Every finding on record at The Methodist Hospitals Inc

Merrillville, Indiana · CCN 157536

46 findings across 4 surveys, in the inspector's own words.

The inspector’s own words from form CMS-2567, unedited, including CMS’s own spacing. Names and some dates are redacted by CMS.

Survey of December 18, 2024

17 findings

E0000

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102 Condition of Participation for Home Health Agencies. Survey Dates: 12/12/2024 to 12/13/2024 and 12/16/2024 to 12/18/2024 Active Census: 95 At this Emergency Preparedness survey, Methodist Home Care Services was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 484.102

G0000

This visit was for a Federal Recertification and State Re-Licensure survey of a Home Health Provider. Survey Dates: 12/12/2024 to 12/13/2024 and 12/16/2024 to 12/18/2024 12-Month Unduplicated Skilled Admissions: 880 This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Refer to State Form for additional State Findings. On 12/16/2024 at 12:16 PM, Administrator was notified the survey was partially extended. Abbreviations used in report: Registered Nurse [RN], Clinical Manager [CM], Clinical Supervisor [CS], Skilled Nurse [SN, Plan of Care [POC], Home Health aide [HHA], start of care [SOC], Physical Therapist [PT], Social Worker [SW], and Occupational Therapist [OT]. QR: 12/29/2024 A1

G0460

Patient refuses services CFR(s): 484.50(d)(4) The patient refuses services, or elects to be transferred or discharged; This ELEMENT is not met as evidenced by: Based on record review and interviews the agency failed to evidence they educated patients, who declined services and requested to be discharged from home health services, on the risks and potential adverse outcomes that may result from discontinuation of services in 2 of 5 closed clinical records reviewed (Patients # 9, 12). Findings include: 1 .The clinical record for Patient #9 included a POC dated 11/1/2024 to 12/30/2024 with services ordered for PT visits once a week for one week then twice a week for four weeks and an OT evaluation dated 11/8/2024 that indicated OT visits were planned once a week for four weeks. The record included documentation of missed visits due to Patient cancellation with PT on 11/11/2024, 11/19/2024, and 11/21/2024, and missed OT visits were documented for 11/15/2024 and 11/22/2024. Documentation of discharge, dated 11/26/204, indicated Patient was discharged due to noncompliance. The clinical record failed to evidence education was provided to Patient regarding the risks and potential adverse outcomes related to missed visits or an early discharge from home health services. During an interview on 12/18/2024 beginning at 2:00 PM, CM relayed there was not documentation that Patient was educated regarding the risks or potential adverse outcomes due to not completed the ordered home health services. 2. The clinical record for Patient #12 revealed an initial SOC comprehensive assessment dated 9/14/2024 that indicated Patient was alert and oriented to person, place and time with forgetfulness. The POC dated 9/14/2024 to 11/13/2024 included services SN once a week for one week then twice a week for four weeks. The 9/17/2024 SN visits was a missed visits due to the Patient not answering the phone. The record included documentation that on 9/19/2024, SN called Patient, spoke to Patient’s family member, Other F, who indicated Patient would like to discontinue home health services. The clinical record included a discharge order dated 9/19/2024; the record failed to evidence education was provided of risks nor potential adverse effects from early discharge from services. During an interview on 12/18/2024 beginning at 10:00 AM, Administrator relayed there was not documentation of education regarding adverse effects from an early discharge to Patient nor Other F.

G0464

Advise the patient of discharge for cause CFR(s): 484.50(d)(5)(i) (i) Advise the patient, representative (if any), the physician(s) or allowed practitioner(s), issuing orders for the home health plan of care, and the patient's 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) that a discharge for cause is being considered; This ELEMENT is not met as evidenced by: Based on record review and interviews the agency failed to evidence the patient, or their designated decision maker, was advised that discharge was imminent in 1 of 1 closed clinical record reviewed with a diagnosis of alcohol use (Patient #12). Findings include: The clinical record for Patient #12 revealed an initial start of care comprehensive assessment dated 9/14/2024 that indicated Patient was alert and oriented to person, place and time with forgetfulness and a primary diagnosis of alcohol use and withdrawals. The POC dated 9/14/2024 to 11/13/2024 included services SN once a week for one week then twice a week for four weeks. The 9/17/2024 SN visit was a missed visits due to the Patient not answering the phone, resulting in zero skilled nurse visits during week 2 of certification period. A communication documentation on 9/19/2024 indicated the SN called Patient and spoke to Patient’s family member, Other F, who indicated Patient would like to discontinue home health services. The clinical record included a discharge order dated 9/19/2024. The clinical record failed to evidence notification nor discussion directly with Patient regarding discharge. The clinical record failed to evidence power of attorney nor health care representative documentation regarding Other F as a designated decision maker for Patient. During an interview on 12/17/2024 beginning at 2:15 PM, CM relayed Other F notified staff that Patient did not want home health services, and the family member was listed as Patient’s emergency contact and relayed the record failed to evidence staff spoke with Patient regarding discharge. 410 IAC 17-12-2(i)

G0514

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on record review and interviews the agency failed to ensure the skilled professional conducted an initial assessment within 48 hours of referral or patient’s return home in 1 of 3 active clinical records with PT only services (Patient #3) and 2 of 5 closed clinical records reviewed (Patients #8, 9). Findings include: 1.The clinical record for Patient #3 revealed a referral for home health PT services dated 11/26/2024. An initial comprehensive assessment was completed on 11/29/2024 by PT 1. The clinical record failed to evidence documentation of physician notification nor order for the delay in the start of home health care. During an interview on 12/16/2024 starting at 3:00 PM, CM relayed there was not documentation regarding the delay in care. She indicated the delay was due to a holiday on 11/28/2024. 2. The clinical record for Patient #8 revealed a referral for home health including a SN and HHA dated 8/21/2024 signed by Patient’s physician. An initial visit that included a comprehensive assessment was completed on 8/25/2025. The clinical record failed to evidence documentation of physician notification nor order for the delay in the start of home health care. During an interview on 12/17/2024 beginning at 2:15 PM, Administrator relayed there was not documentation regarding the delay in the agency start of home health care. 3. The clinical record for Patient #9 revealed a referral for home health including PT and OT dated 10/29/2024 and signed by Patient’s physician. An initial visit that included a comprehensive assessment was documented 11/1/2024. The clinical record failed to evidence documentation of physician notification nor order for the delay in the start of home health care. During an interview on 12/17/2024 beginning at 2:15 PM, Administrator relayed there was not documentation regarding the delay in the start of home health care. 410 IAC 17-14-1(a)(1)(A)

G0520

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 agency failed to ensure the comprehensive assessment was completed no later than 5 calendar days after the start of care for 1 of 1 patient with a home visit observation of PT services, and with a referral for OT and home health aide services, and diagnosis of a dementia. (Patient 4) The Findings Include: The clinical record for Patient 4, included a referral dated 12/4/2024 that requested PT and OT evaluations. The record failed to evidence an OT evaluation was conducted until 12/14/24. During an interview on 12/18/24 beginning at 2:10 PM, the CM indicated there was no documentation related to the reason for the delay in the evaluation or completion of the comprehensive assessment.

G0536

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to evidence 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 for 3 of 4 patients with severe interactions. (Patient 2, 4, 6) The Findings Include: 1.The record for Patient 4 included a SOC comprehensive assessment, dated 12/6/2024, which revealed medications were reconciled with no serious interactions identified during the comprehensive assessment. The drug interaction report indicated major interactions between Patients' atorvastatin (a medication used to treat high cholesterol) and grapefruit juice. The record failed to evidence education and or an assessment of Patient of the major drug interaction. During an interview on 12/18/24 beginning at 2:10 PM, the clinical supervisor indicated the record did not include documentation that the patient or provider was notified of the drug interaction. 2.The record for Patient 6 included a resumption of care comprehensive assessment, dated 11/24/24, which revealed medications were reconciled with no issues found during the assessment. The drug interaction report indicated major interactions between Patients' Ketoconazole (a medication used for the treatment of dandruff) and dofetilide (a medication used for the treatment of irregular heart rate) and furosemide (high blood pressure and body fluid buildup) and dofetilide (a medication used for the treatment of irregular heart rate). The record failed to evidence notification to the patient or provider of the major drug interactions. During an interview on 12/18/24 beginning at 9:45 AM, the clinical supervisor indicated the record did not include documentation that the patient or provider was notified of the drug interaction. 1. The agency policy titled ‘Clinical Records – Documentation,’ revised 6/2024, indicated each patient clinical record will contain information on medication including adverse drug reactions. 2. The clinical record of Patient #2 included an initial POC dated 11/7/2024 to 1/5/2024 with a primary diagnosis of diabetic foot ulcers (wounds) and SN visits twice a week for eight weeks and PT visits. Documentation dated 11/23/24 indicated Patient was treated at the emergency department for leg cramps that included a new prescription for cyclobenzaprine (muscle relaxant) every 8 hours for three days. SN visit was documented 11/25/2024. Patient’s home medication list included tramadol, a pain medication. According to drugs.com, there are major interactions between cyclobenzaprine and tramadol. The clinical record failed to evidence a review of medication interactions with the new prescription nor the notification of the physician regarding the new prescription interactions with Patient’s home medications. During an interview on 12/18/2024 beginning at 10:00 AM, Administrator relayed the medication was entered in the electronic medical record but there was no record of interactions documented in the record. 410 IAC 17-14-1(a)(1)(B)

G0572

G0574

G0576

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure all patient care orders including verbal orders were recorded in the plan of care in 2 of 12 active clinical records reviewed (Patients #2 and 14). Findings include: 1. The clinical record for Patient #2 included an initial POC dated 11/7/2024 to 1/5/2024 for SN and PT services. An OT evaluation was documented on 11/20/2024 with another OT visit documented on 12/3/2024 and 12/10/2024. The POC failed to include OT schedules, services, treatments, nor goals. During an interview on 12/16/2024 beginning at 3:00 PM, Administrator relayed the OT evaluation was completed after the SOC date so it was not included in the POC nor was the POC revised to include OT services. 2. The clinical record for Patient #14 included documentation of PT visits dated 11/22/2024, 11/26/2024, 11/29/2024, 12/02/2024, 12/11/2024, 12/12/2024, and 12/16/2024. The POC failed to include PT services, treatments, and goals. During an interview on 12/17/2024 beginning at 2:15 PM, Administrator relayed the PT visits started after the POC start date of 11/14/2024 and the POC was not revised.

G0580

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure drugs, services, and treatments were administered only as ordered by a physician in 9 of 12 active clinical records reviewed (Patients # 2, 3, 5, 6, 7, 13, 14, 16, and 17) and 4 of 5 closed clinical records reviewed (Patients #8, 9, 10, and 11). Findings include: 4. The clinical record for Patient #2 revealed SN visit notes documented for 11/7/2024 for the SOC, and on 11/9/2024; PT visits were documented for 11/12/2024, 11/13/2024, and 11/14/2024. The clinical record failed to evidence orders were obtained from the attending physician, documented prior to the provision of care, for the skilled care that began on 11/7/2024 to 11/18/2024. During an interview, on 12/16/2024 beginning at 3:00 PM, the Administrator relayed there was not an order obtained from the attending for the skilled care provided, prior to 11/18/2024. 5. The clinical record for Patient #3 revealed PT services began on 11/29/2024 the SOC, then continued during week 2 and week 3 of the certification period. The clinical record failed to evidence orders were obtained from the attending physician, documented prior to the provision of care, for the skilled care that began on 11/29/2024 to 12/10/2024. During an interview on 12/18/2024 beginning at 2:00 PM, CM relayed there was no documentation of an order for the skilled care provided, prior to the signing of the POC on 12/10/2024. 6. The clinical record for Patient #8 revealed SN services began with the SOC on 8/25/2024 and continued weekly through the certification period ending 10/22/2024. The clinical record failed to evidence orders for skilled care were obtained from the attending physician and documented, prior to the provision of care, beginning on 8/25/2025 to 9/10/2024. Patients POC was not signed until 9/10/2024. During an interview on 12/18/2024 beginning at 2:30 PM, Administrator relayed there was not an order for the skilled care provided until the POC was signed on 9/10/2024. 7. The clinical record for Patient #9 revealed documentation of PT visits, dated 11/5/2024, 11/7/2024, and 11/14/2024 and an OT evaluation dated 11/8/2024. The POC was signed by the physician 11/14/2024. The clinical record failed to evidence orders for the skilled care were obtained from the physician, prior to the provision of care, provided beginning on 11/1/2024 to 11/14/2024. During an interview on 12/17/2024 beginning at 2:15 PM, CM relayed the referral dated 10/29/2024 requested PT and OT services; the administrator indicated the record did not include specific orders for the skilled care provided, until the POC was signed on 11/14/2024. 8. The clinical record for Patient #10 included PT visits were documented, dated 09/17/2024, 09/19/2024, and 10/01/2024. The clinical record failed to evidence orders for the skilled care were obtained from the attending, prior to the provision of care and documented, for the skilled care provided from 9/17/2024 to 10/02/2024. During an interview on 12/18/2024 beginning at 10:30 AM, Administrator relayed there are no orders for the skilled care provided until the POC was signed on 10/02/2024. 9. The clinical record for Patient #11 revealed SN care was provided, including wound care documented at the SOC, 9/21/2024, and subsequent visits on 9/25/2024 and 9/27/2024. The clinical record failed to evidence orders for the skilled care provided, were obtained from the attending physician, prior to the provision of care, for the skilled care provided beginning 9/21/2024 to 10/08/2024. During an interview on 12/18/2024 beginning at 10:30 AM, Administrator relayed the record failed to evidence documentation of an order for the care provided beginning on 9/21/2024 to 10/8/2024. 10. The clinical record for Patient #13 revealed documentation of HHA visits dated 11/18/2024 and 11/20/2024 and SN visits dated 11/14/2024 and 11/20/2024. The clinical record failed to evidence documentation of an order was obtained from the attending physician, prior to the provision of care, for the services provided from 11/14/2024 to 11/21/2024. During an interview on 12/18/2024 beginning at 10:30 AM, CM relayed the clinical record failed to evidence documentation of orders, obtained from the attending, for the care which began on 11/14/2024 to 11/21/2024. 11. The clinical record for Patient #14 revealed the SOC was 9/15/2024, when skilled services began, and and continued weekly through the certification period. The clinical record failed to evidence an order for the skilled nurse services was obtained from the attending physician for the skilled care provided from 9/15/2024 to 9/26/2024. The record revealed a PT initial evaluation, dated 11/22/2024 with subsequent PT visits on 11/26/2024, 11/29/2024, 12/02/2024, 12/11/2024, 12/12/2024, and 12/16/2024. The clinical record failed to evidence orders for the PT services that began on 11/22/2024. During an interview on 12/17/2024 beginning at 2:15 PM, Administrator relayed there was not an order for PT services, that began on 11/22/2024 nor orders for the skilled nurse services from 9/15/2024 to 9/26/2024. 12. The clinical record for Patient #16 revealed SN visits that documented skilled care, and included urinary catheter issues, were documented and dated 12/05/2024 and 12/10/2024. The clinical record failed to evidence documentation of verbal orders, nor written orders for the skilled care provided from 11/25/2024 to 12/18/2024. During an interview on 12/18/2024 beginning at 10:30 AM, Administrator relayed there were no orders obtained for the skilled services provided, that began on 11/25/2024 until the physician signed the POC on 12/18/2024. 13. The clinical review on 12/17/2024 for Patient #17, revealed a SOC comprehensive assessment dated 12/10/2024, and subsequent SN visit on 12/14/2024; the record revealed a PT evaluation dated 12/11/2024 and subsequent PT visits on 12/12/2024 and 12/13/2024. On 12/17/2024, the clinical record failed to evidence a POC. The clinical record failed to evidence documentation of a verbal order, nor written orders for the skilled care provided. During an interview on 12/17/2024 beginning at 2:15 PM, the Administrator relayed the POC was not in the clinical record nor was there documentation of verbal orders for the care provided. During a subsequent interview on 12/18/2024 beginning at 9:00 AM, the Administrator revealed the POC was sent to the physician by Other A, a case manager on 12/17/2024. During an interview on 12/18/2024 beginning at 9:35 AM, Other A relayed the POC for Patient #17 was created and sent to the physician on 12/17/24 at 3:45 PM. 410 IAC 17-13-1(a) 1.The clinical record for Patient 5 included a referral, dated 11/1/2024, to evaluate for home health services. The record evidenced an OT evaluation was conducted, dated 11/18/2024, and an OT visit was conducted on 12/2624 to discharge patient from OT services. The record failed to evidence an order for OT services. The POC for the certification period 11/20/24 to 01/5/2024 failed to evidence an order for the OT services provided. During an interview on 12/18/24 beginning at 3:50 PM, the CS indicated they had an order written for OT, it was discontinued on 11/19/24. The CS further indicated there was no order for the OT services provided. 2. An observation of an initial skilled visit, on 12/17/2024 beginning at 9:45AM, established the SOC for Patient 7; Patient was wheelchair bound, paraplegic (a person who does not have functional use of their legs) with neurogenic bladder (the nerves and muscles do not control the bladder). The referral revealed Patient required catheter care. During the visit observed RN 2 anchored a 20 French foley catheter, filled the balloon with 30 ml normal saline. The record failed to evidence an order for the catheter change, nor the skilled care provided during the visit. During an interview on 12/18/24 beginning at 3:00 PM, the CS indicated they did not have an order from the provider as to what size and type of catheter to use nor the amount to fill the balloon. 3. During a home visit observation for Patient 6 on 12/17/24 beginning at 11:00 AM, RN 4 performed pleural drain care, including draining of pleural fluid. During the procedure, it was observed that the nurse continued to drain fluid until the patient reported significant pain. RN 4 then clamped the drain, measured 325 ml fluid had drained and covered Patient 6 drain site with a clean dressing. The record for Patient 6 included a resumption POC, dated 11/24/24 for the certification period 11/09/2024 – 01/07/2025. The POC and clinical record failed to evidence the procedure for pleural drain care, nor minimum or maximum amounts for fluid drainage, during the procedure. During an interview on 12/18/24 beginning at 9:45 AM, the CS indicated the interventions for pleural drain care including the minimum and maximum amount for fluid drainage were on the previous POC, though were discontinued on 11/12/24 and should not have been.

G0644

Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA's governing body. This STANDARD is not met as evidenced by: Based on record review and interviews, the agency failed to ensure the Quality assessment and Performance Improvement (QAPI) program utilized measures derived from Outcome Assessment and Information Set (OASIS) to monitor quality of care and failed to ensure the detail and data collection was approved by the agency’s governing body in 1 of 1 agency. Findings include: The review of agency QAPI documents dated 1/1/2024 to 9/30/2024 included data collections of medication reconciliation, patient falls, and central line associated bloodstream infections with quarterly data collections. The QAPI documents failed to evidence the agency included their OASIS data and failed to evidence their Governing Body approved their detail and data collection. During an interview on on 12/18/2024 beginning at 11:45 AM, Administrator relayed OASIS data was not used for QAPI. She revealed the governing body did not approve nor was the governing body involved in the QAPI program. 410 IAC 17-12-2(a)

G0646

Program activities CFR(s): 484.65(c) (1) The HHA's performance improvement activities must— (i) Focus on high risk, high volume, or problem-prone areas; (ii) Consider incidence, prevalence, and severity of problems in those areas; and (iii) Lead to an immediate correction of any identified problem that directly or potentially threaten the health and safety of patients. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to ensure the performance improvement activities included high risk, high volume, or problem prone areas and lead to an immediate correction of an identified problem that directly affects the health and safety of patients in 1 of 1 agency. Findings include: The review of agency QAPI documentation revealed the agency noted six patients reported falls during January, February, and March of 2024, five patients with falls during April, May, and June of 2024, and 13 patients reported falls during July, August, and September. The fall data included raw data, did not include percentages from the agency's current census. The QAPI documentation failed to evidence that the raw data, the agency collected, was reviewed and analyzed to determine if an immediate intervention was warranted, ending with their 3rd quarter, 9/30/3034. During an interview on 12/18/2024 beginning at 11:25 AM, Administrator relayed the QAPI fall results were reported to their safety committee, on 12/4/2024. She revealed there were no documentation, no immediate interventions regarding the increase in falls and no further documentation was provided prior to exit.

G0682

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation, record review, and interview the agency failed to ensure accepted standards for infection prevention were followed to prevent the transmission of infections and communicable diseases in 4 of 7 active clinical records reviewed with a home visit (Patients #1, 2, 4, 6). Findings include: # The clinical record for Patient #1 revealed a POC dated 11/10/2024 to 01/08/2024 for SN services twice a week for nine weeks. Patient diagnoses include a chronic ulcer (open sore) of the right and left lower leg with SN to provide wound care to the right and left lower leg 2 times a week. The clinical record included documentation that Patient was in contact precautions (infection control measures used to prevent the spread of infection) for methicillin-resistant Staphylococcus aureus (MRSA, a bacteria resistant to certain antibiotics). The MRSA documentation indicated a gown, gloves and eye protection should be used when entering Patient’s room. The POC failed to evidence MRSA documentation nor personal protective equipment required to care for Patient. During a home visit observation on 12/13/2024 beginning at 9:40 AM, RN 1 provided care to Patient that included direct contact for assessment and wound care. RN 1 failed to use a gown and protective eyewear. During an interview on 12/16/2024 beginning at 3:00 PM, CM relayed Patient’s MRSA infection information was in the electronic medical record, however the information did not flow into agency documents. # The clinical record for Patient #2 included an initial POC dated 11/7/2024 to 1/5/2024 for SN and PT services and included the primary diagnoses as diabetic foot ulcers. The clinical record included documentation that Patient was in contact precautions (infection control measures used to prevent the spread of infection) for methicillin-resistant Staphylococcus aureus (MRSA, a bacteria resistant to certain antibiotics). The MRSA documentation indicated a gown, gloves and eye protection should be used when entering Patient’s room. The POC failed to evidence MRSA documentation nor personal protective equipment required to care for Patient. During a home visit observation on 12/13/2024 beginning at 2:00 PM, OT 1 provided care to Patient that included direct physical contact. OT 1 failed to use a gown or protective eyewear. During an interview on 12/16/2024 beginning at 3:00 PM, CM relayed Patient’s MRSA infection information was in the electronic medical record, however the information did not flow into agency documents. 410 IAC 17-12-1(m) *During a home visit observation on 12/16/24 beginning at 11:40 AM for Patient 4, PT 2 was observed taking vital signs of Patient 4 and placing the soiled equipment onto a barrier. It was observed near the end of the visit, PT 2 wiped equipment with a sanitizing wipes and gloved PT 2 had worn throughout the visit while providing care to Patient 4. PT 2 placed equipment back on the soiled barrier to allow to dry. During an interview on 12/16/24 beginning at 12:00 PM, PT 2 indicated they should have used a second barrier to place the clean equipment on to allow to dry. During an interview on 12/16/24 beginning at 2:10 PM the CS indicated it was not standard practice to use the same gloves to sanitize equipment that were used for patient care, nor is it standard practice to place sanitized items on a soiled barrier to allow to dry. *During a home visit observation on 12/17/24 beginning at 11:00 AM for Patient 6, it was observed RN 4 was performing a sterile procedure of plural drain care. During the procedure it was observed RN 4 removed sterile gloves turning them out as they removed the gloves, placed them on a barrier that laid on the bed and performed hand hygiene. RN 4 then retrieved an alcohol prep pads from the clinician bag and reapplied the gloves they had turned out and placed on the barrier. Once gloves were re-applied, RN 4 continued with pleural drain care. During an interview on 12/17/24 beginning at 11:45 AM, RN 4 indicated they reused the first pair of sterile gloves because they needed to retrieve alcohol prep from the clinician bag and did not have another pair of sterile gloves. RN 4 further indicted they used those gloves because they believed them to be the best option. During an interview on 12/17/24 beginning at 4:00 PM, the CS indicated it is not the accepted practice to reuse any gloves.

