, the clinical manager confirmed there was no sliding scale for insulin on the medication profile or in the medical record. 10. Record review for patient #7 was completed on 10/21/2021, start of care date 8/14/2021, for certification period 8/14/2021-10/12/2021, evidenced a document dated 10/12/2021 titled “Recert OASIS [outcome and assessment information set]-D1 ....” stated “... now taking Tylenol 1000mg QID [4 times daily] ....” A document printed on 10/20/2021 titled “Medication Profile” evidenced tylenol 500mg 3 times daily. The medication profile failed to evidence the updated dose and frequency. 17-14-1(a)(1)(B)

Discharge Planning CFR(s): 484.58 Condition of Participation: Discharge planning. This CONDITION is not met as evidenced by: Based on record review and interview, the home health agency (HHA) failed to develop and implement an effective discharge planning process for the agency; failed to develop/maintain discharge/transfer summary policies, which included discharge/transfer summary content and procedure(s) to ensure the receiving facility received necessary medical information; failed to ensure the agency sent discharge summaries with all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences for 2 of 2 discharged records reviewed (#3, 4); and failed to ensure the agency sent a transfer summary for 1 of 1 records reviewed where the patient was transferred to an acute care facility for emergent care which resulted in hospital admission (#4). Standard level tags were also cited (G562, G564) under this condition. This practice had the potential to affect all agency patients. The cumulative effect of this systemic problem resulted in the agency being out of compliance with the Condition of Participation 42 CFR §484.58: Discharge planning. Findings include: 1. A policy revised 2/2017 titled “Discharge Criteria” stated “... After the decision is made for discharge, the patient/caregiver will be notified ....” During an interview on 10/27/2021 at 1:03 PM, the alternate administrator indicated the policy titled “Discharge Criteria” was the only discharge policy the agency had, and it did not include discharge planning needs. 2. A policy revised 10/2021 titled “Initial Assessment of Patient, Family, Caregiver” failed to evidence the comprehensive assessment must include discharge planning needs. During an interview on 10/26/2021 at 10:00 AM, the director of quality assurance indicated the policy titled “Initial Assessment of Patient, Family, Caregiver” represented the agency’s policy for the comprehensive assessment. 3. Record review for patient #3 was completed on 10/27/2021, start of care date 5/19/2021, for certification period 5/19/2021-7/17/2021, discharge date 5/25/2021. A document dated 9/27/2021 titled “SOC OASIS-D1 ....” evidenced (but not limited to) the patient had cancer, would be going back to the hospital “soon” for 3 weeks for stem cell transplant, skilled nursing provided central line care (tube inserted into a vein for direct access to administer medications), taught family how to care for the central line, and stated “... Patient needs post discharge ... None at this time ... Discharge Plans ... When goals met or progress plateaus ....” The document failed to evidence discharge planning needs for care of the central line upon agency discharge. A document titled “Prep Notes Communication” evidenced an entry dated 5/20/2021 which stated “... anticipate discharge once acknowledgement of arrival at ... [hospital M] ... on Tuesday, May 25 ....” The document also evidenced an entry dated 5/25/2021 which stated “... [verbal order] received from [physician N’s] nurse to discharge patient ... is currently admitted to [hospital M] ....” A document dated and signed by registered nurse (RN) T on 5/25/2021, and signed by physician N on 6/4/2021 titled “Discharge Summary” failed to evidence if the patient had any allergies, any pertinent lab values, the reason for the home care admission, the treatments received, presence of a central line, the last time her central line dressing was changed, or post-discharge goals of care. 4. Record review for patient #4 was completed on 10/27/2021, start of care date 3/11/2020, for certification period 9/2/2021-10/31/2021, discharge date 9/25/2021. Documents dated 9/2/2021, 9/9/2021, 9/13/2021, and 9/16/2021 titled “Skilled Nursing Visit Note ... Follow Up Visit ....” all stated “... Discharge Planning ... Not addressed this visit ....” A document dated and signed by RN J on 9/20/2021 titled “Skilled Nursing Visit Note” stated “... Description ... RN Phone call ... patient ... admitted to ... [hospital O] ... over the weekend ... [patient] had a fall and fractured her hip and ... taken to surgery ....” A document dated and signed by registered nurse (RN) J on 9/28/2021, with no physician signature titled “Discharge Summary” failed to evidence if the patient had any allergies, any pertinent lab values, the reason for the home care admission, patient/family discharge instructions, or treatments received. During an interview on 10/27/2021 at 1:00 PM, the director of quality assurance indicated the agency had no policy regarding transfer summaries or transfers, they did not send a transfer summary for the patient on 9/20/2021, and they did not send transfer summaries when any patients were admitted into a hospital.