G0706

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure each patient received a patient-specific assessment for 1 of 1 start of care with comprehensive assessment observed on 12/17/24. (Patient 7) Findings Include: An observation of an initiation of the comprehensive assessment, on 12/17/24 beginning at 9:45 AM, for Patient 7, a wheelchair bound paraplegic (a person who does not have functional use of their legs) with neurogenic bladder (the nerves and muscles do not control the bladder); the assessment established the SOC. RN 2 inserted and anchored a foley catheter and provided catheter care. RN 2 failed to assess Patients' lung sounds, bowel sounds, nor assess Patients' legs nor their feet. During an interview on 12/17/24 beginning at 10:45 AM, RN 2 indicated all body systems are included in the comprehensive assessment at the SOC. RN 2 indicated they did not assess Patient 7s' lungs, bowel sounds, nor their legs and feet. During an interview on 12/17/24 beginning at 4:00 PM, the CM indicated all body systems should be assessed during the comprehensive assessment and that was not done for Patient 7.

G0716

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the agency failed to maintain an accurate clinical record for 1 of 1 record reviewed with a SOC of 12/17/24. (Patient 7) The Findings Include: During a home visit observation on 12/17/2024 beginning at 9:45 AM, RN2 conducted an initial assessment and initiated the comprehensive assessment and established the SOC for Patient 7; Patient was wheelchair bound, a paraplegic (a person who does not have functional use of their legs) with neurogenic bladder (the nerves and muscles do not control the bladder). During the home visit, RN 2 inserted and anchored a foley catheter and provided catheter care. During the visit, RN 2 failed to assess Patients' lung sounds, bowel sounds, nor assessed Patients' legs nor their feet. The CS was present during the observation visit. The record was reviewed on 12/18/24 and evidenced documentation that a comprehensive assessment was completed on 12/17/24 by RN 2. The assessment failed to evidence a complete assessment of the respiratory system, included a gastrointestinal assessment indicating the presence of bowel sounds in all quadrants, and included an integumentary assessment which indicated Patient was assessed for skin integrity issues and none were present. During an interview on 12/18/24 beginning at 3:00 PM the CS indicated they did not observe the RN2 perform a respiratory assessment, gastrointestinal assessment, nor an integumentary assessment and did not know why RN 2 would have documented those assessments.

G0808

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This ELEMENT is not met as evidenced by: Based on record reviews and interviews the agency failed to ensure an appropriate skilled professional supervised HHA’s no less frequently than every 14 days in 2 of 4 active clinical records with HHA services (Patients # 13, 16). Findings include: 1.The clinical record for Patient #13 evidenced SN services and HHA services were provided during the initial certification period of 11/14/2024 to 01/12/2024; SN visits were conducted weekly and HHA visits were conducted 2 times per week. The record evidenced a HHA supervisory visit was completed by the SN on 11/22/2024 and not again until 12/09/2024, a period of 17 days. The record failed to evidence supervisory visits of the HHA were conducted every 14 days, at minimum. During an interview on 12/18/2024 beginning at 10:30 AM, CM relayed Patient was seen by SN between the dates of 11/22/2024 and 12/09/2024, though the supervisory information was not documented. 2. The clinical record for Patient #16 revealed a SOC of 3/30/2024 and Patient received skilled nurse services for urinary catheter care and HHA services twice a week through the certification periods dated 9/26/2024 to 11/25/2024 and from 11/26/2024 to date of survey. The record evidenced HHA visits notes, dated 11/05/2024, 11/07/2024, 11/11/2024, 11/13/2024, and 11/19/2024. The record revealed HHA supervisory visits dated 10/29/2024 and 11/22/24, a period of 24 days between visits. The clinical record failed to evidence a HHA supervisory visits every 14 days, at minimum. During an interview on 12/18/2024 beginning at 10:30 AM, CM relayed the clinical record did not include documentation of the supervisory visits were conducted every 14 days, at minimum. 410 IAC 17-14-1

Survey of April 8, 2022

1 finding

G0580

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure treatment was administered only as ordered by a physician in 1 of 3 clinical records reviewed with a home visit. (#5) The findings include: Review of an agency policy obtained 4/8/2022, revised 8/2021, titled, “Physician Orders,” stated, “…Policy: To ensure that physicians will provide orders for services within accepted standards of care. … Treatments and medications are to be administered by staff only as physician ordered….” Clinical record review on 4/7/2022 for patient #5, start of care 11/27/2021, for certification period 3/27/2022 to 5/25/2022, evidenced an agency document titled, “Home Health Certification and Plan of Care.” This document had a subsection titled, “Orders for Discipline and Treatments (Specify Amount/Frequency/Duration),” which stated, “…Wound Care Therapy [Wound care to promote healing] HH [home health] WOUND CARE – (GENERAL) [Each Visit, Start: 2/18/2022] [Instruct Patient and Caregiver in wound care. Wound care to consist of Cleanse right breast with, saline. Apply SSD [silver sulfadiazine - a topical antibiotic used to treat burns] 1% cream to wound bed, cover with dry dressing and secure with tape, change three times weekly and PRN [as needed] for soilage.] Perform wound care [Each Visit, Start: 3/14/2022] [Instruct Patient and Caregiver in wound care. Wound care to consist of Cleanse left breast with, saline. Apply adaptic [dressing made of knitted cellulose acetate fabric and impregnated with a specially formulated petrolatum emulsion] covered by polymem [a hydrophilic polyurethane matrix dressing with a mild, non-toxic wound cleanser, a soothing moisturizer, a superabsorbent and a semi-permeable film backing]. Cover with dry dressing and secure with tape, change three times weekly and PRN for soilage.] Clinical record review evidenced an agency document titled, “OASIS [Outcome and Assessment Information Set] Recertification,” digitally signed by RN [registered nurse] D and dated 3/23/2022. This document had a subsection titled, “LDA [lines, drains, airways] and Wound Assessment,” which stated, “… Burn Breast Right…3/23/22… Wound Cleansing: Normal Saline, Dressing/Treatment: Absorband [sic] pad; Elastic bandage; Other (Comment) adaptic and polymem … Breast Left … 3/23/22 … Wound Cleansing: Normal Saline, Dressing/Treatment: Absorband [sic] pad; Elastic bandage; Other (Comment) adaptic and polymem….” The document failed to evidence the RN administered treatment as ordered by a physician. Clinical record review evidenced an agency document titled, “SN [skilled nurse] – Home Visit,” digitally signed by RN J and dated 3/24/2022. This document had a subsection titled, “LDA and Wound Assessment,” which stated, “…Burn Breast Right … Wound Cleansing: Normal Saline, Dressing/Treatment: Absorband [sic] pad; Dry dressing; Non adherent polymem … Breast Left … Wound Cleansing: Normal Saline, Dressing/Treatment: Absorband [sic] pad; Non adherent polymem….” The document failed to evidence the RN administered treatment as ordered by a physician. Clinical record review evidenced an agency document titled, “SN – Home Visit,” digitally signed by RN D and dated 3/26/2022. This document had a subsection titled, “LDA and Wound Assessment,” which stated, “Burn Breast Right…3/26/22… Wound Cleansing: Normal Saline, Dressing/Treatment: Absorband [sic] pad; Non adherent Other (Comment) polymem … Breast Left … 3/26/22 … Wound Cleansing: Normal Saline, Dressing/Treatment: Absorband [sic] pad; Non adherent; Other (Comment) polymem….” The document failed to evidence the RN administered treatment as ordered by a physician. Clinical record review evidenced an agency document titled, “SN – Home Visit,” digitally signed by RN D and dated 3/28/2022. This document had a subsection titled, “LDA and Wound Assessment,” which stated, “Burn Breast Right…3/28/22… Wound Cleansing: Normal Saline, Dressing/Treatment: Absorband [sic] pad; Non adherent Other (Comment) polymem … Breast Left … 3/28/22 … Wound Cleansing: Normal Saline, Dressing/Treatment: Absorband [sic] pad; Non adherent; Other (Comment) polymem….” The document failed to evidence the RN administered treatment as ordered by a physician. Clinical record review evidenced an agency document titled, “SN – Home Visit,” digitally signed by RN D and dated 3/30/2022. This document had a subsection titled, “LDA and Wound Assessment,” which stated, “Burn Breast Right…3/30/22… Wound Cleansing: Normal Saline, Dressing/Treatment: Absorband [sic] pad; Non adherent Other (Comment) polymem … Breast Left … 3/30/22 … Wound Cleansing: Normal Saline, Dressing/Treatment: Absorband [sic] pad; Non adherent; Other (Comment) polymem….” The document failed to evidence the RN administered treatment as ordered by a physician. Clinical record review evidenced an agency document titled, “SN – Home Visit,” digitally signed by RN D and dated 4/1/2022. This document had a subsection titled, “LDA and Wound Assessment,” which stated, “Burn Breast Right…4/1/22… Wound Cleansing: Normal Saline, Dressing/Treatment: Absorband [sic] pad; Non adherent Other (Comment) polymem … Breast Left … 4/1/22 … Wound Cleansing: Normal Saline, Dressing/Treatment: Absorband [sic] pad; Non adherent; Other (Comment) polymem….” The document failed to evidence the RN administered treatment as ordered by a physician. Clinical record review evidenced an agency document titled, “SN – Home Visit,” digitally signed by RN H and dated 4/4/2022. This document had a subsection titled, “LDA and Wound Assessment,” which stated, “Burn Breast Right…4/4/22… Wound Cleansing: Normal Saline, Dressing/Treatment: Absorband [sic] pad; Non adherent Other (Comment) polymem … Breast Left … 4/4/22 … Wound Cleansing: Normal Saline, Dressing/Treatment: Absorband [sic] pad; Non adherent; ….” The document failed to evidence the RN administered treatment as ordered by a physician. Clinical record review evidenced an agency document titled, “SN – Home Visit,” digitally signed by RN D and dated 4/6/2022. This document had a subsection titled, “LDA and Wound Assessment,” which stated, “Burn Breast Right…4/6/22… Wound Cleansing: Normal Saline, Dressing/Treatment: Absorband [sic] pad; Non adherent Other (Comment) polymem … Breast Left … 4/6/22 … Wound Cleansing: Normal Saline, Dressing/Treatment: Absorband [sic] pad; Non adherent; Other (Comment) polymem….” The document failed to evidence the RN administered treatment as ordered by a physician. Clinical record review evidenced an agency document titled, “SN – Missed Visit Documentation,” signed by RN D and dated 3/25/2022, which stated, “…Patient is going to wound clinic today….” Further review failed to evidence new orders from the wound clinic. Clinical record review evidenced an agency document titled, “Revised Intervention,” entered and digitally signed by RN D on 4/6/2022 at 10:27 AM, which stated, “…Wound care to consist of Cleanse left breast with, saline. Apply adaptic covered by polymem. Cover with dry dressing and secure with tape or elastic bandage, change three times weekly and PRN for soilage….” The RN failed to administer treatment as ordered by the physician. Clinical record review evidenced an agency document titled, “Revised Intervention,” entered and digitally signed by RN D on 4/6/2022 at 5:42 PM, which stated, “…Wound care to consist of Cleanse right breast with, saline. Apply adaptic covered by polymem. Cover with dry dressing and secure with tape or elastic bandage, change three times weekly and PRN for soilage….” The RN failed to administer treatment as ordered by the physician. During an observation of care on 4/6/2022 at 1:00 PM, RN D was observed cleansing the wounds on patient #5’s right and left breasts with gauze and normal saline. She then placed adaptic dressing to the wound on the right breast, then polymem, and a dry absorbent dressing over it. On the left breast, she placed adaptic and a dry absorbent dressing over it. The RN was observed applying a treatment not ordered by the physician. During an interview on 4/8/2022 at 11:21 AM, administrator A indicated that if a patient goes to the wound clinic, the nurse will find the wound clinic orders in the home or the wound clinic will fax the orders to the agency, then the information would be submitted into the patient’s Plan of Care and updated in the patient’s chart. When queried as to where the orders from the wound clinic would be found, administrator A indicated the wound clinic “is terrible about faxing the orders” but she would have clinical manager B find them. 410 IAC 17-13-1(a)

Survey of January 26, 2022

22 findings

E0000

An Emergency Preparedness survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102. Survey Dates: 1/18/2022, 1/19/2022, 1/20/2022, 1/21/2022, 1/24/2022, 1/25/2022, and 1/26/2022 Facility ID: 003070

E0017

HHA Comprehensive Assessment in Disaster CFR(s): 484.102(b)(1) §484.102(b)(1) Condition for Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (1) The plans for the HHA's patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. This STANDARD is not met as evidenced by: Based on observation, record review and interview, the home health agency failed to ensure the emergency preparedness plan was individualized to meet the needs of each patient at their location in the event of a potential disaster in 17 of 17 clinical records reviewed. (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17) The findings include: *. Record review for patient #10 on 1/24/2022 evidenced an agency document titled "SN [skilled nurse] - OASIS [Home Health Outcome and Assessment Information Set] Start of Care" electronically signed by registered nurse L 9/23/2021, which stated, "Emergency Plan: ... Mobility Considerations: requires assistive device to ambulate, unable to navigate stairs ... Equipment Considerations: access to phone ... Additional Resources: Emergency Preparedness Plan". Review failed to evidence specific emergency preparedness information to include, but not limited to: specific shelter information, transportation needs, and an emergency contact who would not be affected by an emergency in the community. *. During a home visit 1/20/2022, with patient #11, home health aide E, and clinical manager B, review of patient’s home folder at 9:20 AM failed to evidence an individualized emergency preparedness plan with specific relocation information or potential disaster plan. Record review for patient #11 on 1/20/2022, evidenced an untitled agency document which stated, "Emergency Plan ... Emergency Contact #: [Person B] ... Mobility Considerations: bedbound, unable to navigate stairs ... Equipment Considerations: access to phone ... Additional Resources: Emergency Preparedness Plan". Review evidenced Person B lived with the patient and acts as primary caregiver. Review failed to evidence specific emergency preparedness information to include, but not limited to: specific shelter information, transportation needs, and an emergency contact who would not be affected by an emergency in the community. *. During a home visit 1/20/2022, with patient #12, physical therapist K, and clinical manager B, review of patient’s home folder at 1:15 PM failed to evidence an individualized emergency preparedness plan with specific relocation information or potential disaster plan. Record review for patient #12, on 1/20/2022 evidenced an untitled agency document which stated, "Emergency Plan: ... Mobility Considerations: requires assistive device to ambulate ... High risk Medications: Anticoagulants ... Additional Resources: Emergency Preparedness Plan". Review failed to evidence specific emergency preparedness information to include, but not limited to: specific shelter information, transportation needs, and an emergency contact who would not be affected by an emergency in the community. *. During a home visit on 1/21/2022, with patient #13, registered nurse J, and clinical manager B, review of patient’s home instructions at 1:15 PM failed to evidence an individualized emergency preparedness plan with specific relocation information or potential disaster plan. Record review for patient #13 on 1/21/2022 evidenced an untitled agency document which stated, "Emergency Plan ... Mobility Considerations: requires assistive device to ambulate, unable to navigate stairs ... Equipment Considerations: access to phone, pacemaker/defibrillator ... Additional Resources: Emergency Preparedness Plan". Review failed to evidence specific emergency preparedness information to include, but not limited to: specific shelter information, transportation needs, and an emergency contact who would not be affected by an emergency in the community. *. During a home visit 1/21/2022, with patient #14, registered nurse J, and clinical manager B, review of patient’s home folder at 2:15 PM failed to evidence an individualized emergency preparedness plan with specific relocation information or potential disaster plan. Record review for patient #14 on 1/21/2022, evidenced an untitled agency document which stated, "Emergency Plan: Patient/family accepting of emergency plan ... Mobility Considerations: lives along ... Equipment Considerations: access to phone ... Additional Resources: Emergency Preparedness Plan". Review failed to evidence specific emergency preparedness information to include, but not limited to: specific shelter information, transportation needs, and an emergency contact who would not be affected by an emergency in the community. *. Record review for patient #15 on 1/24/2022 evidenced an untitled agency document which stated, "Emergency Plan ... Mobility Considerations: requires assistive device to ambulate, unable to navigate stairs ... non weight bearing status ... Equipment Considerations: access to phone ... Additional Resources: Emergency Preparedness Plan". Review failed to evidence specific emergency preparedness information to include, but not limited to: specific shelter information, transportation needs, and an emergency contact who would not be affected by an emergency in the community. *. Record review for patient #16 on 1/25/2022 evidenced an agency document titled "SN - OASIS Start of Care" electronically signed by registered nurse O 12/15/2021 which stated, "Emergency Plan ... Mobility Considerations: requires assistive device to ambulate, wheelchair bound ... Equipment Considerations: access to phone ... Additional Resources: Emergency Preparedness Plan". Review failed to evidence specific emergency preparedness information to include, but not limited to: specific shelter information and transportation needs. *. Record review for patient #17 on 1/25/2022 evidenced an agency document titled "SN - OASIS Start of Care" electronically signed by registered nurse I on 4/27/20, which stated, "Mobility Considerations: bedbound, wheelchair bound ... equipment considerations ... access to phone ... Additional Resources: Emergency Preparedness Plan". Review failed to evidence specific emergency preparedness information to include, but not limited to: specific shelter information and transportation needs. *. During an interview 1/26/2022 at 11:51 AM, administrator A indicated the individualized emergency preparedness plans are in the patient's electronic medical record. Administrator A indicated patient's are instructed to call 911, and given general emergency instructions for fires, tornados, thunderstorms, and snow but have not planned the specific relocations indicating where each patient would go safely in the case of an emergency. Administrator A agreed emergency preparedness plans were not individualized for each patient. 1. Record review of an agency policy titled, “Emergency Management Plan” revised June 2021, stated “I. Policy: Prepare for and manage and emergency and restore to the same operational capabilities as pre-emergency levels. To ensure that adequate patient services and staff safety are provided when emergency conditions do not allow normal access to or from patient’s home … Phase Three – Response: Implementation of the Emergency Management Plan by management and response to the Emergency Management Plan by all staff … 3) Clinical staff will notify their home care case manager or designee to review patient caseloads. Case managers or their designees are responsible for patient triage ... A list of active patients and employees will be printed and distributed to administrative staff as needed for reference … They will review patient caseloads with clinical staff and establish visit priorities based on patient priority level 1, 2, 3, and four. Patients will be seen by staff as soon as the emergency is over or it is safe to do so. A list of active patients and employees will be printed and distributed to administrative staff as needed for reference … 5) Patients will be given emergency preparedness instructions upon home health admission and will be assured they will not be abandoned during an emergency … Emergency instructions given to a patient/ caregiver will be documented in the medical record. If patient needs to leave/ evacuate their home they are to call the Methodist home care office as soon as possible with their new location … 6) During and emergency event supervisory and/ or field staff will contact active patients to evaluate and assist within the patient arrangements concerning evacuation plans, if any ….” 2. During an observation on 1/21/2022, at 12:56 PM, of a home visit for patient #1, start of care 10/21/2021, the patient’s home folder which contained information provided by the home health agency, was reviewed for required information. Review of the home folder failed to evidence an individualized emergency preparedness plan to include the required potential disaster plan and/or specific relocation information. Clinical record review on 1/26/2022, evidenced an agency document titled "SN [Skilled Nurse] OASIS [Outcome and Assessment Information Set] Recertification" electronically signed by RN [Registered Nurse] I on 12/17/2021. This document had an area subtitled "Emergency Plan" that stated "... In the event of an emergency, it is important to identify an emergency contact person, such as a relative, a friend, a neighbor or a roommate. At least one of these individuals should be someone that would not be affected by an emergency in your community ...." The emergency contact listed was Person F. This section also stated "Mobility Considerations: unable to navigate stairs, wheelchair bound ... Equipment Considerations: access to phone ... Additional Resources: Emergency Preparedness Plan ...." Review evidenced the emergency contact listed was the patients primary caregiver, who would be affected by the same potential disaster as the patient. Review failed to evidence specific emergency preparedness information to include but not limited to emergency contact information, specific shelter information, and transportation needs. 3. During an observation on 1/21/2022,at 2:51 PM, of a home visit for patient #2, start of care 7/14/2020, the patient’s home folder which contained information provided by the home health agency, was reviewed for required information. Review of the home folder failed to evidence an individualized emergency preparedness plan to include the required emergency contact information, potential disaster plan and/or specific relocation information. Clinical record review on 1/26/2022, evidenced an agency document titled "SN OASIS Recertification" from 1/3/2022, by RN Q. This document had an area subtitled "Emergency Plan" that stated "Teaching provided patient/family to develop emergency plan ... In the event of an emergency, it is important to identify an emergency contact person, such as a relative, a friend, a neighbor or a roommate. At least one of these individuals should be someone that would not be affected by an emergency in your community ...." This section also stated "Police/Fire/Rescue: 911 ... Mobility Considerations: unable to navigate stairs ... Additional Resources: Emergency Preparedness Plan ...." Review failed to evidence an emergency contact listed. Review failed to evidence specific emergency preparedness information to include but not limited to emergency contact information, specific shelter information, and transportation needs. 4. During an observation on 1/25/2022, at 3:42 PM, of a home visit for patient #3, start of care 12/28/2021, the patient’s home folder which contained information provided by the home health agency, was reviewed for required information. Review of the home folder failed to evidence an individualized emergency preparedness plan to include the required potential disaster plan and/or specific relocation information. Clinical record review on 1/26/2022, evidenced an agency document titled "SN OASIS Start of Care" from 12/28/2022, by RN H. This document had an area subtitled "Emergency Plan" that stated "... In the event of an emergency, it is important to identify an emergency contact person, such as a relative, a friend, a neighbor or a roommate. At least one of these individuals should be someone that would not be affected by an emergency in your community ...." The emergency contact listed was Person A. This section also stated "Police/Fire/Rescue: 911 ... Mobility Considerations: bedbound ... Equipment Considerations: access to phone, oxygen is in use ... Additional Resources: Emergency Preparedness Plan ...." Review evidenced the emergency contact listed was the patients primary caregiver, who would be affected by the same potential disaster as the patient. Review failed to evidence specific emergency preparedness information to include but not limited to emergency contact information, specific shelter information, and transportation needs. *. Clinical record review on 1/26/2022,for patient #4, start of care 12/18/2021, evidenced an agency document titled "SN OASIS Start of Care" from 12/18/2021, by RN H. This document had an area subtitled "Emergency Plan" that stated "... Police/Fire/Rescue: 911 ... Mobility Considerations: requires assistive device to ambulate … Equipment Considerations: access to phone, pacemaker / defibrillator ... Additional Resources: Emergency Preparedness Plan ...." Review failed to evidence specific emergency preparedness information to include but not limited to specific shelter information, and transportation needs. *. Clinical record review on 1/26/2022,for patient #5, start of care 10/22/2021, evidenced an agency document titled "SN OASIS Recertification" from 12/21/2021, by RN Q. This document had an area subtitled "Emergency Plan" that stated ".... In the event of an emergency, it is important to identify an emergency contact person, such as a relative, a friend, a neighbor or a roommate. At least one of these individuals should be someone that would not be affected by an emergency in your community .... Police/Fire/Rescue: 911 ... Additional Resources: Emergency Preparedness Plan ...." Review failed to evidence an emergency contact listed. Review failed to evidence specific emergency preparedness information to include but not limited to emergency contact information, specific shelter information, and transportation needs. *. Clinical record review on 1/26/2022,for patient #6, start of care 12/17/2021, evidenced an agency document titled "SN OASIS Start of Care" from 12/17/2021, by RN J. This document had an area subtitled "Emergency Plan" that stated "... Police/Fire/Rescue: 911 ... Equipment Considerations: access to phone ... High Risk Medications: Narcotics ... Additional Resources: Emergency Preparedness Plan ...." Review failed to evidence specific emergency preparedness information to include but not limited to specific shelter information, and transportation needs. *. Clinical record review on 1/26/2022, for patient #7, start of care 11/20/2021, evidenced an undated and unsigned agency document titled "Episode Information." This document had an area subtitled "Emergency Plan" that stated "... Police/Fire/Rescue: 911 ... Mobility Considerations: lives alone, requires assistive device to ambulate ... Equipment Considerations: access to phone, oxygen in use ... Additional Resources: Emergency Preparedness Plan ...." Review failed to evidence specific emergency preparedness information to include but not limited to specific shelter information, and transportation needs. *. Clinical record review on 1/26/2022, for patient #8, start of care 11/19/2021, evidenced an agency document titled "Episode Information" which was undated and unsigned. This document had an area subtitled "Emergency Plan" that stated "... Police/Fire/Rescue: 911 ... Mobility Considerations: lives alone, requires assistive device to ambulate, unable to navigate stairs ... Additional Resources: Emergency Preparedness Plan ...." Review failed to evidence specific emergency preparedness information to include but not limited to specific shelter information, and transportation needs. *. Clinical record review on 1/26/2022, for patient #9, start of care 10/14/2021, evidenced an undated and unsigned agency document titled "Episode Information." This document had an area subtitled "Emergency Plan" that stated "... Police/Fire/Rescue: 911 ... Mobility Considerations: bedbound, requires assistive device to ambulate ... Equipment Considerations: access to phone ... Additional Resources: Emergency Preparedness Plan ...." Review failed to evidence specific emergency preparedness information to include but not limited to specific shelter information, and transportation needs.

E0030

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 record review and interview, the home health agency failed to ensure the emergency preparedness plan contained contact information for each employee for reference in the event of a potential emergency. The findings include: Record review of an agency policy titled, “Emergency Management Plan” revised June 2021, stated “I. Policy: Prepare for and manage and emergency and restore to the same operational capabilities as pre-emergency levels. To ensure that adequate patient services and staff safety are provided when emergency conditions do not allow normal access to or from patient’s home … Phase One – Mitigation: … 2) Home Care will establish priorities of the potential emergencies identified in the hazard vulnerability analysis which will need to have mitigation, preparation, response and recovery activities undertaken and procedures developed. Disasters may include but not limited to: … e. Communication outage … g. Computer services unavailable for clinical or office system … Phase Three – Response: Implementation of the Emergency Management Plan by management and response to the Emergency Management Plan by all staff … 1) Command Structure: The Emergency Management Plan will be implemented upon the direction of the Command Center. The person receiving notification of an emergency will immediately notify the Home Care Manager or designee who will implement the Emergency Management Plan. Every employee is given an updated copy of the Emergency Command Structure if changes are applied and a current copy is kept in the On-call Binder. once staff receives notice of the emergency, all staff is to report to the home care office in person or via telephone to report their work availability status. 2) Corporate Policy will be followed as defined in the Methodist hospitals, Inc. Emergency Operations Plan … The Home Care Manager or designee will notify the command center as to the number and type of employees who are available for assignment ... Phase Four – Recovery: Actions that restore essential services and resume normal activities such as assessment of staff support and dealing with community reaction … 2) Staff is to report to the Home Care office by telephone or in person as soon as possible after the acute emergency has passed. Staff reporting in will be verified against the active employee list. Staff will be assigned to assess current patients ... 5) Home Care will provide for alternate communication methods in the event of a communication failure such as two way radio equipment and/ or cell phones ….” Record review on 1/20/22, of the agency's emergency preparedness manual, which was a binder of hard copy information. Review of the content in the emergency preparedness binder failed to evidence contact information for home health agency’s employees. Review of the emergency preparedness manual failed to evidence contact information for all employees. During an interview on 1/20/22, at 9:20 AM, administrator A indicated the agency’s employee contact information was not in the binder at the time of review, but will include the it in emergency preparedness plan moving forward.

G0000

This was a Federal Re-certification, and State licensure survey for a home health agency, conducted by the Indiana Department of Health. Survey Dates: 1/18/2022, 1/19/2022, 1/20/2022, 1/21/2022, 1/24/2022, 1/25/2022, and 1/26/2022 Facility ID: 003070 This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Community Home Care Services, Inc. is precluded from providing its own home health aide training and competency evaluation for a period of two years from 01/26/2022 - 01/25/2024, due to being found out of compliance with Conditions of Participation 484.58 Discharge Planning. Quality Review Completed 02/23/22

G0374

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 ensure the OASIS [The Home Health Outcome and Assessment Information Set] data was accurate, complete, and reflected the patient’s status in 4 of 17 clinical records reviewed. (#10, #11, #16, #17) The findings include: 1. Review of an agency policy revised July 2021 and obtained 1/26/2022, titled “OASIS Information Reporting” stated “Policy: To define the parameters for OASIS data encoding and electronic transmission as required by the Medicare Conditions of Participation … B. After OASIS data is collected and completed by a qualified Clinician as part of the Comprehensive Assessment at the required time points, Methodist Home Care Services staff may take up to seven (7) calendar days to encode OASIS data into the EPIC computer software. During this time, any errors must be corrected. C. the encoded OASIS data must accurately reflect the patient’s status at the time of assessment. It is the responsibility of the home care to monitor the accuracy of the data and to ensure that the M0090 date falls within the correct time frame”. 2. Clinical record review on 1/25/2022 for patient #10, start of care 9/23/2021, certification period 9/23/2021 - 11/21/2021, evidenced a primary diagnosis of multiple sclerosis [a nervous system disease that affects the brain and spinal cord]. Record review evidenced an agency document titled “SN [skilled nurse] – OASIS [The Home Health Outcome and Assessment Information Set] Start of Care” electronically signed by RN [registered nurse] L on 9/23/2021. This document contained a section titled “Mobility” in which sub-sections titled, “GG0170J – Mobility: Walk 50 feet with two turns; GG0179K – Mobility: Walk 150 feet; GG0170L – Mobility: Walking 10 feet on uneven surfaces; GG0170N – Mobility: 4 steps; and GG0170O – Mobility: 12” were all marked as “skipped”. This document failed to ensure OASIS data reflected patient’s status at the time of assessment. Record review for patient #10 evidenced an agency document titled “SN – OASIS Resumption of Care” electronically signed by RN L on 10/7/2021. Section titled “Actions/Narrative” stated “Patient requires assistance with transferring, uses a cane for ambulation”. Review of document titled “PT – Initial Evaluation” electronically signed by PT [physical therapist] M on 10/8/2021 evidenced a section titled “Homebound Status” which stated, “Other homebound reasons: confined to bed/chair, unable to ambulate”. This document evidenced a section titled “Actions/Narrative” which stated, “Patient stated unable to get into motorized wheelchair as mom don’t know how to use it [SIC]… strength in RLE [right lower extremity] is poor – as patient unable to move it at all … Patient transferred from bed to wheelchair using Hoyer lift … Discharge patient as patient is at max rehab at this time.” Record review failed to ensure OASIS data accurately represented patient’s mobility status at the time of assessment. Review of document titled “SN [skilled nurse] – OASIS [Home Health Outcome and Assessment Information Set] Resumption of care”, electronically signed by registered nurse L on 10/7/2021, evidenced section titled “Mobility” in which sub-sections titled, “GG0170J – Mobility: Walk 50 feet with two turns; GG0179K – Mobility: Walk 150 feet; GG0170L – Mobility: Walking 10 feet on uneven surfaces; GG0170N – Mobility: 4; and GG0170O – Mobility: 12 steps” were all marked as “skipped”. This document failed to ensure OASIS data completely and accurately reflected patient’s status at time of assessment. Review of document titled “SN [skilled nurse] – OASIS [Home Health Outcome and Assessment Information Set] Discharge”, dated 10/28/2021 and electronically signed by registered nurse L 11/17/2021, evidenced section titled “Mobility” in which sub-sections titled, “GG0170J – Mobility: Walk 50 feet with two turns; GG0179K – Mobility: Walk 150 feet; GG0170L – Mobility: Walking 10 feet on uneven surfaces; GG0170N – Mobility: 4 steps; and GG0170O – Mobility: 12 steps” were all marked as “skipped”. This document failed to ensure OASIS data was complete and accurately reflected patient’s status at time of the assessment. Review of document titled “SN [skilled nurse] – OASIS [Home Health Outcome and Assessment Information Set] Discharge”, dated 10/28/2021, and electronically signed by registered nurse L on 11/17/2021, evidenced a sub-section titled “M2410 0 Inpatient Facility – To which inpatient facility has the patient been admitted?” which stated, “N/A – No inpatient facility admission”. Sub-section titled “M2420 – Discharge Disposition – Where is the patient after discharge from your agency?” stated, “Patient remained in the community [without formal assistive services]”. Sub-section titled “Discharge Instructions” stated, “discharge to inpatient rehab”. Document failed to accurately represent patient’s discharge location at time of assessment. During an interview 1/26/2022 at 1:30 PM, administrator A indicated OASIS discharge summary for patient #10, gave an unclear picture of location patient was discharged to, and was an error. Administrator A stated registered nurse L “did not update” the discharge summary to accurately reflect patient’s mobility status at time of assessment and the “complex assessment was inaccurate”. Administrator A indicated mobility sections on OASIS documents should not have been skipped, and they would instruct staff to make sure all sections are completed. 3. Clinical record review on 1/20/2022 for patient #11, start of care 8/10/2021, certification period 12/8/2021 - 2/5/2022, evidenced a primary diagnosis of multiple sclerosis [a nervous system disease that affects the brain and spinal cord]. Record review evidenced an agency document titled “Home Health Certification and Plan of Care” electronically signed by registered nurse I 12/6/2021 which stated, “Medications: Dose/Frequency/Route … Zolpidem [for sleep] 5 MG [milligrams] by mouth nightly … baclofen [for muscle spasms] 10 MG tablets, take 3 tablets by mouth 2 times daily … Ascorbic Acid [vitamin C] 500 MG by mouth daily … trazodone [for depression] 100 MG by mouth nightly … oxybutynin [for urinary incontinence] 5 MG by mouth daily … Calcium-Vitamin D-Vitamin K [for osteoporosis] 2 tablets by mouth 2 times daily … Probiotic Product [for digestion] take 1 capsule by mouth daily … linaclotide [for constipation] 145 MCG [micrograms] by mouth as needed for constipation … lisinopril [for blood pressure] 20 MG by mouth daily … rifaximin [antibiotic] 550 MG by mouth twice daily … bisacodyl [for constipation] 10 MG by mouth daily … lactulose [for constipation] 20 G [grams] by mouth 3 times daily … nystatin powder [for skin infection] 100,000 G topically 2 times daily to bilateral breasts and groin, sacrum, and peri area … Triamcinolone Acetonide [for skin rash] 1 applicator topically two times daily near skin folds”. Clinical record review 1/20/2022 for patient #11, evidenced an agency document titled “SN [skilled nurse] - OASIS [Home Health Outcomes and Assessment Information Set] Transfer w/o DC [discharge]” electronically signed by registered nurse N on 12/14/2021. Document stated, “Medications … M2016 – Patient/Caregiver Drug Education Intervention- At the time of, or at any time since the most recent SOC/ROC [start of care/resumption of care] assessment, was the patient/caregiver instructed by agency staff or other health care provider to monitor the effectiveness of drug therapy, adverse drug reactions, and significant side effects, and how and when to report problems that may occur? NA [not applicable] – Patient not taking any drugs”. Record review failed to evidence accurate documentation in OASIS regarding patient’s medications. During an interview 1/26/2022 at 12:02 PM, administrator A stated the OASIS [Home Health Outcomes and Assessment Information Set] documentation stating patient was not taking any drugs, “was an error”. Administrator A stated they would educate staff on proper documentation of OASIS data. 4. Clinical record review on 1/25/2022 for patient #16, start of care 12/15/2021, certification period 12/15/2021 - 2/12/2022, evidenced a primary diagnosis of malignant neoplasm of prostate [prostate cancer]. Record review evidenced an agency document titled “SN [skilled nurse] - OASIS [Home Health Outcomes and Assessment Information Set] Start of Care” electronically signed by registered nurse O on 12/15/2021. Document evidenced a section titled “Mobility” in which sub-sections titled, “GG0170J – Mobility: Walk 50 feet with two turns; GG0179K – Mobility: Walk 150; GG0170L – Mobility: Walking 10 feet on uneven surfaces; GG0170N – Mobility: 4 steps; and GG0170O – Mobility: 12 steps” were all marked as “skipped”. This document failed to include necessary documentation of patient's mobility status to accurately reflect patient's status. 5. Clinical record review on 1/25/2022 for patient #17, start of care 4/27/2020, certification period 12/18/2021-2/15/2022, evidenced a primary diagnosis of neuromuscular dysfunction of bladder [when a person lacks bladder control due to brain, spinal cord or nerve problems]. Record review evidenced an agency document titled “SN [skilled nurse] – OASIS [Home Health Outcome and Assessment Information Set] Recertification” electronically signed by registered nurse I 12/14/2021. This document evidenced a section titled “Mobility” in which sub-sections titled, “GG0170J – Mobility: Walk 50 feet with two turns; GG0179K – Mobility: Walk 150; GG0170L – Mobility: Walking 10 feet on uneven surfaces; and GG0170N – Mobility: 4 steps” were all marked as “skipped”. This document failed to include necessary documentation of patient's mobility status to accurately reflect patient's status. During an interview on 1/26/2022 at 1:40 PM, Administrator A indicated OASIS [Home Health Outcomes and Assessment Information Set] was incomplete and inaccurate due to sections that were marked “skipped”. Administrator A indicated OASIS data should have all sections filled in to be complete.

G0436

Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This ELEMENT is not met as evidenced by: Based on observation, record review and interview, the home health agency failed to ensure patients received all services outlined in the plan of care in 3 of 12 active records reviewed. (#11, #12, #17) The findings include: 1. Review of an agency policy obtained 1/26/2022, revised August 2021, titled “Plan of Care” stated, “Policy: … K. Staff providing services under arrangement or contract must participate in the development of the Plan of Care, deliver services according to the Plan, and notify the physician of any changes in the patient’s condition, per home care policy”. 2. Review of an undated agency document 1/26/2022, titled "Home Health Care Patient Bill of Rights" stated, "Patients/Representatives have the right to: Participate in, and be informed about, and consent or refuse care in advance of and during treatment with respect to: ... The care to be furnished, based on the comprehensive assessment ... The frequency of visits ... Any changes in the care to be furnished ... Receive all services outlined in the plan of care". 3. Clinical record review for patient #11, start of care 8/10/2021, certification period 12/8/2021 - 2/5/2022, evidenced a primary diagnosis of multiple sclerosis [a nervous system disease that affects the brain and spinal cord]. Clinical record review for patient #11 evidenced an untitled agency document which stated, “Care Plan … Aide … Visits: … 3 visits every week for 8 weeks-12/12/2021 to 2/5/2022, 1 visit every week for 1 week-1/2/2022 to 1/8/2022, 2 visits every week for 4 weeks-1/9/2022 to 2/5/2022”. Clinical record review for patient #11, evidenced an agency document titled “Home Health Certification and Plan of Care” electronically signed by registered nurse I 12/6/2021, which stated, “Certification Period: From 12/8/21 To: 2/5/2022 ... Orders for Discipline and Treatments … Aide: …12/12/2021 to 2/5/2022: 3 visits every week for 8 weeks”. During a home visit for patient #11 on 1/20/2022 at 9:00 AM, person B stated patient #11 was supposed to get 3 aide visits a week, but the home health agency changed aide visit frequency to 2 visits a week due to short staffing, even when patient #11 and caregiver did not want to decrease visit frequency. Person B stated they needed 3 aide visits a week for patient #11. Agency failed to provide 3 visits a week to patient #11, as ordered on plan of care. During an interview 1/18/2022 at 9:38 AM, administrator A stated, "due to having only 1 home health aide," the agency had called each patient and cut visits from 3 times a week to 1 or 2 times a week when possible and held off on taking referrals if the agency couldn’t handle the additional patients. During an interview 1/26/2022 at 11:50 AM, administrator A indicated the agency had increased patient #11’s visits to 3 times a week again after home visit on 1/20/2022. 4. Clinical record review on 1/20/2022 for patient #12, start of care 1/11/2022, certification period 1/11/2022 - 3/11/2022, evidenced a primary diagnosis of encounter for other orthopedic aftercare [care after hip surgery]. Record review for patient #12 evidenced an agency document titled “Home Health Certification and Plan of Care”, for certification period 1/11/2022 - 3/11/2022, which stated, “Orders for Discipline and Treatments … PT [physical therapy]: … Each Visit … Assess patient’s incision at every visit and document on the WLDA [wounds, lines, drains, and airways] … Measure incision weekly and document on the WLDA”. Record review for patient #12 evidenced an untitled agency document which stated, “Wound Assessment … Incision Hip Lateral; Right”. This document failed to evidence any incision measurements during home visits on 1/11/2022, 1/13/2022, 1/15/2022, 1/18/2022, and 1/19/2022. Observation of a home visit was conducted on 1/20/2022 for patient #12. This home visit was conducted with physical therapist K and clinical manager B. At 1:00PM, physical therapist K failed to be observed assessing and measuring the patient's right hip incision. The surveyor failed to observe any measurement of the patient's right hip incision by time of exit at 1:47 PM. During an interview on 1/26/2022 at 12:10 PM, administrator A indicated the physical therapist is responsible for assessing patient #12’s incision every visit. Administrator A stated the physical therapist had not documented measurement of incision weekly as ordered. 5. Clinical record review for patient #17, start of care 4/27/20, certification period 12/8/2021 - 2/5/2022, evidenced a primary diagnosis of neuromuscular dysfunction of bladder [when a person lacks bladder control due to brain, spinal cord or nerve problems]. Clinical record review for patient #17 evidenced an agency document titled “Home Health Certification and Plan of Care”, for certification period 12/8/2021 - 2/5/2022, electronically signed by registered nurse I on 12/14/2021. This document stated, “Orders for Discipline and Treatments: … Change catheter … Perform latex change every month using 16 French cath [catheter] with 5ml [milliliter] balloon”. Record review evidenced an untitled agency document which indicated patient had a Foley catheter placed 10/15/2021 by registered nurse I, and was removed 12/1/2021 by registered nurse I. Document indicated that there were 47 days between catheter changes. Agency failed to ensure patient #17 received catheter change monthly as ordered in plan of care. During an interview on 1/26/2022 at 1:16 PM, administrator A stated plan of care orders should be followed, and patient #17’s Foley catheter should have been changed before 47 days.

G0454

HHA can no longer meet the patient's needs CFR(s): 484.50(d)(1) The transfer or discharge is necessary for the patient's welfare because the HHA and the physician or allowed practitioner, who is responsible for the home health plan of care agree that the HHA can no longer meet the patient's needs, based on the patient's acuity. The HHA must arrange a safe and appropriate transfer to other care entities when the needs of the patient exceed the HHA's capabilities; This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the home health agency failed to ensure they arranged an appropriate transfer to another healthcare entity that could meet the needs of the patient in 1 of 7 home visits conducted. (#11) The findings include: Review of an agency policy obtained 1/26/2022, revised August 2021, titled “Patient Rights & Responsibilities” stated, “Rights of patients … include: … M. Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to: … the care to be furnished, based on the comprehensive assessment … the frequency of visits ... expected outcomes of care, including patient-identified goals, and anticipated risks and benefits … any factors that could impact treatment effectiveness … any changes in the care to be furnished”. Review of an agency policy obtained 1/26/2022, revised August 2021, titled “Discharge & Transfer” stated, “11. The HHA [home health agency] and physician responsible for the plan of care agree that the patient’s needs can no longer be met by the HHA based on the patient’s acuity. The HHA must arrange a safe and appropriate transfer to other care entities when the needs of patient exceed the HHA’s capabilities”. Clinical record review 1/20/2022 for patient #11, start of care 8/10/2021, certification period 12/8/2021 - 2/5/2022, evidenced a primary diagnosis of multiple sclerosis [a nervous system disease that affects the brain and spinal cord]. Clinical record review for patient #11 evidenced an untitled agency document which stated, “Care Plan … Aide … Visits: … 3 visits every week for 8 weeks-12/12/2021 to 2/5/2022, 1 visit every week for 1 week-1/2/2022 to 1/8/2022, 2 visits every week for 4 weeks-1/9/2022 to 2/5/2022”. Clinical record review for patient #11, evidenced an agency document titled “Home Health Certification and Plan of Care”, for certification period 12/8/2021 - 2/5/2022, electronically signed by registered nurse I 12/6/2021, which stated, “Orders for Discipline and Treatments … Aide: …12/12/2021 to 2/5/2022: 3 visits every week for 8 weeks”. Observation during a home visit for patient #11 on 1/20/2022 at 9:00 AM, person B stated patient #11 was supposed to get 3 aide visits a week, but the home health agency changed aide visit frequency to 2 visits a week due to short staffing, even when patient #11 and caregiver did not want to decrease visit frequency. Person B indicated they needed 3 aide visits a week for patient #11. Agency failed to offer other resources or additional interventions to resolve caregiver’s request. Interview failed to evidence home health agency had arranged appropriate transfer to other care entities when needs of the patient exceeded the agency’s capabilities. During an interview 1/18/2022 at 9:38 AM, administrator A stated, "due to having only 1 home health aide," the agency had called each patient and cut visits from 3 times a week to 1 or 2 times a week when possible and held off on taking referrals if the agency couldn’t handle the additional patients. During an interview 1/26/2022 at 11:50 AM, administrator A stated the agency had increased patient #11’s visits to 3 times a week again after home visit on 1/20/2022.