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 all patients received the home health services ordered on the plan of care (POC) for 4 of 7 records reviewed, (#1, 3, 6, 7); failed to ensure all patients’ plans of care were individualized, and included patient-specific measurable outcomes and goals for 7 of 7 records reviewed (#1, 2, 3, 4, 5, 6, 7); and failed to ensure all patients’ therapy plans of care were reviewed, approved, and signed by the certifying physician for 3 of 3 records reviewed that received therapy services (#1, 6, 7). Findings include: 1. A document revised 07/2019 titled “Care Plan Establishment and Review” stated “... agency ... must provide a written individualized plan of care that identifies patient-specific measurable outcomes and goals ... established, periodically reviewed, and signed by the attending physician ....” 2. Record review for patient #1 was completed on 10/27/2021, start of care date 9/27/2021. The record failed to evidence the patient received occupational therapy (OT) or speech language pathology (SLP) services as ordered on the plan of care, the plan of care was individualized and included patient-specific measurable outcomes and goals, or the physical therapy (PT) plan of care was reviewed by, approved by, or signed by the certifying physician. A document dated 9/27/2021 titled “SOC [start of care] OASIS-D1 [outcome and assessment information set] ....” evidenced the patient’s self-stated goals/care preferences were to use alternative methods to help complete personal care with the assistance of family, and have better pain management; and his pain goal was “2” (scale of 0-10, with 0= no pain, and 10= worst pain ever). A document titled “Home Health Care Certification and Plan of Care” for certification period 9/27/2021-11/25/2021, was signed by the certifying physician on 10/3/2021, with primary diagnosis amyotrophic lateral sclerosis (ALS, a fatal, degenerative disease affecting the brain and spinal cord, with progressively worse symptoms), and other diagnoses included history of prostate cancer (causes restricted urinary flow and/or difficulty urinating), atherosclerosis (deposit of plaque in the arteries causing blockage) of CABG (coronary artery bypass grafting- a procedure to improve poor blood flow to the heart) without chest pain, and high cholesterol. The document evidenced (but not limited to) orders for SLP (speech language pathologist), PT, and OT to evaluate, goals included optimal independence, stabilization of pulmonary (lung) status, optimal activity level achieved and maintained within baseline respiratory and energy parameters, pain level less than 3 (patient goal was less than 2), and failed to evidence patient-specific measurable outcomes/goals for the patient’s primary diagnosis, high cholesterol, heart disease, fall, skin and nutritional risks, baseline versus stabilized pulmonary status, baseline versus optimal activity level, baseline energy parameters, or the patient’s self-stated goals/care preferences were to use alternative methods to help complete personal care with the assistance of family, and have better pain management. An untitled document dated 10/7/2021 evidenced a PT evaluation was completed on 10/7/2021, interventions and goals were established, and failed to evidence it was approved by, or signed by the certifying physician. During an interview on 10/27/2021 at 4:50 PM, the clinical manager confirmed the record failed to evidence SLP or OT evaluations/treatments were provided to the patient. 3. Record review for patient #2 was completed on 10/27/2021, start of care date 5/1/2020, for certification period 8/24/2021-10/22/2021, and 10/23/2021-12/21/2021. The record failed to evidence the plan of care was individualized, and included patient-specific measurable outcomes and goals. A document titled “Home Health Care Certification and Plan of Care” for certification period 8/24/2021-10/22/2021, was signed by the certifying physician on 8/27/2021, with primary diagnosis ischemic cardiomyopathy (significantly impaired left ventricular heart function), and other diagnoses of chronic heart failure, chronic lung disease with acute exacerbation (active symptoms), high blood pressure, hardening of the arteries without chest pain, bacterial infection causing other disease, high cholesterol, infected implanted device, depression, presence of LVAD (left ventricular assist device- implanted in the chest to help pump blood from the left ventricle of heart out to the rest of the body for patients who have reached end-stage heart failure), and rib fracture. The document failed to evidence measurable outcomes/goals related to weight, heart failure management, lung disease, high cholesterol, depression, or rib fracture. A document dated 10/18/2021 titled “Skilled Nursing Visit Note ... Home Health POC Recertification ....” evidenced patient self-stated goals/care preferences included to maintain current level of personal care ability, and her perceived impact of current illness was decreased ability to perform instrumental activities of daily living (IADLs) such as house cleaning, and cooking. A document titled “Home Health Care Certification and Plan of Care” for certification period 10/23/2021-12/21/2021, not yet signed by the certifying physician, evidenced a primary diagnosis of ischemic cardiomyopathy, and other diagnoses of chronic heart failure, chronic lung disease with acute exacerbation, high blood pressure, hardening of the arteries without chest pain, bacterial infection causing other disease, high cholesterol, infected implanted device, depression, presence of LVAD, and rib fracture. The document failed to evidence measurable outcomes/goals related to weight, heart failure management, lung disease, high cholesterol, depression, or rib fracture. During an interview on 10/27/2021 at 5:15 PM, the alternate administrator and clinical manager confirmed the nurses failed to obtain ordered lab draws as ordered on the plan of care. 4. Record review for patient #3 was completed on 10/27/2021, start of care date 5/19/2021, for certification period 5/19/2021-7/17/2021, discharge date 5/25/2021. The record failed to evidence the patient received a social worker evaluation as ordered on the plan of care, or the plan of care was individualized and included patient-specific measurable outcomes and goals. A document dated 9/27/2021 titled “SOC OASIS-D1 ....” evidenced the patient’s self-stated goals/care preferences were to receive stem cell transplant and it would cure her, she was a high risk for infection, she received daily heparin (blood thinner) flushes and weekly central line (tube inserted into a large vein for administration of fluids, medications) dressing changes to the right chest, bouts of diarrhea due to her treatment, and she would be going to the hospital soon for stem cell transplant. A document titled “Home Health Care Certification and Plan of Care” for certification period 5/19/2021-7/17/2021, signed by the certifying physician on 6/4/2021, evidenced primary diagnosis of multiple myeloma (cancer) not in remission, and other diagnoses of intractable migraine with status migrainosus (severe and long-lasting form of migraine headache), high cholesterol, depression, and hypothyroidism. The document evidenced an order for a social worker to evaluate between dates 5/20/2021-5/23/2021 (the patient was discharged on 5/25/2021), and failed to evidence individualized measurable outcomes or goals for diarrhea, migraine and associated pain, high cholesterol, or depression. 