G0560

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 failed to develop and implement an effective discharge planning process for the agency. The agency failed to ensure they 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 5 of 5 discharge records reviewed. (#7, #8, #9, #10, #15) (see tag 564) The agency failed to assist patients in selecting post-acute care providers using quality measures data and resource use measures in 2 of 2 transfer records reviewed. (#7, #10) (see tag G562) 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. *. Clinical record review on 1/26/2022, for patient #7, start of care 11/20/2021, diagnoses include but were not limited to sepsis [potentially life-threatening infection], pneumonia [infection that inflames one or both lungs, and may be filled with fluid], evidenced an agency document titled, “Case Communication” from 12/16/2021, and signed by RN [Registered Nurse] R. This document had an area subtitled “Communication Notes” which stated, “Topic discussed: Inpatient Hospitalization … Relationship to patient: home care staff … Communication details: Patient switched from observation to inpatient on 12-15-21 at [Entity I] ….” Record review of an agency document titled “SN – OASIS Transfer w/o [without] DC [discharge]” which was signed by RN R on 12/16/2021. Review of the clinical record evidenced the patient went to the emergency department (ED) on 12/12/2021, and was placed on an observation status until 12/15/2021, when Entity I made placed the patient on an inpatient status. Record review of an agency document titled “Case Communication” from 12/21/2021, and signed by RN R. This document had an area subtitled “Communication Notes” which stated “Topic discussed: Re-admission inpatient hospitalization … Communication details: Patient was discharged from [Entity I] on 12-17-21. Methodist HHC [home health care] received a ROC [resumption of care]/order on 12-20-21. Patient re-admitted to [Entity I] ED Inpatient on 12-21-21 with shock, sepsis, hypotension [low blood pressure], and possible pneumonia ….” Review evidenced the patient was discharged from Entity I on 12/27/2021. Review of the clinical record failed to evidence a discharge summary. Review failed to evidence the disposition of the patient. Review failed to evidence Entity I or the patient’s physician received a discharge summary of the patient’s pertinent information. During an interview on 1/26/2022, at 11:33 AM, administrator A indicated if a patient was transferred as "Transfer without discharge" without a ROC, the case manager would discharge when they find out the patient would not come back or is placed at another agency/facility. *. Clinical record review on 1/26/2022, for patient #8, start of care 11/19/2021, primary diagnosis post total knee replacement evidenced an agency document titled, “Home Health Certification and Plan of Care” for certification period 11/19/2021 – 1/17/2022, which was electronically signed by the physician on 12/9/2021. This document had an area subtitled “21. Orders for Discipline and Treatments (Specify Amount/Frequency/Duration)” that stated “PT: … 11/21/2021 to 12/4/2021: 3 visits every week for 2 weeks … SN: … 11/24/2021 to 1/15/2021: 2 visits every week for 8 weeks ..." Another area subtitled "Goals" stated "Potential for post-op [operative] complications ... Patient/caregivers will verbalize understanding of post-op care including infection control, prevention of deep vein thrombosis [blood clots], prevention of constipation and patient specific precautions throughout the service period ...." Record review of an agency document titled “Case Communication” from 11/24/2021, and signed by RN L. This document had an area subtitled “Communication Notes” which stated “… PT on hold until further notice ….” Review evidenced the patient's surgical wound had been draining more than normal for the total knee replacement surgery. Review evidenced PT was put on hold, and SN services started on 11/24/2021. Record review of an agency document titled “SN - OASIS Discharge” signed by RN L, on 12/7/2021. This document had an area subtitled "Discharge Plans" which stated "Reason for Discharge: Goals met ... Discharge from: Nursing ... Alterations in the Plan of Care: No ...." Review evidenced the patient was discharged from SN services. Review evidenced an alteration in the plan of care. Review failed to evidence the patient was discharged from PT. Review failed to evidence PT goals were met as ordered on the plan of care. Review failed to evidence accurate documentation of patients progress towards PT goals at the time discharge. *. Clinical record review on 1/26/2022, for patient #9, start of care 10/14/2021, primary diagnosis post total knee replacement evidenced an agency document titled, “Home Health Certification and Plan of Care” for certification period 11/19/2021 – 1/17/2022, which was electronically signed by the physician on 10/13/2021. Record review of an agency document titled “Case Communication” from 11/27/2021, and signed by RN I. This document had an area subtitled “Communication Notes” which stated, “Communication details: On-call service called to report that the patient was admitted into hospice for further care ….” Review of this document evidenced the patient was transferred to hospice services on 11/27/2021. Record review of an agency document titled "SN - OASIS Discharge" which was signed by RN P on 12/6/2021. This document had an area subtitled "Actions/Narrative" that stated "SN received message patient transferred to Hospice care and to discharge from Methodist home care service.... " Review of this document evidenced the patient was discharged on 12/6/2021. Review evidenced the patient was discharged from the home health agency 10 days after transfer to Hospice care. Review failed to evidence the hospice agency received a discharge summary within 48 hours as required. *. During an interview on 1/26/2022, at 11:30 AM, administrator A indicated the process to follow a patient admitted to the ED consisted of the case manager following up to either schedule a ROC assessment or if the patient would be admitted to the hospital as an inpatient status. *. During an interview on 1/26/2022, at 11:35 AM, administrator A indicated a discharge summary would be sent to the physician when the discharge order is put in and received. The administrator indicated the discharge assessment is the last visit in the home. 1. Review of an agency policy obtained 1/26/2022, revised August 2021, titled, “Discharge & Transfer” stated “Policy: At the time of admission the clinician will begin planning for the patient’s discharge. Discharge plans will be documented in the plan of care. The patient/legal representative will participate in planning for discharge or transfer. The staff will notify the patient/legal representative of reasons for discharge and changes in the plan as they affect the discharge plans. Staff will educate the patient and/or family in self-care, management of medical and health needs, use of community resources, available alternatives, and other appropriate information. Verbal discharge instructions will be provided … The patient/ legal representative or other individual responsible for the patient’s care will be given at least fifteen calendar day notice before services are discontinued … Transfer: transfer to another organization will occur when appropriate and the patient meets discharge criteria. Home care and attending physician will be responsible for the patient during the transfer process. The receiving organization and patient’s physician will be provided with all relevant written or verbal information including: 1) reason for transfer 2) patient’s physical and pertinent psychological status 3) current needs necessitating intervention 4) summary of the care and services provided 5) progress towards achieving identified goals 6) all medication, instructions and/or referral information provided to the patient 7) advance directive information … Discharge/Transfer Summary: A completed discharge summary will be 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 within five business days of the patient discharge … A completed transfer summary will be sent to the health care facility within two business days of a planned transfer if the patient’s care will immediately continue in a health care facility. A completed transfer summary will be sent within two business days to the health care facility and/or responsible health care provider upon becoming aware of an unplanned transfer”. 2. Clinical record review on 1/24/2022 for patient #10, start of care 9/23/2021, discharged 10/28/2021, evidenced a primary diagnosis of multiple sclerosis (exacerbation), [a nervous system disease that affects the brain and spinal cord]. Record review evidenced an agency document titled “Home Health Certification and Plan of Care” electronically signed by registered nurse L on 9/20/2021, which stated, “Discharge Plans … At discharge patient will remain at home, with physician follow-up, live with family member”. Review on 1/24/2022 of agency document titled “OASIS [Home Health Outcome and Assessment Information Set] Start of Care” electronically signed by registered nurse L on 9/23/2021 contained section titled “Mobility GG0170” which stated “Roll Left and Right … Discharge Goal: Independent … Sit to Lying … Discharge Goal: Setup or clean-up assistance … Lying to Sitting on Side of Bed … Discharge Goal: Setup or clean-up assistance … Chair/Bed-to-chair Transfer … Discharge Goal: Supervision or touching assistance". Record review on 1/24/2022 for patient #10 evidenced an agency document titled, “PT [physical therapy] – Initial Evaluation” electronically signed by physical therapist M on 10/8/2021. Section titled “Actions/Narrative” stated, “Patient was seen today for initial evaluation … Discharge patient as patient is at max rehab at this time.” Document failed to document if patient agreed to physical therapy discharge plan, if follow-up would be provided, and if physician was notified of change to discharge plan. Review on 1/24/2022 of agency document titled “Case Communication” electronically signed by registered nurse L on 11/17/2021, stated, “Spoke with patient mother, informed that patient is in an inpatient rehab [rehabilitation] facility … Patient discharged from home health services”. Record review on 1/24/2022 evidenced an agency document titled “Discharge” electronically signed by registered nurse L on 11/17/2021. Document stated, “Reason for Discharge: Patient in rehab facility … Alterations in the Plan of Care: no … Date of Last Home Visit: 10/28/2021”. Review on 1/24/2022 of agency document titled “SN [skilled nurse] – OASIS [Home Health Outcomes and Assessment Information Set] Discharge” electronically signed by registered nurse L on 10/28/2021, and updated with an addendum 11/17/2021, stated “Goal Status on Discharge: Goals met”. Document was dated 10/28/2021, and in a section titled “Inpatient Facility Admission or Agency Discharge” it stated, “Discharge/Transfer/Death Date … 11/17/2021”. This document indicated the patient was discharged 11/17/2021 and last visit was 10/28/2021. This document failed to evidence agency had discussed discharge plans for inpatient rehabilitation with patient in advance. No discharge summary or transfer summary was evidenced. Review on 1/24/2022 of agency document titled “SN-OASIS Discharge” electronically signed by registered nurse L on 10/28/2021 and 11/17/2021 contained section titled “Mobility GG0170” which stated “Roll Left and Right … Discharge Performance: Supervision or touching assistance … Sit to Lying … Discharge Performance: Partial/moderate assistance … Lying to Sitting on Side of Bed … Discharge Performance: Partial/moderate assistance … Chair/Bed-to-chair Transfer … Discharge Performance: Partial/moderate assistance”. Document failed to evidence goals were met at discharge. Record review failed to evidence that a discharge summary had been completed and sent to inpatient rehabilitation. Record review failed to evidence that agency had assisted patient with discharge plans to inpatient rehab. Record review failed to evidence actual date that patient transferred to inpatient rehabilitation. Record review failed to evidence that agency assisted patient #10 with post-acute provider selection. During an interview on 1/26/2022 at 11:34 AM, administrator A stated, “discharge summaries get entered [in the electronic medical record] the date of the last home visit”. During an interview on 1/26/2022 at 1:29 PM administrator A stated regarding patient #10 “the physical therapist should have included a re-evaluation in the initial therapy evaluation since patient had just gotten out of the hospital and could have been weaker because of acute illness.” During an interview on 1/26/2022 at 1:34 PM, administrator A indicated the agency did not find out about patient #10 being transferred to inpatient rehab until registered nurse L contacted patient about setting up a visit. Administrator A agreed the agency had not updated discharge plan to meet patient discharge needs. Administrator A indicated the discharge had been entered 11/17/2021 but dated 10/28/2021 to align with last home visit completed. Administrator A did not know what day patient #10 had transferred to inpatient rehab. Administrator A did not know if a transfer/discharge summary was sent to inpatient rehabilitation facility. 3. Clinical record review on 1/24/2022 for patient #15, start of care 9/9/2021, evidenced a primary diagnosis of orthopedic aftercare following surgical amputation [care after amputation]. Clinical record review for patient #15 evidenced an agency document titled, “Case Communication” electronically signed by physical therapist K on 9/28/2021 which stated, “Patient admitted to the hospital due to wound infection”. Record review evidenced an agency document titled, “Case Communication” electronically signed by registered nurse J on 9/29/2021 which stated, “Patient admitted to inpatient”. Record review evidenced an agency document dated 10/1/2021, titled, “Case Communication” electronically signed by registered nurse C, which stated, “patient transferred to ... [Hospital E] ... for surgery”. Record review evidenced an agency document which was transmitted titled “SN [skilled nurse]-OASIS [ Home Health Outcome and Assessment Information Set] Transfer w/o DC [discharge]" electronically signed by registered nurse C on 10/4/2021. Review failed to evidence a discharge summary was completed. Record review Record review failed to evidence patient treatment preferences, goals of care, and relevant medical information were sent to the hospital upon transfer. Record review failed to evidence any discharge OASIS was completed. Record review failed to evidence any agency follow-up regarding discharge planning after hospital admission. During an interview on 1/26/2022 at 11:34 AM, administrator A stated, “discharge summaries get entered [in the computer] the date of the last home visit”. During an interview on 1/26/2022 at 11:32 AM, administrator A indicated agency did not know whether patient #15 was still in hospital or had returned home. Administrator A indicated the discharge summary was not completed, and if patient not returning to agency after hospital discharge, agency is supposed to complete discharge summary.

G0562

Discharge Planning CFR(s): 484.58(a) Standard: Discharge planning. An HHA must develop and implement an effective discharge planning process. For patients who are transferred to another HHA or who are discharged to a SNF, IRF or LTCH, the HHA must assist patients and their caregivers in selecting a post-acute care provider by using and sharing data that includes, but is not limited to HHA, SNF, IRF, or LTCH data on quality measures and data on resource use measures. The HHA must ensure that the post-acute care data on quality measures and data on resource use measures is relevant and applicable to the patient's goals of care and treatment preferences. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to ensure an effective discharge process, failed to assist patients/caregivers in selecting post-acute care providers and failed to share data on quality measures with patients during discharge process for 2 of 2 patients transferred to an emergency department (ED), from a total of 5 discharged clinical records reviewed. (#7, #10) The findings include: *. Clinical record review on 1/26/2022, for patient #7, start of care 11/20/2021, diagnoses include but were not limited to sepsis [potentially life-threatening infection], pneumonia [infection that inflames one or both lungs, and may be filled with fluid], evidenced an agency document titled, “Case Communication” from 12/21/2021, and signed by RN R. This document had an area subtitled “Communication Notes” which stated “Topic discussed: Re-admission inpatient hospitalization … Communication details: Patient was discharged from [Entity I] on 12-17-21. Methodist HHC [home health care] received a ROC [resumption of care]/order on 12-20-21. Patient re-admitted to [Entity I] ED Inpatient on 12-21-21 with shock, sepsis, hypotension [low blood pressure], and possible pneumonia ….” Review evidenced the patient was discharged from Entity I on 12/27/2021. Review of the clinical record failed to evidence a discharge summary. Review failed to evidence the disposition of the patient. Review failed to evidence Entity I or the patient’s physician received a discharge summary of the patient’s pertinent information. During an interview on 1/26/2022, at 12:31 PM, administrator A stated that in this situation, the patient "must have fallen off the board" and indicated the case manager failed to follow up with the patient's status as a result. Review of an agency policy obtained 1/26/2022, revised August 2021, titled, “Discharge & Transfer” stated “Policy: At the time of admission the clinician will begin planning for the patient’s discharge. Discharge plans will be documented in the plan of care. The patient/legal representative will participate in planning for discharge or transfer. The staff will notify the patient/legal representative of reasons for discharge and changes in the plan as they affect the discharge plans. Staff will educate the patient and/or family in self-care, management of medical and health needs, use of community resources, available alternatives, and other appropriate information. Verbal discharge instructions will be provided … The patient/ legal representative or other individual responsible for the patient’s care will be given at least fifteen calendar day notice before services are discontinued … Transfer: transfer to another organization will occur when appropriate and the patient meets discharge criteria. Home care and attending physician will be responsible for the patient during the transfer process. The receiving organization and patient’s physician will be provided with all relevant written or verbal information including: 1) reason for transfer 2) patient’s physical and pertinent psychological status 3) current needs necessitating intervention 4) summary of the care and services provided 5) progress towards achieving identified goals 6) all medication, instructions and/or referral information provided to the patient 7) advance directive information … Discharge/Transfer Summary: A completed discharge summary will be 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 within five business days of the patient discharge … A completed transfer summary will be sent to the health care facility within two business days of a planned transfer, if the patient’s care will immediately continue in a health care facility. A completed transfer summary will be sent within two business days to the health care facility and/or responsible health care provider upon becoming aware of an unplanned transfer”. Clinical record review on 1/24/2022 for patient #10, start of care 9/23/2021, discharged 10/28/2021, evidenced a primary diagnosis of multiple sclerosis (exacerbation), [a nervous system disease that affects the brain and spinal cord]. Record review 1/24/2022 for patient #10 evidenced an agency document titled “Home Health Certification and Plan of Care” electronically signed by registered nurse L on 9/20/2021. Document stated “Discharge Plans … At discharge patient will remain at home, with physician follow-up, live with family member”. Review on 1/24/2022 of agency document titled “OASIS Start of Care” electronically signed by registered nurse L on 9/23/2021 contained section titled “Mobility GG0170” which stated “Roll Left and Right … Discharge Goal: Independent … Sit to Lying … Discharge Goal: Setup or clean-up assistance … Lying to Sitting on Side of Bed … Discharge Goal: Setup or clean-up assistance … Chair/Bed-to-chair Transfer … Discharge Goal: Supervision or touching assistance". Review on 1/24/2022 of agency document titled “Case Communication” electronically signed by registered nurse L on 11/17/2021 stated, “Spoke with patient mother, informed that patient is in an inpatient rehab [rehabilitation] facility … Patient discharged from home health services”. Record review on 1/24/2022 evidenced an agency document titled “Discharge” electronically signed by registered nurse L on 11/17/2021. Document stated, “Reason for Discharge: Patient in rehab facility … Alterations in the Plan of Care: no … Date of Last Home Visit: 10/28/2021”. Review on 1/24/2022 of agency document titled “SN-OASIS Discharge” electronically signed by registered nurse L on 10/28/2021 and 11/17/2021 stated “Plan for next visit: 11/19/2021”. Document failed to evidence discharge to rehabilitation facility had been discussed in advance with patient. Review on 1/24/2022 of agency document titled “SN-OASIS Discharge” electronically signed by registered nurse L on 10/28/2021 and 11/17/2021 stated “Goal Status on Discharge: Goals met”. Review on 1/24/2022 of agency document titled “SN-OASIS Discharge” electronically signed by registered nurse L on 10/28/2021 and 11/17/2021 contained section titled “Mobility GG0170” which stated “Roll Left and Right … Discharge Performance: Supervision or touching assistance … Sit to Lying … Discharge Performance: Partial/moderate assistance … Lying to Sitting on Side of Bed … Discharge Performance: Partial/moderate assistance … Chair/Bed-to-chair Transfer … Discharge Performance: Partial/moderate assistance”. Document failed to evidence goals were met at discharge. Record review failed to evidence actual date that patient #10 transferred to inpatient rehab. Record review failed to evidence that agency had assisted patient #10 with selecting post-acute care provider. Record review failed to evidence the agency had provided patient with quality measures data and resource use data to select inpatient rehabilitation facility. During an interview on 1/26/2022 at 1:34 PM, administrator A indicated the agency did not find out about patient #10 being transferred to inpatient rehabilitation until registered nurse L contacted patient about setting up a visit on 11/17/2021. Administrator A did not know what day patient #10 had transferred to inpatient rehabilitation. Administrator A indicated agency did not assist patient in selecting the inpatient rehabilitation facility or provide quality measures/resource use measures data for patient.

G0564

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 send discharge summaries containing pertinent medical information, goals of care, and treatment preferences to receiving facility or practitioner in 5 of 5 closed clinical records reviewed. (#7, #8, #9, #10, #15) The findings include: *. Clinical record review on 1/26/2022, for patient #7, start of care 11/20/2021, diagnoses include but were not limited to sepsis [potentially life-threatening infection], pneumonia [infection that inflames one or both lungs, and may be filled with fluid], evidenced an agency document titled, “Home Health Certification and Plan of Care” for certification period 11/20/2021 – 1/18/2022, which was electronically signed by the physician on 12/31/2021. This document had an area subtitled “21. Orders for Discipline and Treatments (Specify Amount/Frequency/Duration)” that stated “PT [physical therapist]: … 11/24/2021 to 12/18/2021: 2 visits every week for 4 weeks … SN [skilled nurse]: … 11/21/2021 to 12/18/2021: 2 visits every week for 4 weeks. Review evidenced PT and SN services was ordered for this patient. Record review of an agency document titled “Case Communication” from 12/16/2021, and signed by RN [Registered Nurse] R. This document had an area subtitled “Communication Notes” which stated “Topic discussed: Inpatient Hospitalization … Relationship to patient: home care staff … Communication details: Patient switched from observation to inpatient on 12-15-21 at [Entity I] ….” Record review of an agency document titled “SN – OASIS Transfer w/o [without] DC [discharge]” which was signed by RN R on 12/16/2021. Review of the clinical record evidenced the patient went to the emergency department (ED) on 12/12/2021, and was placed on an observation status until 12/15/2021, when Entity I made placed the patient on an inpatient status. Record review of an agency document titled “Case Communication” from 12/21/2021, and signed by RN R. This document had an area subtitled “Communication Notes” which stated “Topic discussed: Re-admission inpatient hospitalization … Communication details: Patient was discharged from [Entity I] on 12-17-21. Methodist HHC [home health care] received a ROC [resumption of care]/order on 12-20-21. Patient re-admitted to [Entity I] ED Inpatient on 12-21-21 with shock, sepsis, hypotension [low blood pressure], and possible pneumonia ….” Review evidenced the patient was discharged from Entity I on 12/27/2021. Review of the clinical record failed to evidence a discharge summary. Review failed to evidence the disposition of the patient. Review failed to evidence Entity I or the patient’s physician received a discharge summary of the patient’s pertinent information. *. Clinical record review on 1/26/2022, for patient #8, start of care 11/19/2021, primary diagnosis post total knee replacement evidenced an agency document titled, “Home Health Certification and Plan of Care” for certification period 11/19/2021 – 1/17/2022, which was electronically signed by the physician on 12/9/2021. This document had an area subtitled “21. Orders for Discipline and Treatments (Specify Amount/Frequency/Duration)” that stated “PT: … 11/21/2021 to 12/4/2021: 3 visits every week for 2 weeks … SN: … 11/24/2021 to 1/15/2021: 2 visits every week for 8 weeks ..." Another area subtitled "Goals" stated "Potential for post-op [operative] complications ... Patient/caregivers will verbalize understanding of post-op care including infection control, prevention of deep vein thrombosis [blood clots], prevention of constipation and patient specific precautions throughout the service period ...." Record review of an agency document titled “Case Communication” from 11/24/2021, and signed by RN L. This document had an area subtitled “Communication Notes” which stated “… PT on hold until further notice ….” Review evidenced the patient's surgical wound had been draining more than normal for the total knee replacement surgery. Review evidenced PT was put on hold, and SN services started on 11/24/2021. Record review of an agency document titled “SN - OASIS Discharge” signed by RN L, on 12/7/2021. This document had an area subtitled "Discharge Plans" which stated "Reason for Discharge: Goals met ... Discharge from: Nursing ... Alterations in the Plan of Care: No ...." Review evidenced the patient was discharged from SN services. Review evidenced an alteration in the plan of care. Review failed to evidence the patient was discharged from PT. Review failed to evidence PT goals were met as ordered on the plan of care. *. Clinical record review on 1/26/2022, for patient #9, start of care 10/14/2021, primary diagnosis post total knee replacement evidenced an agency document titled, “Home Health Certification and Plan of Care” for certification period 11/19/2021 – 1/17/2022, which was electronically signed by the physician on 10/13/2021. Record review of an agency document titled “Case Communication” from 11/27/2021, and signed by RN I. This document had an area subtitled “Communication Notes” which stated “Communication details: On-call service called to report that the patient was admitted into hospice for further care ….” Review of this document evidenced the patient was transferred to hospice services on 11/27/2021. Record review of an agency document titled "SN - OASIS Discharge" which was signed by RN P on 12/6/2021. This document had an area subtitled "Actions/Narrative" that stated "SN received message patient transferred to Hospice care and to discharge from Methodist home care service.... " Review of this document evidenced the patient was discharged on 12/6/2021. Review evidenced the patient was discharged from the home health agency * days after transfer to Hospice care. Review failed to evidence the receiving agency received a discharge summary within 48 hours as required. 1. Review of an agency policy obtained 1/26/2022, revised August 2021, titled, “Discharge & Transfer” stated “Policy: At the time of admission the clinician will begin planning for the patient’s discharge. Discharge plans will be documented in the plan of care. The patient/legal representative will participate in planning for discharge or transfer. The staff will notify the patient/legal representative of reasons for discharge and changes in the plan as they affect the discharge plans … Transfer: transfer to another organization will occur when appropriate and the patient meets discharge criteria. Home care and attending physician will be responsible for the patient during the transfer process. The receiving organization and patient’s physician will be provided with all relevant written or verbal information including: 1) reason for transfer 2) patient’s physical and pertinent psychological status 3) current needs necessitating intervention 4) summary of the care and services provided 5) progress towards achieving identified goals 6) all medication, instructions and/or referral information provided to the patient 7) advance directive information … Discharge/Transfer Summary: A completed discharge summary will be 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 within five business days of the patient discharge … A completed transfer summary will be sent to the health care facility within two business days of a planned transfer if the patient’s care will immediately continue in a health care facility. A completed transfer summary will be sent within two business days to the health care facility and/or responsible health care provider upon becoming aware of an unplanned transfer”. 2. Clinical record review on 1/24/2022 for patient #10, start of care 9/23/2021, , evidenced a primary diagnosis of multiple sclerosis (exacerbation), [a nervous system disease that affects the brain and spinal cord]. Clinical record review 1/24/2022 for patient #10 evidenced agency document titled “Case Communication” electronically signed by registered nurse L on 11/17/2021 which stated, “Spoke with patient mother, informed that patient is in an inpatient rehab [rehabilitation] facility … Patient discharged from home health services”. Record review on 1/24/2022 evidenced an agency document titled “Discharge” electronically signed by registered nurse L on 11/17/2021. Document stated, “Reason for Discharge: Patient in rehab [rehabilitation] facility … Alterations in the Plan of Care: no … Date of Last Home Visit: 10/28/2021”. Record review failed to evidence agency had sent a discharge summary or transfer summary to inpatient rehab facility. During an interview on 1/26/2022 at 11:34 AM, administrator A stated, “discharge summaries get entered the date of the last home visit”. During an interview on 1/26/2022 at 1:34 PM, administrator A indicated the agency did not find out about patient #10 being transferred to inpatient rehab until registered nurse L contacted patient about setting up a visit on 11/17/2021. Administrator A agreed the agency had not updated discharge plan to meet patient discharge needs. Administrator A did not know what day patient #10 had transferred to inpatient rehab. Administrator A did not know if discharge summary/transfer summary had been sent to inpatient rehab facility. 3. Clinical record review on 1/24/2022 for patient #15, start of care 9/9/2021, evidenced a primary diagnosis of orthopedic aftercare following surgical amputation [care after amputation]. Clinical record review for patient #15 evidenced an agency document titled, “Case Communication” electronically signed by physical therapist K on 9/28/2021 which stated, “Patient admitted to the hospital due to wound infection”. Record review evidenced an agency document titled, “Case Communication” electronically signed by registered nurse registered nurse J on 9/29/2021 which stated, “Patient admitted to inpatient”. Record review evidenced an agency document dated 10/1/2021, titled, “Case Communication” electronically signed by registered nurse C, which stated, “patient transferred to ... [Hospital E] ... for surgery”. Record review evidenced an agency document which was transmitted titled “SN [skilled nurse]-OASIS [Home Health Outcome and Assessment Information Set] Transfer w/o DC [discharge]” electronically signed by registered nurse C on 10/4/2021. Review failed to evidence a discharge summary was completed or sent to hospital. Record review Record review failed to evidence patient treatment preferences, goals of care, and relevant medical information were sent to the hospital upon transfer. Record review failed to evidence any discharge OASIS was completed. Record review failed to evidence agency follow-up with patient regarding discharge planning after hospital admission. During an interview on 1/26/2022 at 11:34 AM Administrator A stated, “discharge summaries get entered the date of the last home visit”. During an interview on 1/26/2022 at 11:32 AM, administrator A indicated agency did not know whether patient #15 was still in hospital or had returned home. Administrator A indicated a discharge summary was not completed, and if a patient does not return to agency after hospital discharge, a discharge summary should be completed.

G0572

G0574

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure the individualized plan of care included all medications and treatments, safety measures to protect against injury, and the frequency and duration of treatments in 5 of 12 active clinical records reviewed. (#5, #6, #11, #13, #16) The findings include: *. Clinical record review on 1/26/2022, for patient #5, start of care 10/22/2021, diagnoses include but were not limited to an unspecified open wound of the right and left arms, evidenced an agency document titled, “Home Health Certification and Plan of Care” for certification period 12/21/2021 – 2/18/2022, which was electronically signed by the physician on 12/20/2021. This document had an area subtitled “10. Medications: Dose/Frequency/Route (N)ew (C)hanged" which remained blank. Review of the plan of care failed to evidence the patient's medications were listed and individualized on the plan of care as required. *. Clinical record review on 1/26/2022, for patient #6, start of care 12/17/2021, a pertinent diagnosis included but was not limited to an abscess of the breast, evidenced an agency document titled, “Home Health Certification and Plan of Care” for certification period 12/17/2021 – 2/14/2022, which was electronically signed by the physician on 12/30/2021. This document had an area subtitled “10. Medications: Dose/Frequency/Route (N)ew (C)hanged” that stated “Ginseng [supplement] 250 MG [milligrams] PO [by mouth] CAPS [capsules] Take by mouth – Oral … Turmeric [supplement] PO Take by mouth – Oral … Lactobacillus (Probiotic Acidophilus PO) Take by mouth – Oral … Vitamin E PO Take by mouth – Oral ….” Review of this document failed to evidence the dosage/amount and frequency of all medications listed. Review failed to evidence the plan of care was individualized as required, to show specific medication instructions. *. During an interview on 1/26/2022, at 11:27 AM, administrator A indicated name, dosage, route, time, and strength should be included in medication orders and instructions. 1. Review of an agency policy obtained 1/26/2022, revised August 2021, titled “Plan of Care” stated, “Policy: … A. Every patient must have a written Plan of Care. This plan must be designed to meet the needs of the patient. The Plan of Care is developed from the physician’s orders, and is developed and maintained by home care staff in consultation with the physician … C. The Plan of Care must include the type of services to be provided and the frequency and duration of these services, including: 1) Disciplines and frequency & duration of visits … 2) Specific procedures & treatments, including frequency & duration … 3) Specific modalities & amount of therapy services … 4) PRN (as needed) visits with a specified number and reason … 5) Prescribed medications with dose, route, and frequency … 6) Over-the-counter medications which staff will administer and/or pour … 7) Mental status … 8) Goals & Prognosis … 9) Rehabilitation Potential …. 10) Discharge Plan … 11) Functional Limitations … 12) Activities permitted … 13) Nutritional requirements … 14) Any safety measures to protect against injury … 15) Instruction for timely discharge or referral and any other appropriate items … G. All drugs and treatments ordered by the physician will be incorporated into the Plan of Care. All other drugs and treatments observed by the nurse on assessment will also be incorporated into the Plan of Care”. *. Clinical record review on 1/20/2022 for patient #11, start of care 8/10/2021, certification period 12/8/2021-2/5/2022, evidenced a primary diagnosis of multiple sclerosis [a nervous system disease that affects the brain and spinal cord]. Clinical record review for patient #11 evidenced a document titled “Home Health Certification and Plan of Care” electronically signed by registered nurse I 12/6/2021 which stated, “Medications: Dose/Frequency/Route … Zolpidem [for sleep] 5 MG [milligrams] by mouth nightly … baclofen [for muscle spasms] 10 MG tablets, take 3 tablets by mouth 2 times daily … Ascorbic Acid [vitamin C] 500 MG by mouth daily … trazodone [for depression] 100 MG by mouth nightly … oxybutynin [for urinary incontinence] 5 MG by mouth daily … Calcium-Vitamin D-Vitamin K [for osteoporosis] 2 tablets by mouth 2 times daily … Probiotic Product [for digestion] take 1 capsule by mouth daily … linaclotide [for constipation] 145 MCG [micrograms] by mouth as needed for constipation … lisinopril [for blood pressure] 20 MG by mouth daily … rifaximin [antibiotic] 550 MG by mouth twice daily … bisacodyl [for constipation] 10 MG by mouth daily … lactulose [for constipation] 20 G [grams] by mouth 3 times daily … nystatin powder [for skin infection] 100,000 G topically 2 times daily to bilateral breasts and groin, sacrum, and peri area … Triamcinolone Acetonide [for skin rash] 1 applicator topically two times daily near skin folds”. During a home visit 1/20/2022 at 8:45 AM with patient #11, home health aide E, and clinical manager B, caregiver B provided patient #11’s home medications for review. Review of patient’s home medications evidenced baclofen [for muscle spasms] 10 MG [milligram] tablets, take 3 tablets by mouth 2 times a day; oxybutynin [for urinary incontinence] 5 MG by mouth daily; and Methenamine Hippurate [for urinary tract infection] 1 G [gram] by mouth 2 times daily. Observation failed to evidence that plan of care contained complete and accurate medication list compared to medications patient taking at home. During an interview 1/26/2022 at 11:53 AM, administrator A indicated the plan of care medication list was not accurate or updated with all of patient’s medications. *. Clinical record review on 1/21/2022 for patient #13, start of care 12/26/2021, evidenced a primary diagnosis of pleural effusion [a buildup of fluid between the tissues that line the lungs and the chest]. Record review evidenced an unsigned agency document titled “Outpatient Medications on the Plan of Care” which listed the following medications: “aspirin [to prevent blood clots] 81 MG [milligram] chewable tablet - take 240 MG by mouth daily; bumetanide [for swelling] 2 MG PO [by mouth] tablet; carvedilol [for blood pressure] 25 MG tablet - take one tablet by mouth twice daily with meals; glipizide [for blood sugar] 10 MG tablet - take 10 MG by mouth 2 times daily before meals; hydrocodone-acetaminophen [for pain] 5-325 MG per tablet - take 1 tablet by mouth every 8 hours as needed for pain; losartan [for blood pressure] 100 MG tablet - take one tablet by mouth once daily; lovastatin [for cholesterol] 40 MG PO tablet - take 40 MG by mouth nightly; Melatonin [for sleep] 1 MG capsule - take 1 tablet by mouth nightly x1; metolazone [for swelling] 2.5 MG PO tablet - take 2.5 MG by mouth; Novolin [for blood sugar] 70/30 100 unit/ML [milliliter] SC [subcutaneous] suspension - 2 times daily; pantoprazole [for stomach acid] 40 MG PO tablet - take 40 mg by mouth; warfarin [for blood clots] 2.5 MG PO tablet – take 1 tablet by mouth daily”. During a home visit on 1/21/2022 for patient #13, at 1:00 PM, with registered nurse J and clinical manager B, review of patient’s home medications evidenced the following medications not included in plan of care: “finasteride[for prostate] 5 MG [milligram] by mouth daily, potassium chloride [electrolyte] 20 milliequivalent by mouth twice a day, Flomax [for prostate] 0.4 MG by mouth daily, colestipol [for cholesterol] 1 gram by mouth daily, gabapentin [for nerve pain] 300 MG by mouth three times a day, and Jardiance [for diabetes] 10 MG by mouth daily”. During a home visit on 1/21/2022 with patient #13, clinical manager B, and registered nurse J , at 1:00 PM, review of patient’s home medications failed to evidence patient was taking the following medications which were listed on the plan of care: aspirin [to prevent blood clots] 240 MG by mouth daily, hydrocodone-acetaminophen [for pain] 5-325 MG by mouth every 8 hours as needed for pain, losartan [for blood pressure] 100 MG tablet by mouth daily, melatonin [for sleep] 1 MG by mouth nightly, and pantoprazole [for stomach acid] 40 MG by mouth. During home visit 1/21/2022 with patient #13, clinical manager B, and registered nurse J, at 1:00PM, review of patient’s home medications evidenced patient was taking carvedilol [for blood pressure] 6.25 MG by mouth twice a day, and glipizide [for blood sugar] 5 MG by mouth twice a day, which differed from dosage on plan of care. During an interview 1/26/2022 at 12:11 PM, administrator A indicated the plan of care medication list did not include all medications patient was taking, and plan of care should list all medications patient is taking. Clinical record review 1/21/2022 for patient #13 evidenced an agency document titled “Home Health Certification and Plan of Care” electronically signed by registered nurse J 12/26/2021. This document contained a section titled “Safety Measures” which failed to ensure bleeding precautions were in effect for a patient taking blood thinners. During interview 1/26/2022 at 12:14 PM, administrator A indicated bleeding precautions should be listed as safety measures for patients taking blood thinners. *. Clinical record review for patient #16, start of care, 12/15/2021, certification period 12/15/2021-2/12/2022, evidenced a primary diagnosis of malignant neoplasm of prostate [prostate cancer]. Record review evidenced an agency document titled “Home Health Certification and Plan of Care” electronically signed 12/10/2021 by registered nurse O, which stated, “Orders for Discipline and Treatments … PT [physical therapy] 12/16/2021 to 12/18/2021: 1 visit every week for 1 week … 12/19/2021 to 1/15/2022: 2 visits every week for 4 weeks … SN [skilled nursing] 12/15/2021 to 1/8/2022: 2 visits every week for 4 weeks”. Document failed to evidence current treatment frequency and visit schedule ordered through end of certification period 2/12/2022. Clinical record review of an untitled agency document evidenced section titled “Care Plan” which stated, “Aide … Visits …. 1 visit every week for 1 week … 1/9/2022 to 1/15/2022 … 2 visits every week for 3 weeks … 1/16/2021 to 2/5/2022 … PT … Visits … 2 visits every week for 3 weeks … 1/16/2022 to 2/5/2022 … SN … Visits … 2 visits every week for 4 weeks … 1/9/2022 to 2/5/2022”. Record review failed to evidence plan of care was updated with correct frequency and duration of visits. During an interview on 1/26/2022 at 1:02 PM, administrator A indicated the plan of care for patient #16 did not match the current frequency and duration of visits ordered. Administrator A stated the plan of care should be updated with recertification and start of care. Administrator A stated computer system didn’t automatically update plan of care with current orders.

G0590

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the agency failed to alert the physician to changes in the patient’s condition or needs that suggest the plan of care should be altered in 2 of 12 active records reviewed. (#5, #11) The findings include: *. Review of a reliable website source, the American Heart Association (www.heart.org) stated "Blood pressure categories ... Hypertension Stage 2 ... Hypertension Stage 2 is when blood pressure consistently ranges at 140/90 mm Hg [millimeters of Mercury] or higher. At this stage of high blood pressure, doctors are likely to prescribe a combination of blood pressure medications and lifestyle changes ... Your blood pressure numbers and what they mean ... Your blood pressure is recorded as two numbers: ... Systolic blood pressure (the first number) - indicates how much pressure your blood is exerting against your artery walls when the heart beats ... Diastolic blood pressure ... (the second number) - indicates how much pressure your blood is exerting against your artery walls while the heart is resting between beats ...." *. Clinical record review on 1/26/2022, for patient #5, start of care 10/22/2021, diagnosis included but was not limited to an primary hypertension (high blood pressure), evidenced an agency document titled, “SN - Home Visit" from 12/27/2021, and signed by RN [Registered Nurse] Q. This document had an area subtitled "Vitals" which stated "BP [Blood Pressure] ... 149/91 ...." Review evidenced the patient's blood pressure indicated hypertension. Review failed to evidence physician notification. Record review evidenced an agency document titled, “SN - Home Visit" from 12/31/2021, and signed by RN Q. This document had an area subtitled "Vitals" which stated "BP ... 146/92 ...." Review evidenced the patient's blood pressure indicated stage 2 hypertension. Review failed to evidence physician notification. Record review evidenced an agency document titled, “SN - Home Visit" from 1/5/2022, and signed by RN Q. This document had an area subtitled "Vitals" which stated "BP ... 148/96 ...." Review evidenced the patient's blood pressure indicated stage 2 hypertension. Review failed to evidence physician notification. Record review evidenced an agency document titled, “SN - Home Visit" from 1/7/2022, and signed by RN Q. This document had an area subtitled "Vitals" which stated "BP ... 153/94 ...." Review evidenced the patient's blood pressure indicated stage 2 hypertension. Review failed to evidence physician notification. Record review evidenced an agency document titled, “SN - Home Visit" from 1/12/2022, and signed by RN Q. This document had an area subtitled "Vitals" which stated "BP ... 148/94 ...." Review evidenced the patient's blood pressure indicated stage 2 hypertension. Review failed to evidence physician notification. Record review evidenced an agency document titled, “SN - Home Visit" from 1/19/2022, and signed by RN Q. This document had an area subtitled "Vitals" which stated "BP ... 133/98 ...." Review evidenced the patient's blood pressure indicated stage 2 hypertension. Review failed to evidence physician notification. Record review evidenced an agency document titled, “SN - Home Visit" from 1/21/2022, and signed by RN Q. This document had an area subtitled "Vitals" which stated "BP ... 146/100 ..." Another area subtitled "Actions/Narrative" stated "... discussed with the pt [patient] the need to monitor [his/her] blood pressure; requested that [he/she] start to pay more attention to [his/her] diet/salt intake; and requested that [he/she] get a blood pressure cuff for the home; pt currently does not take any medications for [his/her] blood pressure ...." Review evidenced the patient's blood pressure indicated stage 2 hypertension. Review failed to evidence physician notification. During an interview on 1/26/2021, at 11:21 AM, administrator A indicated vital sign parameters would be individualized by the patient's physician. The administrator also indicated there was not a policy for general vital sign parameter guidelines. *. Review of an agency policy obtained 1/26/2022, revised August 2021, titled “Plan of Care” stated, “E. the Plan of Care must be reviewed by the clinician and attending physician at least every 60 days and more often if the patient’s condition warrants. The clinician will promptly inform the physician of changes in the patient’s condition that indicates and alteration in the plan and the physician must agree to any changes in the plan of care … F. Effectiveness of the Plan of Care will be documented on visit notes at the time each nurse or therapist visits the patient”. *. Review of an agency policy obtained 1/26/2022, revised September 2021, titles “Wound, Ostomy and Continence Care” stated, “… The following criteria will be used to identify surgical incisions, vascular ulcers, skin tears or any other type of break in skin integrity: 1. Partial Thickness – Loss of epidermis and possible partial loss of dermis 2. Full Thickness – Tissue destruction extending through the dermis to involve the subcutaneous level and possible muscle/bone … Wound documentation is completed at every patient visit. Documentation to include: Assessment of wound, peri wound assessment, closure, drainage amount, drainage description, non-staged wound description, wound odor, wound cleansing, dressing/treatment, dressing change, dressing status at beginning of visit,, wound length – width- depth – tunneling – undermining in centimeters, describe wound margins … Wound measurements will be taken at least once a week on Mondays … or when significant wound change occurs … Wounds will be documented in the visit documentation under wounds, lines, drains, and airways”. *. During a home visit 1/20/2022 at 8:45 AM with patient #11 who had a primary diagnosis of multiple sclerosis [a nervous system disease that affects the brain and spinal cord], home health aide E, and clinical manager B, a darkened, scabbed area of skin was noted to top of patient's left foot, about the size of a quarter. Record review for patient #11, start of care 8/10/2021, evidenced an agency document titled “Home Health Certification and Plan of Care” electronically signed by registered nurse I 12/6/2021, which stated, “Orders for Discipline and Treatments … Aide: … Inspect skin for signs of pressure or irritation. Report any observed or patient reported concerns to RN [registered nurse] … Progress was made in the following areas: wounds healed … Wound Care and Measurements: none”. Record review for patient #11 evidenced an agency document titled “SN [skilled nurse]-OASIS [Home Health Outcome and Assessment Information Set] Resumption of Care” electronically signed by registered nurse J 12/25/2021, which stated, “Integumentary … Issues: dry skin, rash”. Record review failed to evidence documentation of darkened area to top of left foot and subsequent notification of physician. During an interview 1/26/2022 at 11:25 AM, administrator A stated "wounds should get documented every visit". Administrator A described a wound as any skin alterations or open areas. During an interview 1/26/2022 at 11:55 AM, administrator A indicated a scab should have been added to the plan of care, and the aide should have notified the registered nurse, "which would then trigger a skilled nurse home visit to assess patient’s skin and notify physician of changes in the patient’s status". Administrator A agreed physician should have been notified of alterations in patient #11’s skin integrity.