5. Record review for patient #4 was completed on 10/27/2021, start of care date 3/11/2020, for certification period 9/2/2021-10/31/2021, discharge date 9/25/2021. The record failed to evidence the patient’s most current A1c (a blood test to determine average blood sugar over the past 2-3 months), the plan of care was individualized or included patient-specific measurable outcomes and goals. A document titled “Home Health Care Certification and Plan of Care” for certification period 9/2/2021-10/31/2021, signed by the certifying physician on 10/5/2021, evidenced (but not limited to) a primary diagnosis of diabetes with hyperglycemia (high blood sugar), and a 2200 calorie restricted diabetic diet. The document failed to evidence patient-specific measurable outcomes and goals for hyperglycemia or diabetic diet. During an interview on 10/27/2021 at 1:00 PM, the clinical manager indicated there should have been an intervention to review a blood sugar readings log, there was no A1c in the record, an A1c would be beneficial to determine a measurable outcome, and there was no evidence to measure if the patient followed a 2200 calorie diabetic diet. 6. Record review for patient #5 was completed on 10/26/2021, start of care date 10/7/2021, for certification period 10/7/2021-12/5/2021. The record failed to evidence the plan of care was individualized, or included patient-specific measurable outcomes and goals. A document dated 10/7/2021 titled “SOC OASIS-D1 ....” evidenced the patient had a stage 2 pressure sore (an open wound characterized by partial-thickness skin loss into but no deeper than the depth of the skin, and would include intact or ruptured blisters) on his lower back/buttock area, a venous stasis ulcer (a wound caused by decreased circulation) on the bottom of the right foot, had a size 16 french/10 cc (cubic centimeter) indwelling foley catheter, the patient had “horrible” pain, his pain goal was “2”, his self-stated goal was to have his wounds healed, less pain, and ability to complete personal care with minimal assistance; and was only eating about 50% of his meals. A document titled “Home Health Care Certification and Plan of Care” for certification period 10/7/2021-12/5/2021, signed by the certifying physician on 10/18/2021, evidenced (but not limited to) a primary diagnosis of osteomyelitis (infection into the bone) of the right ankle and foot, and other diagnoses included nonrheumatic aortic valve disorder (dysfunction of heart valve), chronic kidney disease, stage 2 (mild), atrial fibrillation (irregular heartbeats), presence of foley catheter, and high cholesterol. The document failed to evidence individualized measurable outcomes or goals related to ability to self-perform personal care (patient’s personal goal), pain, prevention of skin breakdown, prevention of UTI or dehydration, dietary and fluid intake, or goals for heart and kidney disease, or high cholesterol. 7. Record review for patient #6 was completed on 10/26/2021, start of care date 8/26/2021, for certification period 8/26/2021-10/24/2021. The record failed to evidence the patient received OT as ordered on the plan of care, the plan of care was individualized and included patient-specific measurable outcomes and goals, the PT plan of care was reviewed, approved, or signed by the certifying physician, or the SLP plan of care was reviewed, approved, or signed by the certifying physician. A document titled “Home Health Care Certification and Plan of Care” for certification period 8/26/2021-10/24/2021, signed by the certifying physician on 9/14/2021, evidenced primary diagnosis of multi-system degeneration of the autonomic nervous system/MSA (a neurodegenerative disorder that can cause a multitude of symptoms in any combination including impairments to balance, difficulty with movement, poor coordination, bladder dysfunction, sleep disturbances and poor blood pressure control), and other pertinent diagnoses included (but not limited to) parkinson’s disease (a progressive nervous system disorder that affects movement), benign prostatic hyperplasia (BPH) with lower urinary tract symptoms (condition in which an overgrowth of prostate tissue pushes against the urethra and the bladder, blocking the flow of urine), high blood pressure, history of falling, fainting and collapse, traumatic bruising of the brain (due to fall), and diabetes with foot ulcer. The document also evidenced (but not limited to) orders for skilled nursing for wound care, PT, OT, and SLP to evaluate and treat, regular diet, and failed to evidence individualized interventions, measurable outcomes, or goals related to MSA, BPH, high blood pressure, or diabetic diet. A document dated 9/2/2021 titled “PT eval [evaluation/plan of care]” evidenced a PT evaluation was completed on 9/2/2021, interventions and goals were established, and failed to evidence it was reviewed, with, approved by, or signed by the certifying physician. A document dated 9/1/2021 titled “Speech Therapy [SLP] Assessment” evidenced a SLP evaluation was completed on 9/1/2021, interventions and goals were established, and failed to evidence it was reviewed with, approved by, or signed by the certifying physician. During an interview on 10/26/2021 at 11:00 AM, the alternate administrator indicated he couldn’t find an OT evaluation in the record, the clinical director of quality assurance indicated there was not an OT evaluation in the record, and the clinical manager and alternate administrator confirmed the therapy evaluations failed to evidence the certifying physician was contacted to review or approve the therapy plans of care, and the evaluations were not signed by the certifying physician. 8. Record review for patient #7 was completed on 10/21/2021, start of care date 8/14/2021, for certification period 8/14/2021-10/12/2021, and 10/13/2021-12/11/2021. The record failed to evidence the patient received OT services, a PT evaluation was completed on 9/8/2021 with goals for future visits, but no other PT visits were made, no weekly home health aide (HHA) visits were made during the weeks of 9/5/2021 or 9/19/2021 as ordered on the plan of care, the plans of care were individualized and included patient-specific measurable outcomes and goals, or the PT plan of care was reviewed with, approved by, or signed by the certifying physician. titled “Home Health Care Certification and Plan of Care” for certification period 8/14/2021-10/12/2021, was signed by the certifying physician on 10/12/2021, with primary diagnosis chronic combined systolic and diastolic heart failure (both left and right sided heart failure, resulting in inability for the heart to adequately pump blood to and from the heart), and other pertinent diagnoses of paroxysmal atrial fibrillation (a rapid, erratic heart rate that begins suddenly and then stops on its own within 7 days), hearing loss, history of prostate cancer, high cholesterol, fainting and collapse, obesity, nonrheumatic aortic valve stenosis (rigidity of heart/aortic valve not caused by rheumatoid arthritis), history of falling, and long term (current) use of anticoagulants (blood thinners). The document evidenced (but not limited to) orders for skilled nursing, HHA weekly beginning 8/22/2021, PT/OT to evaluate and treat, and failed to evidence individualized and patient-specific measurable outcomes and goals for heart failure, paroxysmal atrial fibrillation, hearing loss, history of prostate cancer, high cholesterol, fainting and collapse, obesity, nonrheumatic aortic valve stenosis, history of falling, or long-term use of anticoagulants. An untitled document dated 9/8/2021 evidenced a PT evaluation was completed on 9/8/2021, interventions and goals were established, and failed to evidence it was approved by, or signed by the certifying physician. During an interview on 10/21/2021 at 1:00 PM, the director of quality assurance confirmed OT was not provided to the patient, and there were no additional PT visit notes in the record after the evaluation on 9/8/2021, which also included the certification period 10/13/2021-12/11/2021. 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 and interview, the agency failed to ensure the patient’s plan of care included all required elements such as (but not limited to) all pertinent diagnoses, the patient’s mental, psychosocial, and/or cognitive status, all equipment and/or supplies, all medications and/or treatments, or all necessary interventions to address the patient’s underlying risk factors for emergency department visits and hospital re-admission for 7 of 7 records reviewed (#1, 2, 3, 4, 5, 6, 7). Findings include: 1. A document revised 07/2019 titled “Care Plan Establishment and Review” stated “... agency ... must provide a written individualized plan of care that identifies patient-specific measurable outcomes and goals ... will include patient/family/caregiver needs including medical, nursing, functional ... psycho-social ....” 2. A document revised 09/2017 titled “Plan of Care: Physician Certification” stated “... The plan of care shall include, but is not limited to ... An assessment of the patients [sic] needs and identification of services ... scope and frequency of services/disciplines needed in order to meet the patient’s/caregiver’s needs ....” 3. A University of California, San Francisco web-based reference cited on 10/21/2021, https://www.ucsfhealth.org/medical-tests/mental-status-testing, indicated (but not limited to) mental status testing is done to check a person's thinking ability, to determine if any problems are getting better or worse, a health care provider will ask a number of questions to determine orientation to self, place, time, ability to problem solve, comprehend, and react to normal circumstances. 4. Record review for patient #1 was completed on 10/27/2021, start of care date 9/27/2021, evidenced a document dated 9/27/2021 titled “SOC [start of care] OASIS-D1 [outcome and assessment information set] ....”, which evidenced the patient used heat for pain relief, was chairfast, had contractures (joint/tendon/ligament stiffness causing limited mobility), was a risk for skin breakdown due to bony prominences, immobility and inability to change positions, had chest pain with activity, a productive cough, utilized a CPAP/BiPAP (a machine that forces air into the lungs either continuously or intermittently while breathing), used a size 32 condom catheter (a urinary drainage device that is fitted over the penis to drain urine into a bag), had GERD (acid reflux), was symptomatic of depression, took an antidepressant, had a PEG (tube inserted into the stomach to administer nutrition, fluids, and/or medications), received scheduled intermittent tube feedings for nutrition, was a moderate nutritional risk, unable to take nutrients by mouth, fall risk, unable to self-administer medications, used cough assist and oral suctioning, unable to transfer self, was dependent on another person for completion of personal care, and risk factor(s) for emergency department (ED) visit/hospital re-admission included the patient took 5 or more medications. A document titled “Home Health Care Certification and Plan of Care” for certification period 9/27/2021-11/25/2021, was signed by the certifying physician on 10/3/2021, with primary diagnosis amyotrophic lateral sclerosis (ALS, a fatal, degenerative disease affecting the brain and spinal cord, with progressively worse symptoms), and other diagnoses included history of prostate cancer (causes restricted urinary flow and/or difficulty urinating), atherosclerosis (deposit of plaque in the arteries causing blockage) of CABG (coronary artery bypass grafting- a procedure to improve poor blood flow to the heart) without chest pain, and high cholesterol. The document evidenced the patient’s mental status was “oriented”, but failed to evidence what the patient was oriented to (person, place, time, situation); failed to evidence psychosocial (family dynamics/support, household needs) or cognitive status (comprehension and understanding); failed to evidence other pertinent diagnoses of depression, GERD, presence of a PEG tube, or pain; failed to evidence functional limitations of inability to transfer self, dependent for personal care, and non-ambulatory; failed to evidence the safety measure of aspiration (ingestion of food, other objects, or fluids into the lung) precautions due to presence of a PEG tube and diagnosis of GERD or need for 24 hour care/supervision due to dependent status; failed to evidence all supplies the patient needed such as PEG tube supplies, CPAP/BiPAP equipment, mask, tubing, oral suctioning machine and supplies, or supplies to clean PEG insertion site; nutrition status failed to evidence the patient could take nothing by mouth; failed to evidence interventions for use of heat as pain mitigation, instructions to check PEG tube placement and how often, PEG insertion site care and precautions, indications and instructions for suctioning, indications and instructions for use of CPAP/BiPAP, or who administered medications, medication administration teaching, or verification of medication competency. 