G0604

Integrate all orders CFR(s): 484.60(d)(2) Integrate orders from all physicians or allowed practitioners involved in the plan of care to assure the coordination of all services and interventions provided to the patient. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure coordination of all services and interventions by integrating all orders from physicians in the plan of care in 1 of 5 discharge clinical records reviewed. (#10) The findings include: Review of an agency policy obtained 1/26/2022, revised August 2021, titled “Plan of Care” stated, “Policy: … A. Every patient must have a written Plan of Care. This plan must be designed to meet the needs of the patient. The Plan of Care is developed from the physician’s orders and is developed and maintained by home care staff in consultation with the physician … B. Prior to the initial assessment visit, a verbal or written order is needed from the attending physician. This may come in the form of a referral. The clinician will complete the Plan of Care for certification and recertification of the patient. The Plan of Care must have physician approval. C. The Plan of Care must include the type of services to be provided and the frequency and duration of these services, including: 1) Disciplines and frequency & duration of visits … 2) Specific procedures & treatments, including frequency & duration … 3) Specific modalities & amount of therapy services … 4) PRN (as needed) visits with a specified number and reason … 5) Prescribed medications with dose, route, and frequency … 6) Over-the-counter medications which staff will administer and/or pour … 7) Mental status … 8) Goals & Prognosis … 9) Rehabilitation Potential …. 10) Discharge Plan … 11) Functional Limitations … 12) Activities permitted … 13) Nutritional requirements … 14) Any safety measures to protect against injury … 15) Instruction for timely discharge or referral and any other appropriate items … G. All drugs and treatments ordered by the physician will be incorporated into the Plan of Care. All other drugs and treatments observed by the nurse on assessment will also be incorporated into the Plan of Care”. Clinical record review on 1/24/2022 for patient #10, start of care 9/23/2021, certification period 9/23/2021 - 11/21/2021, discharged 10/28/2021, evidenced a primary diagnosis of multiple sclerosis (exacerbation), [a nervous system disease that affects the brain and spinal cord]. Clinical record review for patient #10 evidenced an untitled agency document, which stated, “Episode Referral … Referral Instructions … Notes copied from referral order (MD [medical doctor] D 9/22/2021): Please evaluate for admission to Home health … Disciplines requested: PT [physical therapy]/OT [occupational therapy]/RN [registered nurse]/Aide …”. Clinical record review for patient #10 evidenced an agency document titled “Home Health Certification and Plan of Care” for certification period 9/23/2021 - 10/28/2021, electronically signed by registered nurse L on 9/30/2021, and medical doctor D on 9/23/2021, which stated, “Face to Face Attestation … Medically necessary services you are ordering: Skilled Nursing, Physical Therapy, Occupational Therapy and Home health tech …”. Document failed to evidence physical therapy, occupational therapy, or home health aide services were ordered or provided to patient by home health agency as ordered by medical doctor D. During an interview 1/26/2022 at 1:26 PM, administrator A indicated QA [quality assurance] C, case manager, or registered nurse on patient #10’s case should have reviewed the referral order from the physician and made sure the plan of care integrated all requested services including physical therapy, occupational therapy, and home health aide. 17-12-2(h)

G0608

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to coordinate care delivery to meet the patient’s needs and involve the patient in coordination of care activities in 3 of 5 discharged clinical records reviewed. (#7, #9, #10) The findings include: *. Clinical record review on 1/26/2022, for patient #7, start of care 11/20/2021, diagnoses include but were not limited to sepsis [potentially life-threatening infection], pneumonia [infection that inflames one or both lungs, and may be filled with fluid], evidenced an agency document titled, “SN – OASIS Transfer w/o [without] DC [discharge]” which was signed by RN R on 12/16/2021. Review of the clinical record evidenced the patient went to the emergency department (ED) on 12/12/2021, and was placed on an observation status until 12/15/2021, when Entity I placed the patient on an inpatient status. Record review of an agency document titled “Case Communication” from 12/21/2021, and signed by RN R. This document had an area subtitled “Communication Notes” which stated “Topic discussed: Re-admission inpatient hospitalization … Communication details: Patient was discharged from [Entity I] on 12-17-21. Methodist HHC [home health care] received a ROC [resumption of care]/order on 12-20-21. Patient re-admitted to [Entity I] ED Inpatient on 12-21-21 with shock, sepsis, hypotension [low blood pressure], and possible pneumonia ….” Review evidenced the patient was discharged from Entity I on 12/27/2021. Review of the clinical record failed to evidence a discharge summary. Review failed to evidence the disposition of the patient. Review failed to evidence Entity I or the patient’s physician received a discharge summary of the patient’s pertinent information. During an interview on 1/26/2022, at 11:33 AM, administrator A indicated if a patient was transferred as "Transfer without discharge" without a ROC, the case manager would discharge when they find out the patient would not come back or is placed at another agency/facility. *. Clinical record review on 1/26/2022, for patient #9, start of care 10/14/2021, primary diagnosis post total knee replacement evidenced an agency document titled, “Home Health Certification and Plan of Care” for certification period 11/19/2021 – 1/17/2022, which was electronically signed by the physician on 10/13/2021. Record review of an agency document titled “Case Communication” from 11/27/2021, and signed by RN I. This document had an area subtitled “Communication Notes” which stated “Communication details: On-call service called to report that the patient was admitted into hospice for further care ….” Review of this document evidenced the patient was transferred to hospice services on 11/27/2021. Record review of an agency document titled "SN - OASIS Discharge" which was signed by RN P on 12/6/2021. This document had an area subtitled "Actions/Narrative" that stated "SN received message patient transferred to Hospice care and to discharge from Methodist home care service.... " Review of this document evidenced the patient was discharged on 12/6/2021. Review evidenced the patient was discharged from the home health agency 10 days after transfer to Hospice care. Review failed to evidence the hospice agency received a discharge summary within 48 hours as required. Review failed to evidence care coordination was conducted with the receiving agency to meet the needs of the patient. *. During an interview on 1/26/2022, at 11:30 AM, administrator A indicated the process to follow a patient admitted to the ED consisted of the case manager following up to either schedule a ROC assessment or if the patient would be admitted to the hospital as an inpatient status. An agency policy obtained 1/26/2022, revised August 2021, titled “Plan of Care” stated, “…J. The patient will be informed in advance of any changes in the Plan of Care before the change is made. The patient has the right to participate in planning the care or treatment in advance of such care”. An agency policy titled “Therapists/MSW Responsibilities” obtained 1/26/2022, revised July 2021, stated, “Policy: … Patients will be admitted to therapy (physical therapy, occupational therapy, speech therapy) and Medical Social Work service by written referral from licensed physicians … All patients will be evaluated and will be accepted for home care if there is potential for progress. Treatment will be discontinued when functional goals are met”. Clinical record review on 1/24/2022 for patient #10, start of care 9/23/2021, evidenced a primary diagnosis of multiple sclerosis (exacerbation), [a nervous system disease that affects the brain and spinal cord]. Record review on 1/24/2022 for patient #10 evidenced an agency document titled “SN [skilled nurse] - OASIS [Home Health Outcome and Assessment Information Set] Resumption of Care” electronically signed by registered nurse L on 10/7/2021. This document stated, “Lying to sitting on Side of Bed: … Discharge Goal … Setup or clean-up assistance … Sit to Stand: … Discharge Goal … Supervision or touching assistance … Chair/Bed-to-chair Transfer: … Discharge Goal … Supervision or touching assistance”. Record review on 1/24/2022 for patient #10 evidenced an agency document titled “PT [physical therapy] – Initial Evaluation” electronically signed by PT [physical therapist] M on 10/8/2021. A section titled “Actions/Narrative” stated, “Patient was seen today for initial evaluation. Patient was sitting at edge of bed with mom present. Patient stated unable to get into motorized wheelchair as mom don’t know how to use it [SIC] … muscle strength in RLE [right lower extremity] is poor – as patient is unable to move it at all. Performed therapy exercises in form of passive range of motion for both lower extremities. Patient transferred from bed to wheelchair using Hoyer lift … Discharge patient as patient is at max rehab [rehabilitation] at this time.” Document failed to evidence that goals of care plan were met. Review failed to evidence if patient agreed to physical therapy discharge plan and if physician was notified. Record review on 1/24/2022 evidenced an agency document titled “Case Communication” electronically signed by registered nurse L on 10/28/2021, which stated, “Patient requested to be re-evaluated by PT, patient stated she feels like her first PT evaluation wasn’t correct. Writer placed PT order at this time. Writer educated patient on multiple sclerosis signs and symptoms and progression of disorder. Patient stated she understands, but she was ambulating before she got Covid.” Record review failed to evidence the agency had coordinated therapy services to meet patient needs. Record review 1/24/2022 evidenced an agency document titled “Case Communication” electronically signed by registered nurse L on 11/17/2021, which stated, “Spoke with patient mother, informed that patient is in an inpatient rehab [rehabilitation] ... Patient discharged from home health services.”. Record review failed to evidence patient had been involved in care coordination of care to meet needs and goals. During an interview on 1/26/2022 at 1:29PM, administrator A stated, “the physical therapist should have included a re-evaluation in the initial therapy evaluation since patient had just gotten out of the hospital and could have been weaker because of acute illness.” Agency failed to coordinate physical therapy services and include the patient in coordination of care. Agency failed to accurately document patient’s potential for rehabilitation progress.

G0614

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the home health agency failed to ensure every patient was provided with the required written visit schedule consistent with the patient's plan of care for 7 of 7 patients for which a home visit was conducted. (#1, #2, #3, #11, #12, #13, #14) The findings include: *. During a home visit 1/20/2022 at 9:00 AM with patient #11, home health aide E, and clinical manager B, review of patient’s home folder failed to evidence a visit schedule. *. During a home visit 1/20/2022 at 1:00 PM with patient #12, physical therapist K, and clinical manager B, review of patient’s home folder failed to evidence a visit schedule. *. During a home visit on 1/21/2022 at 1:00 PM with patient #13, registered nurse J, and clinical manager B, review of patient’s home instructions failed to evidence a visit schedule. *. During a home visit 1/21/2022 at 2:15 PM with patient #14, registered nurse J, and clinical manager B, review of patient’s home folder failed to evidence a visit schedule. *. During an interview 1/26/2022 at 11:51 AM, administrator A stated the staff should be updating a white board with visit schedule. Administrator A agreed patients were not provided visit schedules. 1. Record review of an agency policy titled “Patient Rights & Responsibilities” revised August 2021, stated, “Policy: To inform the patient/ legal representative, in writing, of his/her rights as a patient of Home Care in advance of furnishing care, and ensure Home Care personnel promote and protect the patient’s rights while providing service … A. A written Statement of Rights and Responsibilities will be given to each patient/representative during the Initial Assessment Visit, which outlines the patient’s regarding services performed by Home Care. Patients must be notified in writing of their rights and obligations in advance of furnishing care ... 2) Information regarding Plan of Treatment as authorized by the physician, opportunity to participate in developing the Plan, the right to refuse treatment, the right to make informed decisions about their care ... 6) Notice of the disciplines that will be providing services and proposed frequency of visits ... E. The patient will be supplied with a copy of their current plan of care ... M. Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to: ... The disciplines that will furnish the care ... The frequency of visits …." 2. During an observation of a home visit on 1/21/2022, at 12:33 PM, for patient #1, start of care 10/21/2021, with Registered Nurse (RN) I to observe care. At 12:56 PM, failed to evidence a visit schedule written for skilled nurse (SN) services. Review failed to evidence a visit schedule to include the frequencies of every discipline providing services in to the patient. Review failed to evidence the patient had the required written visit schedule in the patient's home. During an interview on 1/21/2022, 12:54 PM, person F indicated staff has a basic set schedule and will call the day before a visit and adjust times/days as needed. 3. During an observation of a home visit on 1/21/2022, at 2:32 PM, for patient #2, start of care 7/14/2020, with RN Q to observe routine wound care provided by the skilled nurse. At 2:51 PM, the patient's home folder was reviewed. Review failed to evidence a visit schedule to include the frequencies of the skilled nurse. Review failed to evidence the patient had the required written visit schedule in the patient's home. During an interview on 1/21/2022, 2:56 PM, person G indicated staff will contact person H for visits, but there is pretty much an ongoing set schedule. 4. During an observation of a home visit on 1/25/2022, at 2:59 PM, for patient #3, start of care 12/28/2022, with Occupational Therapist (OT) D to observe a routine occupational therapy session. At 3:42 PM, the patient's home folder was reviewed. Review failed to evidence a visit schedule for OT services. Review failed to evidence a visit schedule to include the frequencies of every discipline providing services in to the patient. Review failed to evidence the patient had the required written visit schedule in the patient's home. During an interview on 1/25/2022, 3:39 PM, person A indicated staff will call or text message the day before a visit. Person A also indicated the visit schedule is usually the same, unless there are doctor appointments that interfere.

G0616

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 agency failed to ensure patients written instructions provided to patient's included all medication instructions including medication name, dosage, and frequency of administration for 6 of 7 patients where a home visit was conducted. (#2, #3, #11, #12, #13, #16) The findings include: *. Review of an agency policy obtained 1/26/2022, revised August 2021, titled “Medication Administration and Oversight” stated, “Policy: … A. … The clinical record must contain physician orders for all medications prescribed for the patient … B. Medications orders: 1) Orders must include the drug name (generic or trade name), dose, route, and frequency of administration … 4) All PRN [as needed] medication orders must specify the purpose for the medication’s use … 11) The clinician will inform the physician of any concerns related to medications and will document any physician contact or orders … C) Staff will teach the patient and/or caregiver and document the following in the clinical record: 1) Name and description of medication including any medication dosage change or newly prescribed medication … F) …. If a verbal order is taken for a new medication or medication dosage changed, there needs to be a computer check of possible interactions. The Case Manager will notify the physician as applicable”. *. During a home visit 1/20/2022 at 8:45 AM with patient #11, primary diagnosis of multiple sclerosis [a nervous system disease that affects the brain and spinal cord], home health aide E, and clinical manager B, person B provided patient #11’s home medications for review. Review of patient’s home medications evidenced baclofen [for muscle spasms] 10 MG [milligram] tablets, take 3 tablets by mouth 2 times a day; oxybutynin [for urinary incontinence] 5 MG by mouth daily; and Methenamine Hippurate [for urinary tract infection] 1 G [gram] by mouth 2 times daily. During home visit with patient #11, a document was observed in the home folder, which was titled “Outpatient Medications on the Plan of Care” and stated, “baclofen [for muscle spasms] 10 MG [milligram] tablets, take 1 tablet by mouth 2 times daily… bisacodyl [for constipation] 10 MG by mouth daily … Calcium-Vitamin D-Vitamin K [for osteoporosis] 2 tablets by mouth 2 times daily … Enoxaparin Sodium [for blood clots] inject 0.4 milliliters in the skin daily … linaclotide [for constipation] 145 MCG [micrograms] by mouth as needed for constipation … lisinopril [for blood pressure] 20 MG by mouth daily … nystatin powder [for skin infection] 100,000 G [gram] topically 2 times daily to bilateral breasts and groin, sacrum, and peri area … oxybutynin [for urinary incontinence] 5 MG by mouth daily … Probiotic Product [for digestion] take 1 capsule by mouth daily … rifaximin [antibiotic] 550 MG by mouth twice daily … Triamcinolone Acetonide [for skin rash] 1 applicator topically two times daily near skin folds”. Observation failed to evidence that medication list provided to patient was accurate and included all medications patient was taking. During an interview 1/26/2022 at 11:53 AM, administrator A indicated home medication list should be a complete and accurate list of medications patient is currently taking. Administrator A agreed patient #11’s medication list was inaccurate and should have been updated by the nurse. *. During a home visit 1/20/2022 at 1:00 PM with physical therapist K, clinical manager B, and patient #12 who had a primary diagnosis of encounter for other orthopedic aftercare [care after hip surgery], the patient’s home folder was reviewed, which evidenced a document titled “Outpatient Medications on the Plan of Care” which stated, “Calcium Carb-Cholecalciferol [for calcium and vitamin D levels] 600 tablets by mouth once daily … lisinopril-hydrochlorothiazide [for blood pressure] 10-12.5 MG [milligram] 1 tablet by mouth as needed”. Document failed to evidence correct dosage of Calcium Carb-Cholecalciferol. Document failed to evidence indication for taking lisinopril-hydrochlorothiazide as needed. During an interview on 1/26/2022 at 11:27 AM, administrator A stated, “a complete medication order includes medication name, dose, route, frequency, and PRN [as needed] orders should include the indication”. Administrator A agreed patient #12’s lisinopril-hydrochlorothiazide order was incomplete without the indication. During an interview 1/26/2022 at 12:06 PM, administrator A stated the Calcium Carb-Cholecalciferol dosage of 600 tablets was incorrect and was entered in error. *. Clinical record review on 1/21/2022 for patient #13, start of care 12/26/2021, evidenced a primary diagnosis of pleural effusion [A buildup of fluid between the tissues that line the lungs and the chest]. Record review evidenced an unsigned agency document titled “Outpatient Medications on the Plan of Care” which listed the following medications: “aspirin [to prevent blood clots] 81 MG [milligram] chewable tablet - take 240 MG by mouth daily; bumetanide [for swelling] 2 MG PO [by mouth] tablet; carvedilol [for blood pressure] 25 MG tablet - take one tablet by mouth twice daily with meals; glipizide [for blood sugar] 10 MG tablet - take 10 MG by mouth 2 times daily before meals; hydrocodone-acetaminophen [for pain] 5-325 MG per tablet - take 1 tablet by mouth every 8 hours as needed for pain; losartan [for blood pressure] 100 MG tablet - take one tablet by mouth once daily; lovastatin [for cholesterol] 40 MG PO tablet - take 40 MG by mouth nightly; Melatonin [for sleep] 1 MG capsule - take 1 tablet by mouth nightly x1; metolazone [for swelling] 2.5 MG PO tablet - take 2.5 MG by mouth; Novolin [for blood sugar] 70/30 100 unit/ML [milliliter] SC [subcutaneous] suspension - 2 times daily; pantoprazole [for stomach acid] 40 MG PO tablet - take 40 mg by mouth; warfarin [for blood clots] 2.5 MG PO tablet – take 1 tablet by mouth daily”. Record review failed to evidence frequency of medication administration for bumetanide, metolazone, and pantoprazole. During a home visit on 1/21/2022 for patient #13, at 1:00 PM, with registered nurse J and clinical manager B, review of patient’s home medications evidenced the following medications not included in medication list: “finasteride[for prostate] 5 MG [milligram] by mouth daily, potassium chloride [electrolyte] 20 milliequivalent by mouth twice a day, Flomax [for prostate] 0.4 MG by mouth daily, colestipol [for cholesterol] 1 gram by mouth daily, gabapentin [for nerve pain] 300 MG by mouth three times a day, and Jardiance [for diabetes] 10 MG by mouth daily”. During a home visit on 1/21/2022 with patient #13, clinical manager B, and registered nurse J , at 1:00 PM, review of patient’s home medications failed to evidence patient was taking the following medications which were listed on the medication list: aspirin [to prevent blood clots] 240 MG by mouth daily, hydrocodone-acetaminophen [for pain] 5-325 MG by mouth every 8 hours as needed for pain, losartan [for blood pressure] 100 MG tablet by mouth daily, melatonin [for sleep] 1 MG by mouth nightly, and pantoprazole [for stomach acid] 40 MG by mouth. During home visit 1/21/2022 with patient #13, clinical manager B, and registered nurse J, at 1:00PM, review of patient’s home medications evidenced patient was taking carvedilol [for blood pressure] 6.25 MG by mouth twice a day, and glipizide [for blood sugar] 5 MG by mouth twice a day, which differed from dosage on medication list. Registered nurse J did not update patient’s home medications during home visit. During an interview 1/26/2022 at 11:27 AM, administrator A stated, “a complete medication order includes medication name, dose, route, frequency, and PRN [as needed] orders should include the indication”. Administrator A stated regarding keeping medication list up to date, “the nurse looks at each bottle, each medication, and checks the order with what is listed in the medication list and adds any new medication to the medication list”. Administrator A indicated the nurse should review patient’s medications each visit. Administrator A indicated patient #13’s medication list was inaccurate and incomplete. *. Clinical record review on 1/25/2022 for patient #16 evidenced a primary diagnosis of malignant neoplasm of prostate [prostate cancer]. Review evidenced an untitled agency document which stated, “Outpatient Current Medications as of 1/26/2022 … tramadol [for pain] 50 MG [milligrams] PO [by mouth] tablet …. Take 50 MG by mouth every 6 hours as needed”. Record review failed to ensure PRN [as needed] medication order included a purpose for taking the medication. During an interview on 1/26/2022 at 11:27 AM, administrator A stated, “a complete medication order includes medication name, dose, route, frequency, and PRN [as needed] orders should include the indication”. Administrator A agreed patient #16’s medication order was incorrect without the indication. 1. Record review of an agency policy titled “Patient Rights & Responsibilities” revised August 2021, stated, “Policy: To inform the patient/ legal representative, in writing, of his/her rights as a patient of Home Care in advance of furnishing care, and ensure Home Care personnel promote and protect the patient’s rights while providing service … A. A written Statement of Rights and Responsibilities will be given to each patient/representative during the Initial Assessment Visit, which outlines the patient’s regarding services performed by Home Care. Patients must be notified in writing of their rights and obligations in advance of furnishing care ... 2) Information regarding Plan of Treatment as authorized by the physician, opportunity to participate in developing the Plan, the right to refuse treatment, the right to make informed decisions about their care ... E. The patient will be supplied with a copy of their current plan of care ... M. Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to: ...The care to be furnished based on the comprehensive assessment …. " *. During an observation of a home visit on 1/21/2022, at 2:32 PM, for patient #2, start of care 7/14/2020, with RN Q to observe routine wound care provided by the skilled nurse. At 2:51 PM, the patient's home folder was reviewed for required information provided by the home health agency. Review failed to evidence a required medication schedule in the patient's home to include but not limited to the name, dosage, and route. *. During an observation of a home visit on 1/25/2022, at 2:59 PM, for patient #3, start of care 12/28/2022, with Occupational Therapist (OT) D to observe a routine occupational therapy session. At 3:42 PM, the patient's home folder was reviewed for the required provided information by the home health agency. Review failed to evidence the required medication schedule in the patient's home to include but not limited to the name, dosage, and route.