5. Record review for patient #2 was completed on 10/27/2021, start of care date 5/1/2020, for certification period 8/24/2021-10/22/2021, evidenced a document titled “Home Health Care Certification and Plan of Care” for certification period 8/24/2021-10/22/2021, signed by the certifying physician on 8/27/2021, with primary diagnosis ischemic cardiomyopathy (significantly impaired left ventricular heart function), and other diagnoses of chronic heart failure, chronic lung disease with acute exacerbation (active symptoms), high blood pressure, hardening of the arteries without chest pain, bacterial infection causing other disease, high cholesterol, infected implanted device, depression, presence of LVAD (left ventricular assist device- implanted in the chest to help pump blood from the left ventricle of heart out to the rest of the body for patients who have reached end-stage heart failure), and rib fracture. The document evidenced (but not limited to) the patient’s mental status was “oriented”, interventions for lab draws, assessment for weight change, weekly PICC (a tube inserted into a vein for administration of fluids or medications) dressing change, teach family how to administer IV (intravenous) medications via PICC, how to flush PICC, but failed to evidence what the patient was oriented to; failed to evidence psychosocial or cognitive status; failed to evidence supplies also included syringes for flushing the PICC, type and frequency of labs to be drawn, current anticoagulant therapy lab values, current or desired weight, or last PICC dressing change and when next due to be changed. 6. Record review for patient #3 was completed on 10/27/2021, start of care date 5/19/2021, for certification period 5/19/2021-7/17/2021, discharge date 5/25/2021, evidenced a document dated 9/27/2021 titled “SOC OASIS-D1 ....”, which evidenced the patient was a high risk for infection, she received daily heparin (blood thinner) flushes and weekly central line (tube inserted into a large vein for administration of fluids, medications) dressing changes to the right chest, had bouts of diarrhea due to her treatment, and she would be going to the hospital soon for stem cell transplant. A document titled “Home Health Care Certification and Plan of Care” for certification period 5/19/2021-7/17/2021, signed by the certifying physician on 6/4/2021, evidenced primary diagnosis of multiple myeloma (cancer) not in remission, and other diagnoses of intractable migraine with status migrainosus (severe and long-lasting form of migraine headache), high cholesterol, depression, and hypothyroidism. The document evidenced (but not limited to) the patient’s mental status was “oriented”, diet “as tolerated”, risk for ED visits/hospital re-admissions was “none”; and failed to evidence what the patient was oriented to; failed to evidence psychosocial or cognitive status; failed to evidence supplies also included syringes for flushing the central line, specific instructions to flush the central line, or interventions to mitigate diarrhea, migraine and associated pain, high cholesterol (such a dietary choices), or depression. 7. Record review for patient #4 was completed on 10/27/2021, start of care date 3/11/2020, for certification period 9/2/2021-10/31/2021, discharge date 9/25/2021, evidenced a document titled “Home Health Care Certification and Plan of Care” for certification period 9/2/2021-10/31/2021, signed by the certifying physician on 10/5/2021, which evidenced (but not limited to) a primary diagnosis of diabetes with hyperglycemia (high blood sugar), a 2200 calorie restricted diabetic diet, risk for ED visits/hospital re-admissions included history of falls – or any fall with injury – in the past 12 months, unintentional weight loss of a total of 10 or more pounds in the last 12 months, multiple hospitalizations (2 or more) in the past 6 months, multiple ED visits (2 or more) in the past 6 months, reported or observed history of difficulty complying with any medical instructions (for example, medications, diet, exercise) in the past 3 months, currently taking 5 or more medications, and currently reports exhaustion. The document failed to evidence patient-specific interventions to mitigate high blood sugar, interventions to monitor and educate on maintaining a 2200 calorie diabetic diet, or specific interventions to address risks for ED visits/hospital re-admissions. During an interview on 10/27/2021 at 1:00 PM, the clinical manager indicated there should have been an intervention to review a blood sugar readings log, there was no A1c in the record, and there was no evidence to measure if the patient followed a 2200 calorie diabetic diet. 8. Record review for patient #5 was completed on 10/26/2021, start of care date 10/7/2021, for certification period 10/7/2021-12/5/2021, evidenced a document dated 10/7/2021 titled “SOC OASIS-D1 ....”, which evidenced the patient had a stage 2 pressure sore (an open wound characterized by partial-thickness skin loss into but no deeper than the depth of the skin, and would include intact or ruptured blisters) on his lower back/buttock area, a venous stasis ulcer (a wound caused by decreased circulation) on the bottom of the right foot, had a size 16 french/10 cc (cubic centimeter) indwelling foley catheter that was last changed 9/30/2021, was due to be changed 10/30/2021, the patient had “horrible” pain, he had privately paid caregiver(s), he was non-weight-bearing, bedbound, had contractures, high risk for skin breakdown, bradycardia (slow heart rate), his urine was dark amber colored, incontinent of bowel, was a fall risk, home health aide was referred, and was only eating about 50% of his meals. A document titled “Home Health Care Certification and Plan of Care” for certification period 10/7/2021-12/5/2021, signed by the certifying physician on 10/18/2021, evidenced (but not limited to) a primary diagnosis of osteomyelitis (infection into the bone) of the right ankle and foot, and other diagnoses included nonrheumatic aortic valve disorder (dysfunction of heart valve), chronic kidney disease, stage 2 (mild), atrial fibrillation (irregular heartbeats), presence of foley catheter, and high cholesterol. The document also evidenced the patient’s mental status was “oriented”, had a regular diet, foley catheter was to be changed monthly and as needed; and failed to evidence a diagnosis of pain, individualized interventions for mitigation of pain, prevention of skin breakdown, signs/symptoms of UTI or dehydration, methods to increase/monitor dietary and fluid intake, nutritional requirements to aid with wound healing, kidney disease or low cholesterol food choices, fall prevention, management/goals for heart and kidney disease, or high cholesterol, failed to include what the patient was oriented to, his psychosocial or cognitive status, or interventions to prevent ED visits or hospital re-admissions. 9. Record review for patient #6 was completed on 10/26/2021, start of care date 8/26/2021, for certification period 8/26/2021-10/24/2021, evidenced a document titled “Home Health Care Certification and Plan of Care” for certification period 8/26/2021-10/24/2021, signed by the certifying physician on 9/14/2021, which evidenced primary diagnosis of multi-system degeneration of the autonomic nervous system/MSA (a neurodegenerative disorder that can cause a multitude of symptoms in any combination including impairments to balance, difficulty with movement, poor coordination, bladder dysfunction, sleep disturbances and poor blood pressure control), and other pertinent diagnoses included (but not limited to) parkinson’s disease (a progressive nervous system disorder that affects movement), benign prostatic hyperplasia (BPH) with lower urinary tract symptoms (condition in which an overgrowth of prostate tissue pushes against the urethra and the bladder, blocking the flow of urine), high blood pressure, history of falling, fainting and collapse, traumatic bruising of the brain (due to fall), and diabetes with foot ulcer. The document also evidenced the patient’s mental status was “oriented”, a regular diet, and failed to evidence what the patient was oriented to, his psychosocial or cognitive status, specific wound supplies, individualized interventions related to MSA, BPH, high blood pressure, diabetic diet, prevention of new or worsening skin breakdown, or interventions to prevent ED visits or hospital re-admissions. 10. Record review for patient #7 was completed on 10/21/2021, start of care date 8/14/2021, for certification period 8/14/2021-10/12/2021, evidenced a document titled “Home Health Care Certification and Plan of Care” for certification period 8/14/2021-10/12/2021, signed by the certifying physician on 10/12/2021, with primary diagnosis chronic combined systolic and diastolic heart failure (both left and right sided heart failure, resulting in inability for the heart to adequately pump blood to and from the heart), and other pertinent diagnoses of paroxysmal atrial fibrillation (a rapid, erratic heart rate that begins suddenly and then stops on its own within 7 days), hearing loss, history of prostate cancer, high cholesterol, fainting and collapse, obesity, nonrheumatic aortic valve stenosis (rigidity of heart/aortic valve not caused by rheumatoid arthritis), history of falling, and long term (current) use of anticoagulants (blood thinners). The document evidenced the patient’s mental status was “oriented, forgetful”, low sodium diet, the patient was on a blood thinner, and failed to evidence what the patient was oriented to, psychosocial or cognitive status, bleeding precautions due to taking a blood thinner, individualized and patient-specific measurable interventions for heart failure, paroxysmal atrial fibrillation, hearing loss, history of prostate cancer, high cholesterol, fainting and collapse, obesity, nonrheumatic aortic valve stenosis, history of falling, or long-term use of anticoagulants. 11. During an interview on 10/27/2021 at 6:30 PM, the alternate administrator, clinical manager, and director of quality assurance C confirmed the plans of care for the clinical records reviewed were not individualized, or satisfactory to meet regulatory requirements. 17-13-1(a)(1)(B) 17-13-1(a)(1)(C ) 17-13-1(a)(1)(D)(i) 17-13-1(a)(1)(D)(ii) 17-13-1(a)(1)(D)(vii) 17-13-1(a)(1)(D)(viii) 17-13-1(a)(1)(D)(ix) 17-13-1(a)(1)(D)(x)

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 record review and interview, the agency failed to ensure the physician was notified for 1 of 1 patient (#4) who experienced a significant change in condition resulting in an emergency department (ED) visit and subsequent hospitalization, from a total sample of 7. Findings include: A document revised date 07/2019 titled “Physician and Care Team Review of Plan of Care” stated “... Verbal communication will be given to the physician and documented accordingly in the patient’s record indicating ... the physician was notified as frequently as the patient’s conditions warrant ... plan of care is reviewed by the attending physician ... as often as the severity of the patient’s condition requires ... a significant change in condition ....” Record review for patient #4 was completed on 10/27/2021, start of care date 3/11/2020, for certification period 9/2/2021-10/31/2021, discharge date 9/25/2021, evidenced a document dated and signed by RN (registered nurse) J on 9/20/2021 titled “Skilled Nursing Visit Note” stated “... Description ... RN Phone call ... patient ... admitted to ... [hospital O] ... over the weekend ... [patient] had a fall and fractured her hip and ... taken to surgery ....” The document failed to evidence the physician was notified. During an interview on 10/27/2021 at 2:03 PM, director of quality assurance C indicated family called 2 days after the patient fell to let the agency know, it happened over a weekend, she went from the hospital to a rehabilitation facility, and the record did not reflect the physician was notified of the change in condition. 17-13-1(a)(2)

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 (HHA) failed to provide all patients and/or caregivers a written home visit schedule that included frequency of visits by HHA personnel and personnel acting on behalf of the HHA for 3 of 3 home visits observed (#5, 6, 7). Findings include: 1. A home visit observation was conducted with patient #7 on 10/21/2021 at 9:00 AM. During this time, the home folder was reviewed, which failed to evidence documentation of a written home visit schedule. Also during this visit, the patient’s spouse indicated the patient also received weekly nursing visits, physical therapy services, she never knew when they were coming, they did not leave schedules, and she wished the HHA would come twice weekly instead of once. 2. A home visit observation was conducted with patient #6 on 10/22/2021 at 10:30 AM. During this time, the home folder was reviewed, which failed to evidence documentation of a written home visit schedule. 3. A home visit observation was conducted with patient #5 on 10/22/2021 at 1:00 PM. During this time, the patient’s caregiver indicated there were no HHA documents or folder present in the home.

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, record review and interview, the home health agency (HHA) failed to provide all patients and/or caregivers a written medication schedule for 3 of 3 home visits observed (#5, 6, 7). Findings include: 1. A home visit observation was conducted with patient #7 on 10/21/2021 at 9:00 AM. During this time, the home folder was reviewed, which failed to evidence documentation of the patient’s written medication schedule. 2. A home visit observation was conducted with patient #6 on 10/22/2021 at 10:30 AM. During this time, the home folder was reviewed, which failed to evidence documentation of the patient’s written medication schedule, and RN (registered nurse) J indicated she never provided patients with written medication schedules. 3. A home visit observation was conducted with patient #5 on 10/22/2021 at 1:00 PM. During this time, the patient’s caregiver indicated there were no HHA documents or folder present in the home.