G0618

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 and interview, the home health agency failed to ensure a copy of ordered therapy and treatments furnished by the agency was kept in every patients home for 2 of 7 patient home visits. (#3, #11) The findings include: *. During a home visit 1/20/2022 at 9:00 AM with patient #11, home health aide E, and clinical manager B, review of patient’s home folder failed to evidence current plan of care, including treatments to be administered. During an interview 1/26/2022 at 11:54 AM, administrator A indicated patient's should have the most up to date plan of care in their homes. 1. Record review of an agency policy titled “Patient Rights & Responsibilities” revised August 2021, stated, “Policy: To inform the patient/ legal representative, in writing, of his/her rights as a patient of Home Care in advance of furnishing care, and ensure Home Care personnel promote and protect the patient’s rights while providing service … A. A written Statement of Rights and Responsibilities will be given to each patient/representative during the Initial Assessment Visit, which outlines the patient’s regarding services performed by Home Care. Patients must be notified in writing of their rights and obligations in advance of furnishing care ... 2) Information regarding Plan of Treatment as authorized by the physician, opportunity to participate in developing the Plan, the right to refuse treatment, the right to make informed decisions about their care ... 6) Notice of the disciplines that will be providing services and proposed frequency of visits ... E. The patient will be supplied with a copy of their current plan of care ... M. Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to: ... The care to be furnished, based on the comprehensive assessment ... Establishing and revising the Plan of Care ... The disciplines that will furnish the care ... The frequency of visits …." *. During an observation of a home visit on 1/25/2022, at 2:59 PM, for patient #3, start of care 12/28/2022, with Occupational Therapist (OT) D to observe a routine occupational therapy session. At 3:42 PM, the patient's home folder was reviewed for the required provided information by the home health agency. Review failed to evidence the required plan of care or copy of ordered therapies and treatments in the patient's home.

G0710

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 observation, record review and interview the agency failed to ensure services were provided as ordered in the plan of care in 7 of 12 active clinical records reviewed. (#1, #2, #5, #11, #12, #13, #17) The findings include: *. Clinical record review on 1/26/2022, for patient #2, start of care 7/14/2020, diagnosis includes but not limited to a pressure ulcer of the sacral (region of the sacrum; a flat triangular bone in the lower back formed from fused vertebrae and sits between two hip bones) region, evidenced an agency document titled, “Home Health Certification and Plan of Care” for certification period 1/5/2022 – 3/5/2022, which was electronically signed by the physician on 1/18/2022. This document had an area subtitled “21. Orders for Discipline and Treatments (Specify Amount/Frequency/Duration)” that stated "... Infection Prevention - Catheter ... Instruct in urinary tract prevention infection ... Learning/Teaching Needs ... SN [skilled nurse] to visit to teach patient/caregiver in care of urethral catheter ...." Record review of agency documents titled "SN - Visit Note" signed by RN (Registered Nurse) Q failed to evidence documentation of foley catheter care and patient/caregiver education for the following dates: 1/7/2022, 1/10/2022, and 1/14/2022. Review failed to evidence the SN provided all services in the plan of care as ordered by the physician. *. Clinical record review on 1/26/2022, for patient #1, start of care 10/21/2021, diagnoses include but were not limited to a non-pressure ulcer of the left foot and chronic kidney disease (CKD, an incurable condition where the kidneys deteriorate and lose the function of eliminating wastes in the body), evidenced an agency document titled, “Home Health Certification and Plan of Care” for certification period 12/20/2021 – 2/17/2022, which was electronically signed by the physician on 1/19/2022. This document had an area subtitled “21. Orders for Discipline and Treatments (Specify Amount/Frequency/Duration)” that stated "... Aide: ... Aide catheter care ... Cleanse skin and catheter tubing with soap and water ... SN ... Infection Prevention - Catheter ... Instruct in urinary tract infection prevention ... SN to visit to teach patient/caregiver in care of urethral catheter ...." Review evidenced the patient has a foley catheter in place for bladder elimination. Record review of an agency document titled, "SN - Visit Note" from 1/12/2022, and signed by RN I. This document had an area subtitled "LDA [lines, drains, airway] and Wound Assessment" which failed to evidence documentation for an assessment of the foley catheter. Review failed to evidence instruction, demonstration and/or teaching provided at every visit. Review failed to evidence the SN provided all services in the plan of care as ordered by the physician. *. During an interview on 1/26/2022, at 11:19 AM, administrator A indicated if a patient had foley catheter, the SN should assess every visit, including but not limited to color, site, drainage, and patency. *. Clinical record review on 1/26/2022, for patient #5, start of care 10/22/2021, diagnoses include but were not limited to an unspecified open wound of the right and left arms, evidenced an agency document titled, “Home Health Certification and Plan of Care” for certification period 12/21/2021 – 2/18/2022, which was electronically signed by the physician on 12/20/2021. This document had an area subtitled “21. Orders for Discipline and Treatments (Specify Amount/Frequency/Duration)” that stated "... Wound Care Therapy ... Cleanse wound to the RIGHT AXILLARY [underarm] with peroxide; pat dry; apply bactroban [antibiotic to treat skin infections] ointment to the wound bed; cover with dry dressing.....change dressing 3x [times] weekly ... Cleanse wound to the LEFT AXILLARY with peroxide; pat dry; apply bactroban ointment to the wound bed; cover with dry dressing.....change dressing 3x [times] weekly ...." Record review of agency documents titled "SN - Visit Note" which were signed by RN Q. These documents failed to evidence documentation of wound care for the right and left axillaries on 12/31/2021 and 1/12/2022. *. Review of an agency policy obtained 1/26/2022, revised August 2021, titled “Plan of Care” stated, “K. Staff providing services under arrangement or contract must participate in the development of the Plan of Care, deliver services according to the Plan, and notify the physician of any changes in the patient’s condition, per home care policy”. *. Review of agency’s physical therapist job description, obtained 1/20/2022, evidenced a section titled “Principal Duties and Responsibilities (Essential Functions)” which stated, “Evaluates patients muscle strength, ROM [range of motion], endurance, balance, pain, skin integrity and overall function level”. *. Clinical record review for patient #11, start of care 8/10/2021, evidenced a primary diagnosis of multiple sclerosis [a nervous system disease that affects the brain and spinal cord]. Clinical record review for patient #11 evidenced an untitled agency document which stated, “Care Plan … Aide … Visits: … 3 visits every week for 8 weeks-12/12/2021 to 2/5/2022, 1 visit every week for 1 week-1/2/2022 to 1/8/2022, 2 visits every week for 4 weeks-1/9/2022 to 2/5/2022”. Clinical record review for patient #11, evidenced an agency document titled “Home Health Certification and Plan of Care” electronically signed by registered nurse I 12/6/2021, which stated, “Orders for Discipline and Treatments … Aide: …12/12/2021 to 2/5/2022: 3 visits every week for 8 weeks”. During an home visit for patient #11 1/20/2022 at 9:00 AM, person B stated that patient #11 was supposed to get 3 aide visits a week, but "the home health agency changed aide visit frequency to 2 visits a week due to short staffing", even when patient #11 and caregiver did not want to decrease visit frequency. Person B stated patient #11 needed 3 aide visits a week. During an interview 1/18/2022 at 9:38 AM, administrator A stated, "due to having only 1 home health aide", the agency had called each patient and cut visits from 3 times a week to 1 or 2 times a week when possible and held off on taking referrals if the agency couldn’t handle the additional patients. During an interview 1/26/2022 at 11:50 AM, administrator A stated the agency had increased patient #11’s visits to 3 times a week again after home visit. *. Clinical record review on 1/20/2022 for patient #12, start of care 1/11/2022, evidenced a primary diagnosis of encounter for other orthopedic aftercare [care after hip surgery]. Record review for patient #12 evidenced an agency document titled “Home Health Certification and Plan of Care” which stated, “Orders for Discipline and Treatments … PT [physical therapy]: … Each Visit … Assess patient’s incision at every visit and document on the WLDA [wounds, lines, drains, and airways] … Measure incision weekly and document on the WLDA”. Record review for patient #12 evidenced an untitled agency document which stated, “Wound Assessment … Incision Hip Lateral; Right”. This document failed to evidence any incision measurements during home visits on 1/11/2022, 1/13/2022, 1/15/2022, 1/18/2022, and 1/19/2022. During a home visit 1/20/2022 with patient #12, physical therapist K, and clinical manager B, at 1:00 PM, physical therapist K failed to assess and measure patient’s incision. During an interview on 1/26/2022 at 12:10 PM, administrator A indicated the physical therapist is responsible for assessing patient #12’s incision every visit. Administrator A agreed physical therapist had not documented measurement of incision weekly as ordered. *. Clinical record review on 1/21/2022 for patient #13 evidenced a primary diagnosis of pleural effusion [a buildup of fluid between the tissues that line the lungs and the chest]. Record review for patient #13 evidenced an agency document titled “Home Health Certification and Plan of Care” which stated, “Orders for Discipline and Treatments SN[skilled nurse]: … Document the drainage volume and character …Drain Pleurx Catheter frequency TWO TIMES WEEKLY”. Record review on 1/21/2022 for patient #13 evidenced an agency document titled “SN [skilled nurse] -Home Visit” electronically signed by registered nurse J 1/11/2022. This document stated, “Additional Narrative … Patient seen for visit … Pleurx drained per MD’s orders and dressing change provided patient tolerated well”. Record review failed to evidence documentation of volume or characteristics of pleural fluid drained during visit on 1/11/2022. During an interview 1/26/2022 at 12:17 PM, administrator A stated "Pleurx catheter should have been drained every visit, and documented the volume, color, and catheter site assessment”. Administrator A agreed the nurse had not documented this information. *. Clinical record review for patient #17, start of care 4/27/20, evidenced a primary diagnosis of neuromuscular dysfunction of bladder [when a person lacks bladder control due to brain, spinal cord or nerve problems]. Clinical record review for patient #17 evidenced an agency document titled “Home Health Certification and Plan of Care” electronically signed by registered nurse I on 12/14/2021. This document stated, “Orders for Discipline and Treatments: … Change catheter … Perform latex change every month using 16 French cath [catheter] with 5ml [milliliter] balloon”. Record review evidenced an untitled agency document which indicated patient had a Foley catheter placed 10/15/2021 by registered nurse I, and was removed 12/1/2021 by registered nurse I. Document indicated that there were 47 days between catheter changes. Agency failed to ensure patient #17 received catheter change monthly as ordered in plan of care. During an interview on 1/26/2022 at 1:16 PM, administrator A indicated plan of care orders should be followed, and patient #17’s Foley catheter should have been changed before 47 days.

G0716

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the home health agency failed to ensure all skilled professional prepared clinical documentation with accurate patient information for 1 of 4 patients observed during a skilled nurse visit, from a total of 12 active records reviewed. (#2) The findings include: Record review of an agency policy titled "Clinical Records - Documentation" revised July 2021, stated "Policy: To establish guidelines for documentation in the clinical record that complies with professional standards and federal, state, and local laws. To present a true and accurate picture of the patient's status and the care provided ... Clinical Documentation: It is the responsibility of all authorized disciplines (RN's [registered nurse's] ...) to document accurately on patient charts and records, on each visit to the home and include all pertinent information regarding patient care, treatment, and progress ... 2. A clinical or visit note is to be used to document a contact with a patient that is written and dated by a clinician, and describes signs and symptoms, treatment and drugs administered ...." Clinical record review on 1/26/2022, for patient #2, start of care 7/14/2020, diagnosis includes but not limited to a pressure ulcer of the sacral (region of the sacrum; a large, flat triangular bone in the lower back formed from fused vertebrae and sits between two hip bones) region, evidenced an agency document titled, “Home Health Certification and Plan of Care” for certification period 1/5/2022 – 3/5/2022, which was electronically signed by the physician on 1/18/2022. This document had an area subtitled “21. Orders for Discipline and Treatments (Specify Amount/Frequency/Duration)” that stated "SN [skilled nurse]: ... Wound Care Therapy ... Instruct wound care ... Sacrum: Cleanse with Normal Saline, apply opticell [an absorbent dressing with gelling fibers to protect the wound from damaged or infected tissue] to wound bed, cover with dry dressing or foam dressing 3x [times] weekly ...." During an observation of a home visit on 1/21/2022, RN [Registered Nurse] Q performed routine wound care for patient #2. At 2:45 PM, RN Q turned the patient to their left side, pulled down the patient's brief, and removed a soiled dressing from the patients sacral area. The wound appeared about a dime sized, beefy red, surrounded by a few inches of pink skin in diameter. RN Q changed the sacral wound dressing as ordered in the plan of care; cleansed with normal saline, patted dry, removed soiled gloves, sanitized hands, donned new gloves, and applied dressing to sacral area. Record review of agency documents titled "SN - Home Visit" signed by RN [Registered Nurse] Q, evidenced an area subtitled "LDA and Wound Assessment." This section evidenced the wound care being documented under "Pressure Ulcer ... Coccyx [tailbone; small triangular bone at the base of the spinal column] ...." for the following dates: 1/7/2022, 1/10/2022, 1/14/2022, 1/17/2022, and 1/21/2022. Review evidenced an order for wound care to the sacral area. Review evidenced documentation of wound care to the coccyx. Review failed to evidence documentation of sacral wound care as ordered on the plan of care. Review failed to evidence the skilled nurse documented to present a true and accurate picture of the patient's status per agency policy. During an interview on 1/26/2022, at 11:20 AM, clinical manager B indicated the sacrum is located above (superior) to the coccyx. During an interview at 1/26/2022, at 11:44 AM, administrator A indicated the order was for wound care to the sacrum, documentation should also indicate care was provided to the sacrum. 17-14-1(a)(1)(E)

G0768

Competency evaluation CFR(s): 484.80(c)(1)(2)(3) Standard: Competency evaluation. An individual may furnish home health services on behalf of an HHA only after that individual has successfully completed a competency evaluation program as described in this section. (1) The competency evaluation must address each of the subjects listed in paragraph (b)(3) of this section. Subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section must be evaluated by observing an aide's performance of the task with a patient or pseudo-patient. The remaining subject areas may be evaluated through written examination, oral examination, or after observation of a home health aide with a patient, or with a pseudo-patient as part of a simulation. (2) A home health aide competency evaluation program may be offered by any organization, except as specified in paragraph (f) of this section. (3) The competency evaluation must be performed by a registered nurse in consultation with other skilled professionals, as appropriate. This STANDARD is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure every home health aide (HHA) had an annual competency evaluation as described in the agency’s policy for 2 of 2 HHA personnel records reviewed. (HHA E, HHA F) The findings include: 1. Record review of an agency policy titled, “Home Health Tech Training & Evaluation” revised October 2021, stated “I. Policy: to develop and implement an ongoing training program for Home Health Techs (HHT) that fulfills the requirements specified in the Conditions of Participation and ensures that individuals who perform home health tech duties meet the competency requirements ... A. The Home Health Tech Must meet the personnel qualifications as defined in the Medicare Conditions of Participation (484.4) … Competency will be verified at the time of hire through a written and practical test ... C. Competency Evaluation: The qualified instructor will evaluate a Home Health Tech’s competency initially at the time of hire, and annually thereafter, and will observe performance of at least: 1) reading and recording temperature, pulse, respirations, & blood pressure … 2) appropriate & safe techniques in personal hygiene … 3) safe transfer techniques and ambulation … 4) normal range of motion and positioning … 5) other areas through written or oral examination or observation ... G. Ongoing Education: All Home Health Techs will receive no less than twelve (12) hours of mandatory in service training within a 12 month period. Compliance monitoring will be done on a quarterly basis. The in-service may occur while an HHT is furnishing care to patients … H. Home Health Tech will be evaluated on an annual basis reflecting practical skills, documentation, communication techniques and reliability. The annual review will be conducted per home health policy ….” 2. Record review of an agency policy titled “Continuing Education & Meetings” revised August 2021, stated, “Policy: To encourage each staff member to keep updated in his or her skills and knowledge base and to remain informed about issues in the department in which they work … B. The Methodist Hospitals will provide various educational opportunities to enhance professional practice. Home Health Techs will be provided with 12 hours of education yearly within the department … E. Requirements are as follows: … 3) Annual Mandatory Hospital Competencies ….” 3. Record review of an agency policy titled, “Home Health Tech Competency & Supervision” revised August 2021, stated “I. Policy: To ensure the Home Health Tech (HHT) is competent in skills and performance provides care according to the assignment, homecare standards, rules, and regulations ... C. Documentation of competency will be maintained in the personnel file. Competency through supervisory home visits will be evaluated as part of the annual performance review. Review will include status of practical skills, documentation, communication techniques, and reliability … E. An orientation program is provided to inform HHT’s of the expectations and responsibilities detailed in their job descriptions. Orientation will include: 1) ongoing education requirements ….” 4. Personnel record review on 1/19/2022, for Home Health Aide (HHA) F, evidenced a start date of 9/16/2019, and a document titled, "HHT In-Service Education 2019" which was unsigned and undated. Review failed to evidence HHA F received the 12 hours of in-service training for 2020 and 2021, that discussed the required subjects per the agency policy. 5. Personnel record review on 1/19/2022, for HHA E, evidenced a start date f 10/15/2001. Record review failed to evidence of documentation for the required in-service and competency training. Review failed to evidence HHA E received the 12 hours of in-service training for 2020 and 2021, that discussed the required subjects per the agency policy. 6. During an interview on 1/19/2022, at 2:16 PM, administrator A indicated since the beginning of the Covid-19 pandemic, staffing had been difficult and was unable to bring the home health aides in to the office of in-service training. 17-14-1(l)(1)(A)

G1022

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, agency failed to send transfer summaries within two business days of becoming aware of planned transfer and failed to complete and send discharge summaries in 3 of 5 discharge records reviewed. (#7, #10, #15) The findings include: Clinical record review on 1/26/2022, for patient #7, start of care 11/20/2021, diagnoses include but were not limited to sepsis [potentially life-threatening infection], pneumonia [infection that inflames one or both lungs, and may be filled with fluid], evidenced an agency document titled, “ Record review of an agency document titled “Case Communication” from 12/21/2021, and signed by RN R. This document had an area subtitled “Communication Notes” which stated “Topic discussed: Re-admission inpatient hospitalization … Communication details: Patient was discharged from [Entity I] on 12-17-21. Methodist HHC [home health care] received a ROC [resumption of care]/order on 12-20-21. Patient re-admitted to [Entity I] ED [emergency department] Inpatient on 12-21-21 with shock, sepsis, hypotension [low blood pressure], and possible pneumonia ….” Review evidenced the patient was discharged from Entity I on 12/27/2021. Review of the clinical record failed to evidence a discharge summary. Review failed to evidence the disposition of the patient. Review failed to evidence Entity I or the patient’s physician received a discharge summary of the patient’s pertinent information. 1. Review of an agency policy obtained 1/26/2022, revised August 2021, titled, “Discharge & Transfer” stated “Policy: At the time of admission the clinician will begin planning for the patient’s discharge. Discharge plans will be documented in the plan of care. The patient/legal representative will participate in planning for discharge or transfer. The staff will notify the patient/legal representative of reasons for discharge and changes in the plan as they affect the discharge plans. Staff will educate the patient and/or family in self-care, management of medical and health needs, use of community resources, available alternatives, and other appropriate information. Verbal discharge instructions will be provided … The patient/ legal representative or other individual responsible for the patient’s care will be given at least fifteen calendar day notice before services are discontinued … Transfer: transfer to another organization will occur when appropriate and the patient meets discharge criteria. Home care and attending physician will be responsible for the patient during the transfer process. The receiving organization and patient’s physician will be provided with all relevant written or verbal information including: 1) reason for transfer 2) patient’s physical and pertinent psychological status 3) current needs necessitating intervention 4) summary of the care and services provided 5) progress towards achieving identified goals 6) all medication, instructions and/or referral information provided to the patient 7) advance directive information … Discharge/Transfer Summary: A completed discharge summary will be 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 within five business days of the patient discharge … A completed transfer summary will be sent to the health care facility within two business days of a planned transfer, if the patient’s care will immediately continue in a health care facility. A completed transfer summary will be sent within two business days to the health care facility and/or responsible health care provider upon becoming aware of an unplanned transfer”. 2. Clinical record review on 1/24/2022 for patient #10, start of care 9/23/2021, discharged 10/28/2021, evidenced a primary diagnosis of multiple sclerosis (exacerbation), [a nervous system disease that affects the brain and spinal cord]. Review on 1/24/2022 for patient #10 evidenced agency document titled “Case Communication” electronically signed by registered nurse L on 11/17/2021 which stated, “Spoke with patient mother, informed that patient is in an inpatient rehab [rehabilitation] facility … Patient discharged from home health services”. Record review on 1/24/2022 evidenced an agency document titled “Discharge” electronically signed by registered nurse L on 11/17/2021. Document stated, “Reason for Discharge: Patient in rehab facility … Alterations in the Plan of Care: no … Date of Last Home Visit: 10/28/2021”. Record review failed to evidence agency had sent a discharge summary or transfer summary to inpatient rehab facility. During an interview on 1/26/2022 at 11:34 AM, administrator A stated, “discharge summaries get entered the date of the last home visit”. During an interview on 1/26/2022 at 1:34 PM, administrator A did not know what day patient #10 had transferred to inpatient rehab. Administrator A indicated the OASIS discharge had been entered 11/17/2021 but dated 10/28/2021 to align with last home visit completed. Administrator A did not know if discharge summary was sent to inpatient rehabilitation center. 3. Clinical record review on 1/24/2022 for patient #15 with a primary diagnosis of orthopedic aftercare following surgical amputation [care after amputation], start of care 9/9/2021, evidenced an agency document titled, “Case Communication” electronically signed by physical therapist physical therapist K on 9/28/2021 which stated, “Patient admitted to the hospital due to wound infection”. Record review evidenced an agency document titled, “Case Communication” electronically signed by registered nurse J on 9/29/2021 which stated, “Patient admitted to inpatient”. Record review evidenced an agency document dated 10/1/2021, titled, “Case Communication” electronically signed by registered nurse C, which stated, “patient transferred to ... [Hospital E] ... for surgery”. Record review evidenced an agency document which was transmitted titled “SN[skilled nurse]-OASIS [Home Health Outcome and Assessment Information Set] Transfer w/o DC [discharge]” electronically signed by registered nurse C on 10/4/2021. Review failed to evidence a discharge summary was completed or sent to hospital. During an interview on 1/26/2022 at 11:34 AM, administrator A stated, “discharge summaries get entered the date of the last home visit”. During an interview on 1/26/2022 at 11:32 AM, administrator A indicated agency did not know whether patient #15 was still in hospital or had returned home. Administrator A indicated discharge summary was not completed, and that if patient becomes inpatient in hospital, agency is supposed to complete discharge summary.