Treatments and therapy services CFR(s): 484.60(e)(3) Any treatments to be administered by HHA personnel and personnel acting on behalf of the HHA, including therapy services. This ELEMENT is not met as evidenced by: Based on observation, record review and interview, the agency failed to provide all patients and/or caregivers written documentation of any treatments or care that was administered/provided by agency personnel and/or personnel acting on behalf of the agency, which included therapy services, for 3 of 3 home visits observed (#5, 6, 7). Findings include: 1. A home visit observation was conducted with patient #7 on 10/21/2021 at 9:00 AM. Home health aide (HHA) H applied a gait belt (a device put on a patient who has mobility issues to assist with transfers or walking) to the patient, assisted him to the bathroom, and provided personal care (shower, assistance with dressing). During this visit, the patient’s spouse indicated the patient also received weekly nursing visits, and physical therapy services. When asked, she indicated there was no written home exercise plan/program (HEP) provided by the physical therapist (PT). The home folder was also reviewed, which failed to evidence documentation of the patient’s HHA care plan (instructions for care the HHA provided), written HEP for therapy services, or any care/services provided by the nurse. 2. A home visit observation was conducted with patient #6 on 10/22/2021 at 10:30 AM. RN (registered nurse) J performed wound care to the patient’s right foot. The foot was cleansed with saline, medical-grade honey was applied to the wound bed, calcium alginate (absorbent dressing) was applied, covered with a gauze wrap, and the foot was wrapped with an elastic bandage (ace wrap). Family indicated she did wound care when needed, the agency also provided speech, physical, and occupational therapies, but she did not have any written documentation for wound care or exercises they should do. During this time, the home folder was reviewed, which failed to evidence documentation of wound care instructions, or HEP for therapy services received. 3. A home visit observation was conducted with patient #5 on 10/22/2021 at 1:00 PM. RN P indicated the patient received nursing services for wound care and foley catheter care (a tube inserted into the bladder to drain urine). The patient’s caregiver indicated there were no agency documents or folder present in the home.

Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This ELEMENT is not met as evidenced by: Based on observation, record review and interview, the agency failed to provide all patients and/or caregivers written documentation of the name and contact information of the agency’s clinical manager for 3 of 3 home visits observed (#5, 6, 7). Findings include: 1. A home visit observation was conducted with patient #7 on 10/21/2021 at 9:00 AM. During the visit, the patient’s home folder was reviewed, which failed to evidence documentation of the name and contact information of the agency’s clinical manager. 2. A home visit observation was conducted with patient #6 on 10/22/2021 at 10:30 AM. During the visit, the patient’s home folder was reviewed, which failed to evidence documentation of the name and contact information of the agency’s clinical manager. 3. During an interview at a home visit on 10/22/2021 at 1:00 PM, patient #5's caregiver indicated there were no agency documents or folder present in the home.

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 agency failed to ensure skilled professionals provided services that were ordered by the physician for 4 of 7 records reviewed (#1, 2, 6, 7). Findings include: 1. A policy revised 10/2021 titled “Therapy Services” stated “... ensure that necessary therapies ... are available to patients ... will be provided according to the plan of care ....” 2. Record review for patient #1 was completed on 10/27/2021, start of care date 9/27/2021, for certification period 9/27/2021-11/25/2021, evidenced a document signed by certifying physician F on 10/3/2021 titled “Home Health Care Certification and Plan of Care” stated “... the following services are medically necessary for home health services ... Physical Therapy [PT] ... Speech Language Pathology [SLP] ... Occupational Therapy [OT] ....” The clinical record failed to evidence SLP or OT services were provided. During an interview on 10/27/2021 at 4:50 PM, the clinical manager confirmed the clinical record failed to evidence documentation that SLP or OT services was provided to the patient. 3. Record review for patient #2 was completed on 10/27/2021, start of care date 5/1/2020, for certification period 8/24/2021-10/22/2021, evidenced a document signed by certifying physician G on 8/27/2021 titled “Home Health Care Certification and Plan of Care” evidenced (but not limited to) the patient had a PICC (a tube inserted into a vein in the upper arm to administer substances via blood) line, received intravenous (IV) vancomycin (an antibiotic which required routine laboratory monitoring for therapeutic level) daily, took warfarin (a blood thinner/anticoagulant which required routine laboratory monitoring for therapeutic level), and stated “... Orders ... Skilled Nursing [SN] ... PICC line management ... and lab draws ... Assess anticoagulant therapy lab values ....” A prescription document signed by physician F on 10/7/2021 titled “Rx: [prescription] Skilled Nursing” stated “... weekly lab work ....” During an interview on 10/27/2021 at 5:15 PM, the clinical manager and director of quality assurance C confirmed the clinical record failed to evidence any laboratory results, and failed to evidence skilled nurses obtained blood samples for laboratory testing or monitored lab values for therapeutic blood levels. 4. Record review for patient #6 was completed on 10/26/2021, start of care date 8/26/2021, for certification period 8/26/2021-10/24/2021, evidenced a document signed by certifying physician H on 9/14/2021 titled “Home Health Care Certification and Plan of Care” evidenced (but not limited to) OT was ordered to evaluate and treat the patient. During an interview on 10/26/2021 at 11:00 AM, the alternate administrator indicated he could not find an OT evaluation in the patient’s clinical record, and director of quality assurance C confirmed OT was not provided to the patient. 5. Record review for patient #7 was completed on 10/21/2021, start of care date 8/14/2021, for certification period 8/14/2021-10/12/2021, evidenced a document signed by certifying physician I on 10/12/2021 titled “Home Health Care Certification and Plan of Care” evidenced (but not limited to) PT and OT services were ordered for safety due to high fall risk and recently starting an anticoagulant. The clinical record evidenced a PT evaluation was completed on 9/8/2021 with goals for future visits, but no other PT visits were documented, and no OT evaluation was completed. During an interview on 10/21/2021 at 1:00 PM, director of quality assurance C confirmed OT was not provided to the patient, and there were no additional PT visit notes in the record after the evaluation on 9/8/2021.

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the skilled professional (registered nurse, therapist) communicated with the physician related to the current plan of care for 4 of 7 records reviewed (#1, 4, 6, 7). Findings include: 1. A policy revised 07/2019 titled “Care Plan Establishment and Review” stated “... must provide a written individualized plan of care ... which is established, periodically reviewed, and signed by the attending physician ....” 2. A document revised date 07/2019 titled “Physician and Care Team Review of Plan of Care” stated “... Verbal communication will be given to the physician and documented accordingly in the patient’s record indicating ... the physician was notified as frequently as the patient’s conditions warrant ... plan of care is reviewed by the attending physician ... as often as the severity of the patient’s condition requires ... a significant change in condition ....” 3. Record review for patient #1 was completed on 10/27/2021, start of care date 9/27/2021, evidenced an untitled document dated 10/7/2021, which evidenced a PT (physical therapy/physical therapist) evaluation was completed on 10/7/2021, interventions and goals were established, and failed to evidence the PT communicated with the physician to review approve the PT plan of care, or the plan of care was signed by the certifying physician. During an interview on 10/27/2021 at 4:50 PM, the alternate administrator and clinical manager confirmed the record failed to evidence the therapist communicated with the physician. 4. Record review for patient #4 was completed on 10/27/2021, start of care date 3/11/2020, for certification period 9/2/2021-10/31/2021, discharge date 9/25/2021, evidenced a document dated and signed by registered nurse (RN) J on 9/20/2021 titled “Skilled Nursing Visit Note”, which stated “... Description ... RN Phone call ... patient ... admitted to ... [hospital O] ... over the weekend ... [patient] had a fall and fractured her hip and ... taken to surgery ....” The document failed to evidence RN notified the physician. During an interview on 10/27/2021 at 2:03 PM, director of quality assurance C indicated family called 2 days after the patient fell to let the agency know, it happened over a weekend, she went from the hospital to a rehabilitation facility, and the record did not reflect the physician was notified. 5. Record review for patient #6 was completed on 10/26/2021, start of care date 8/26/2021, for certification period 8/26/2021-10/24/2021, evidenced a document dated 9/2/2021 titled “PT eval [evaluation/plan of care]”, which evidenced a PT evaluation was completed on 9/2/2021, interventions and goals were established, and failed to evidence the PT communicated with the physician to review approve the PT plan of care, or the plan of care was signed by the certifying physician. A document dated 9/1/2021 titled “Speech Therapy [SLP] Assessment” evidenced a SLP evaluation was completed on 9/1/2021, interventions and goals were established, and failed to evidence the SLP communicated with the physician to review approve the SLP plan of care, or the plan of care was signed by the certifying physician. During an interview on 10/26/2021 at 11:00 AM, the clinical manager and alternate administrator confirmed the therapy evaluations failed to evidence the certifying physician was contacted to review or approve the therapy plans of care, and the evaluations were not signed by the certifying physician. 6. Record review for patient #7 was completed on 10/21/2021, start of care date 8/14/2021, for certification period 8/14/2021-10/12/2021, and 10/13/2021-12/11/2021, evidenced an untitled document dated 9/8/2021, which evidenced a PT evaluation was completed on 9/8/2021, interventions and goals were established, and failed to evidence the PT communicated with the physician to review approve the PT plan of care, or the plan of care was signed by the certifying physician. During an interview on 10/21/2021 at 1:00 PM, the alternate administrator, clinical manager, and director of quality assurance C confirmed the record did not evidence the therapist communicated with the physician. 17-14-1(a)(1)(G)

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure all clinical record documents were legible, complete, appropriately authenticated, and/or timed for 3 of 7 records reviewed (#1, 6, 7). Findings include: 1. Record review for patient #1 was completed on 10/27/2021, start of care date 9/27/2021, for certification period 9/27/2021-11/25/2021, evidenced an untitled document dated 10/7/2021, which evidenced a PT (physical therapy/physical therapist) evaluation was completed on 10/7/2021. The handwritten document of the assessment/treatment was largely illegible, the clinician’s signature was illegible, and the document failed to evidence the clinician’s name or title, or the time and duration of the visit. Untitled documents dated 10/8/2021, 10/12/2021, 10/13/2021, and 10/17/2021 evidenced PT visits were completed, the handwritten documents of the assessments/treatments were largely illegible, the clinician’s signature was illegible, and the document failed to evidence the clinician’s name or title, or the time and duration of the visit. During an interview on 10/27/2021 at 4:50 PM, the alternate administrator and clinical manager reviewed the handwritten therapy documents and indicated the documents were illegible, the clinician’s name and title was not present on the documents, the signature was illegible, and there were no times on the documents. 2. Record review for patient #6 was completed on 10/26/2021, start of care date 8/26/2021, for certification period 8/26/2021-10/24/2021, evidenced a document dated 9/2/2021 titled “PT eval [evaluation/plan of care]”, which evidenced a PT evaluation was completed on 9/2/2021. The handwritten document of the assessment/treatment was largely illegible, the clinician’s signature was illegible, failed to evidence the clinician’s name or title, the time and duration of the visit, and failed to evidence the sections titled posture/alignment, joints, upper and lower extremities, hip, knee, ankle, trunk/cervical (neck), motor function, muscle tone, wheelchair mobility, bed mobility, transfers, skilled treatment this visit, or communication was completed. Documents dated 9/10/2021, 9/14/2021, 9/16/2021, and 9/21/2021 titled “THHS PT Progress Note” evidenced visits were made by a PT assistant (PTA), the clinician’s signature was illegible, the documents failed to evidence the clinician’s name, or the time and duration of the visits. A document dated 9/1/2021 titled “Speech Therapy [SLP] Assessment” evidenced a SLP evaluation was completed on 9/1/2021. The document failed to evidence the time and duration of the visit. During an interview on 10/26/2021 at 11:00 AM, the alternate administrator confirmed the visits should have the times on the visits, and the documents were hard to read. 3. Record review for patient #7 was completed on 10/21/2021, start of care date 8/14/2021, for certification period 8/14/2021-10/12/2021, evidenced an untitled document dated 9/8/2021, which evidenced a PT evaluation was completed on 9/8/2021. The document was illegible, the clinician’s signature was illegible, the document failed to evidence the clinician’s name or title, or the time and duration of the visit. 4. During an interview on 10/27/2021 at 6:30 PM, the alternate administrator reviewed the handwritten therapy documents and confirmed they were illegible, incomplete, failed to evidence the clinician’s name or title, or the time and duration of the visits. 17-15-1(a)(7)