Survey of March 31, 2021

6 findings

G0000

This visit was a complaint survey with 1 complaint. The survey visit took place 3/26/2021 to 3/31/2021. Complaint: IN00317648 - substantiated with related and unrelated findings. Facility ID: 003070 This deficiency report reflects State Findings cited in accordance with 410 IAC Article 17. Refer to State Form for additional State Findings. Quality Review Completed: 05/03/2021 Area 1

G0572

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 home health agency failed to ensure the medical plan of care was followed and individualized in 2 of 2 active clinical records. (#1, #3) The findings include: 1. Record review on 3/31/2021, evidenced an agency policy titled, "Plan of Care", revised 06/2020, which stated, " ... POLICY: To establish guidelines that promotes [sic] appropriate care planning to ensure acceptable delivery of care. A. Every patient must have a written Plan of Care. This plan must be designed to meet the needs of the patient. The Plan of Care is developed from the physician's orders, and is developed and maintained by home care staff is consultation with the physician. The patient is encouraged to participate in the development and revision of the Plan of Care ... C. The Plan of Care must include the type of services to be provided and the frequency and duration of these services, including: ... 2. Specific procedures & treatments, including frequency & duration ... 14. Any safety measures to protect against injury ... E. The Plan of Care must be reviewed by the clinician and attending physician at least every 60 days, and more often if the patient's condition warrants. The clinician will promptly inform the physician of changes in patient's condition that indicates an alteration in the plan and the physician must agree to any changes in the plan of care ... G. All other drugs and treatments observed by the nurse on assessment will also be incorporated into the Plan of Care...." 2. Record review on 3/31/2021, evidenced an agency policy titled, "Clinical Records - Documentation", revised 06/2020, which stated, " ... POLICY: To establish guidelines for documentation in the clinical record that complies with professional standards and federal, state, and local laws. To present a true and accurate picture of the patient's status and the care provided. A clinical record must be maintained for each patient in accordance with the accepted professional standards ... Each clinical record will contain the following elements ... 4. Documentation of all teaching and patient and family education provided ... Safety measures taken to protect the patient from harm and notes on the suitability of the environment for the care or services to be provided, when applicable ... 15. The patient's plan of care which is updated as needed and the patient's response to care, treatment and services 16. All relevant diagnostic and therapeutic procedures, treatments, and tests' and their results ... Clinical Documentation: 2. A clinical or visit note is to be used to document a contact with a patient that is written and dated by a clinician, and describes signs and symptoms, treatment and drugs administered, including any reactions of the patient, progress towards goals, and any changes in physical, emotional, or social conditions which may affect outcomes or response to care. During each home visit the patient's response to care against established goals will include but not be limited to: care, interventions, treatment, medications, teaching ... Visits notes should include any assessment findings, services rendered, instruction given, patient's progress, any physician contact or consultation, and care coordination with other disciplines...." 3. Clinical record review on 3/30/2021 for patient #1, with start of care 2/27/2021, certification period 2/27/2021 to 4/27/2021, primary diagnosis of Type 2 diabetes mellitus with foot ulcer (onset), evidenced an agency document titled, "HOME HEALTH CERTIFICATION AND PLAN OF CARE", signed by the physician on 3/9/2021. This plan of care had a subcategory titled, "Orders for Discipline and Treatments (Specify Amount / Frequency / Duration)", which stated, " ... Specimen sample ... Lab draw ... Start: 2/27/2021 ... Labs to be drawn on Monday and Thursday and results to be sent to [physician C] - labs include CBC / DIFF [complete blood count with differential], CMP [complete metabolic panel], ESR [erythrocyte sedimentation rate] WHILE ON IV [intravenous] ANTIBIOTICS...." Review on 3/30/2021, of the patient's electronic medical record (Epic) evidenced on 3/1/2021, the nurse drew CBC / DIFF, CMP, and CRP [c-reactive protein]. The nurse failed to draw an ESR. Clinical record review failed to evidence an order to draw for CRP. On 3/26/2021 at 11:30 a.m., the administrator indicated she did not know why the nurse drew CRP and not ESR. Review on 3/30/2021, of the patient's electronic medical record (Epic) evidenced on 3/15/2021 and 3/25/2021, the nurse drew CBC / DIFF, CMP, and CPK [creatine phosphokinase] During an interview on 3/26/2021 at 11:00 a.m., the administrator identified a physician order dated 2/27/2021 as the correct lab draw order, which indicated CBC / DIFF, CMP, and CPK to be drawn weekly while on antibiotics, and results sent to physician E. When queried, the administrator indicated this order was not present in the plan of care in "Epic hyperspace". She indicated it is something "IT" was working on to make the plan of care a "living document". No additional documentation was received. Clinical record review of nurse's notes and review of the patient's electronic medical record failed to evidence any labs were drawn on the week of 3/7/2021 to 3/13/2021. The skilled nurse failed to follow the medical plan of care. During an interview on 3/26/2021 at 11:02 a.m., the administrator indicated the patient was on IV antibiotics during that time and should have had labs drawn. Both the administrator and employee B, RN [registered nurse] reviewed the patient's medical record and indicated the nurse failed to draw any labs that week as ordered in the plan of care. Clinical record review of an agency document titled, "Home Health Certification And Plan of Care" for certification period 2/27/2021 to 4/27/2021, evidenced an area subtitled "Orders for Discipline and Treatments (Specify Amount/Frequency/Duration)". This subtitled area stated, "SN [skilled nurse] 2/27/2021 to 2/27/2021(is this date right?) Yes, they wrote it like that because the first visit was at the end of the week: 1 visit every week for 1 week, 2/28/2021 to 3/27/2021: 3 visits every week for 4 weeks ...." Review of the patient's electronic medical record and clinical record review of the nurse's notes for the week of 3/7/2021 to 3/13/2021 evidenced only one SN visit. The week of 3/14/2021 to 3/20/2021 evidenced only one SN visit. The week of 3/21/2021 to 3/27/2021 evidenced only one SN visit. The skilled nurse failed to follow the medical plan of care as ordered by the primary care physician. During an interview on 3/31/2021 at 10:37 a.m., the administrator indicated a physician order was received on 3/25/2021, to change SN visit frequency to one visit per week. The agency failed to update the plan of care with this order. When queried, the administrator indicated the order was in Epic, but was not part of the plan of care found in Epic hyperspace. The administrator indicated the agency failed to provide 3 SN nursing visits per week for the weeks of 3/7/2021 to 3/13/2021 and 3/14/2021 to 3/20/2021. (Did you place the finding under revision to the plan of care as well?) Yes 4. Clinical record review on 3/29/2021 for patient #3, with start of care 2/18/2021, certification period 2/18/2021 to 4/18/2021, primary diagnosis of Covid-19 and secondary diagnoses including but not limited to Acute on chronic systolic (congestive) heart failure (exacerbation) and Hypertensive chronic kidney disease, evidenced an agency document titled, "HOME HEALTH CERTIFICATION AND PLAN OF CARE", signed by the physician on 3/3/2021. This plan of care had a subcategory titled, "Orders for Discipline and Treatments (Specify Amount / Frequency / Duration)", which stated, " ... Specimen sample ... Lab draw ... Start: 2/18/2021 ... lab draw to be perform [sic] x2 [two times] weekly cbc with diff, cmp with results going to [physician C] and [infusion specialty pharmacy D]...." Clinical record review evidenced a group of documents, identified by the administrator as the nurse's visit notes. The nurse visit notes for the week of 3/7/2021 to 3/13/2021, failed to evidence two times lab draws were performed. The nurse visit notes for the week of 3/14/2021 to 3/20/2021, failed to evidence two times lab draws were performed. The skilled nurse failed to follow the medical plan of care as ordered by the primary care physician. Review of patient #3's electronic medical record (Epic) failed to evidence two lab draws were performed for the week of 3/7/2021 to 3/13/2021 and the week of 3/14/2021 to 3/20/2021. During an interview on 3/31/2021 at 10:22 a.m., the administrator indicated the patient was supposed to have lab tests drawn twice weekly. When informed of the findings, the administrator and employee B reviewed the patient's electronic medical record. The administrator indicated the patient had nursing visits on 3/11/2021 and 3/18/2021 when the labs should have been drawn by the nurse. The record failed to evidence labs were drawn on 3/11/2021 and 3/18/2021. The administrator and employee B indicated the nurse failed to perform lab draws two times weekly for the week of 3/7/2021 to 3/13/2021 and the week of 3/14/2021 to 3/20/2021. The administrator stated, "I don't see anything to explain it". Clinical record review of an agency document titled, "Home Health Certification And Plan of Care" for certification period 2/27/2021 to 4/27/2021, evidenced an area subtitled "Orders for Discipline and Treatments (Specify Amount/Frequency/Duration)". This subtitled area stated, " ... Disease Knowledge Deficit ... Absence or deficiency of knowledge in the placement of pacemaker ... Assess patient's understanding of disease process, management and complications ... Start: 2/18/2021 ... Patient / caregiver may have misconceptions about the disease that should be corrected. Identify baseline knowledge to help facilitate and establish a plan of care for patient and family education by week 2 ... Disease Management ... Instruct chronic renal disease ... Start: 2/18/2021 ... Instruct patient and Caregiver on disease management, including signs & symptoms, risk factors and lifestyle modifications ... Disease Management ... Instruct atrial fibrillation [an irregular heart rhythm] Start 2/18/2021 ... Instruct Patient and Caregiver on disease management, including signs & symptoms, risk factors and lifestyle modifications ... Fluid Retention - HF [heart failure] ... Instruct fluid restrictions ... Start 2/18/2021 ... Restrict fluid intake to 1500 ml [milliliters] per day as instructed by your physician. Teach that fluids include: ice cubes, tea, coffee, juice, soup, gelatin, ice cream, sherbet, milk and soda ... Instruct to maintain daily log of HF [heart failure] signs and symptoms ... Start: 2/18/2021 ... Use HF notebook to instruct / coach the patient / caregiver: HF disease process, medications, reduced sodium in diet, reading & understanding food labels, daily log of signs & symptoms, exercising, and when to call Methodist HH [home health] and / or physician...." Clinical record review evidenced a group of documents, identified by the administrator as the nurse's visit notes. The nurse's visit notes were dated: 2/19/2021, 2/22/2021, 2/25/2021, 3/1/2021, 3/3/2021, 3/8/2021, 3/11/2021, 3/15/2021, 3/18/2021, 3/22/2021, and 3/24/2021. Each of these notes failed to evidence patient education for the placement of a pacemaker. Each of these notes failed to evidence patient education for chronic renal disease. Each of these notes failed to evidence patient education for atrial fibrillation. Each of these notes failed to evidence patient education for heart failure. Each of these notes failed to evidence the patient was on or educated about a fluid restriction. The skilled nurse failed to follow the medical plan of care as ordered by the primary care physician. During an interview on 3/31/2021 at 9:45 a.m., employee B, RN, indicated patient teaching should be documented in each visit. When informed of the findings, the administrator and employee B reviewed the electronic medical record for patient #3. The administrator stated, "There's none in the record. It should be in there." The administrator indicated if a patient was on a fluid restriction, it should be documented in a heart failure template or a narrative note within the nurse's notes. The administrator and employee B indicated the nurse's notes failed to evidence the fluid restriction. 17-13-1(a)

G0574

G0576

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the plan of care was revised to include all patient care orders, in 2 of 2 clinical records reviewed of patients with wounds. (#1, #2) The findings include: 1. Record review on 3/31/2021, evidenced an agency policy titled, "Plan of Care", revised 06/2020, which stated, " ... POLICY: To establish guidelines that promotes [sic] appropriate care planning to ensure acceptable delivery of care. A. Every patient must have a written Plan of Care. This plan must be designed to meet the needs of the patient. The Plan of Care is developed from the physician's orders, and is developed and maintained by home care staff is consultation with the physician. The patient is encouraged to participate in the development and revision of the Plan of Care ... C. The Plan of Care must include the type of services to be provided and the frequency and duration of these services, including: ... 1) Disciplines and frequency & duration of visits 2) Specific procedures & treatments, including frequency & duration ... 14. Any safety measures to protect against injury ... E. The Plan of Care must be reviewed by the clinician and attending physician at least every 60 days, and more often if the patient's condition warrants. The clinician will promptly inform the physician of changes in patient's condition that indicates an alteration in the plan and the physician must agree to any changes in the plan of care ... G. All other drugs and treatments observed by the nurse on assessment will also be incorporated into the Plan of Care. Any medication side-effects, drug allergies or adverse reactions, contra- indicated medications, will be evaluated by the clinician and will be reported to the physician...." 2. Record review on 3/31/2021, evidenced an agency policy titled, "Clinical Records - Documentation", revised 06/2020, which stated, " ... POLICY: To establish guidelines for documentation in the clinical record that complies with professional standards and federal, state, and local laws. To present a true and accurate picture of the patient's status and the care provided. A clinical record must be maintained for each patient in accordance with the accepted professional standards ... Each clinical record will contain the following elements ... 7. A complete Medication profile, allergies and sensitivities, vital signs, height and weight when appropriate. 15. The patient's plan of care which is updated as needed and the patient's response to care, treatment and services 16. All relevant diagnostic and therapeutic procedures, treatments, and tests' and their results...." 3. Clinical record review on 3/30/2021 for patient #1, with start of care 2/27/2021, certification period 2/27/2021 to 4/27/2021, primary diagnosis of Type 2 diabetes mellitus with foot ulcer (onset), evidenced an agency document titled, "HOME HEALTH CERTIFICATION AND PLAN OF CARE", signed by the physician on 3/9/2021. This plan of care had a subcategory titled, "Orders for Discipline and Treatments (Specify Amount / Frequency / Duration)", which stated, " ... Specimen sample ... Lab draw ... Start: 2/27/2021 ... Labs to be drawn on Monday and Thursday and results to be sent to [physician C] - labs include CBC / DIFF [complete blood count with differential], CMP [complete metabolic panel], ESR [erythrocyte sedimentation rate] WHILE ON IV [intravenous] ANTIBIOTICS...." Review on 3/30/2021, of the patient's electronic medical record (Epic) evidenced on 3/15/2021 and 3/25/2021, the nurse drew CBC / DIFF, CMP, and CPK [creatine phosphokinase]. The ski During an interview on 3/26/2021 at 11:00 a.m., the administrator identified a physician order dated 2/27/2021 as the correct lab draw order, which indicated CBC / DIFF, CMP, and CPK to be drawn weekly while on antibiotics, and results sent to physician E. When queried, the administrator indicated this order was not present in the plan of care in "Epic hyperspace". She indicated it is something IT is working on to make the plan of care a "living document". No additional documentation was received. Clinical record review evidenced an agency document titled, "HOME HEALTH CERTIFICATION AND PLAN OF CARE", signed by the physician on 3/9/2021. This plan of care had a subcategory titled, "Orders for Discipline and Treatments (Specify Amount / Frequency / Duration)" of the plan of care also evidenced the order, "SN [skilled nurse] 2/27/2021 to 2/27/2021: 1 visit every week for 1 week, 2/28/2021 to 3/27/2021: 3 visits every week for 4 weeks ...." Review of the patient's electronic medical record and clinical record review of the nurse's notes for the week 3/7/2021 to 3/13/2021 evidenced only one SN visit. The week of 3/14/2021 to 3/20/2021 evidenced only one SN visit. The week of 3/21/2021 to 3/27/2021 evidenced only one SN visit. During an interview on 3/31/2021 at 10:37 a.m., the administrator indicated a physician order was received on 3/25/2021 to change SN visit frequency to one visit per week. The agency failed to update the plan of care with this order. When queried, the administrator indicated the order was in Epic, but was not part of the plan of care found in Epic hyperspace. The administrator indicated the agency failed to provide 3 SN nursing visits per week for the weeks of 3/7/2021 to 3/13/2021 and 3/14/2021 to 3/20/2021. Clinical record review evidenced an agency document titled, "HOME HEALTH CERTIFICATION AND PLAN OF CARE", signed by the physician on 3/9/2021. Review of the plan of care evidenced a subcategory titled, "Medications: Dose / Frequency / Route....", which stated, " ... ceFAZolin Sodium-Dextrose [an IV antibiotic] 2 GM [gram] IV SOLR piggyback Inject 2 g [gram] into the vein every 8 hours for 40 days...." The plan of care also had a subcategory titled, "Allergies", which stated, "Vancomycin, Azithromycin". Review of the patient's electronic medical record evidenced an encounter note titled, "ED [emergency department]", dated 3/5/2021, electronically signed by physician F. This note stated, " ... On patient re-evaluation, reporting improvement in symptoms. Itching improved. No new symptoms. Pt [patient] instructed to d/c [discontinue] ancef [cefazolin]...." Review of the patient's electronic medical record evidenced a physician order dated 3/9/2021, signed by physician E, which stated, " ... Daptomycin (Cubicin) [an antibiotic] 700 mg [milligram] in sodium chloride 0.9% 50 mL [milliliter] IVPB [IV piggyback]...." Review of the patient's electronic medical record evidenced a document titled, "Office Visit", dated 3/22/2021, electronically signed by physician E. This note stated, " ... This man was on Cefazolin but developed allergic reaction and so it was discontinued and Daptomycin started...." Clinical record review evidenced the plan of care failed to reflect the patient's most recent medications and allergies. During an interview on 3/31/2021 at 10:39 a.m., the administrator indicated the agency failed to update the plan of care with the Cefazolin allergy. When queried, the administrator indicated the orders to discontinue Cefazolin and the new order for Daptomycin were not present in the plan of care in "Epic hyperspace". She indicated it is something IT is working on to make the plan of care a "living document". No additional documentation was received by end of survey dated 03/31/2021. 4. Clinical record review on 3/30/2021 for patient #2, with start of care 6/25/2019, certification period 6/25/2019 to 8/23/2019, primary diagnosis of Sepsis due to methicillin resistant Staphylococcus aureus (onset), evidenced an agency document titled, "HOME HEALTH CERTIFICATION AND PLAN OF CARE", signed by the physician on 7/1/2019. The plan of care had a subcategory titled, "Medications...." This subcategory stated, " ... rifampin (Rifadin) [an oral antibiotic] 300 MG [milligram] capsule Take 1 capsule by mouth every 12 hours for 40 days. - Oral ... Vancomycin HCl in NACl [an IV antibiotic] 750-0.9 MG [milligram] / 150 ML [milliliter] SOLN [solution] PREMIX Inject 150 mLs into the vein every 12 hours for 40 days - Intravenous...." Clinical record review evidenced an agency document titled, "PROVIDER VERBAL ORDER", dated 6/27/2019, from physician G, signed by the nurse, which stated, " ... D/C [discontinue] Vancomycin. Daptomycin [an IV antibiotic] 6 mg [milligram] / kg [kilogram] (600 mg) IV Daily thru 8-4-19...." The plan of care failed to evidence a revision to include this medication change order. Clinical record review evidenced an agency document titled, "PROVIDER VERBAL ORDER", dated 7/8/2019, from physician G, signed by the nurse, which stated, " ... Hold Daptomycin until further orders. Hold po [by mouth] Rifampin...." The plan of care failed to evidence this medication change order. Review of the patient's electronic medical record evidenced a document, identified by the administrator as infusion clinic orders, dated 7/12/2019, from physician G, which stated, " ... Medication order ceftaroline fosamil (TEFLARO) 600 mg, sodium chloride 0.9% 100 mL...." Clinical record review evidenced an agency document titled, "Case Communication", dated 7/13/2021, signed by employee D, RN, which stated, " ... Communication Details Patient called and stated IV antibiotics was changed on Friday, initial dose of Teflaro 600 mg IV was given and [sic] infusion clinic. Patient was told at clinic that HH [home health] will be out on Saturday to educate on how to administer IV antibiotics, no communication was given to Homehealth. Writer done visit with patient and educated on new antibiotics and frequency of medication. Informed to call if any concerns arises, voiced understanding...." The plan of care failed to evidence the patient was taking Teflaro. During an interview on 3/31/2021 at 12:10 p.m., the administrator indicated the plan of care failed to evidence the patient's medication changes. The administrator stated, "I can't see it. I will talk to IT". 17-14-1(a)(1)(C)

G0590

G1024

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 entries were legible, clear, complete, and appropriately authenticated in 2 of 3 clinical records reviewed for patients receiving physical therapy services. ( #2, #3) The findings include: 1. Record review on 3/31/2021, evidenced an agency policy titled, "Clinical Records - Documentation", revised 06/2020, which stated, " ... POLICY: To establish guidelines for documentation in the clinical record that complies with professional standards and federal, state, and local laws. To present a true and accurate picture of the patient's status and the care provided. A clinical record must be maintained for each patient in accordance with the accepted professional standards ... Each clinical record will contain the following elements ... 3. Routine and relevant visit notes with pertinent findings and the skill for the visit, and periodic summaries provided to they physician as applicable ... 9. Safety measures taken to protect the patient from harm and notes on the suitability of the environment for the care or services to be provided, when applicable ... Clinical Documentation: 2. A clinical or visit note is to be used to document a contact with a patient that is written and dated by a clinician, and describes signs and symptoms, treatment and drugs administered, including any reactions of the patient, progress towards goals, and any changes in physical, emotional, or social conditions which may affect outcomes or response to care. During each home visit the patient's response to care against established goals will include but not be limited to: care, interventions, treatment, medications, teaching ... Visits notes should include any assessment findings, services rendered, instruction given, patient's progress, any physician contact or consultation, and care coordination with other disciplines...." 2. Clinical record review on 3/30/2021 for patient #2, with start of care 6/25/2019, certification period 6/25/2019 to 8/23/2019, primary diagnosis of Sepsis due to methicillin resistant Staphylococcus aureus (onset), evidenced an agency document titled, "HOME HEALTH CERTIFICATION AND PLAN OF CARE", signed by the physician on 7/1/2019. The plan of care had a subcategory titled, "Orders for Discipline and Treatments....", which stated, " ... Post-op care ... Instruct on fall prevention ... Start 6/25/2019 ... Instruct patient / caregiver in drain care...." Clinical record review evidenced an agency document titled, "OASIS [Outcome and Assessment Information Set] [a standardized assessment used in home health] Start of Care", dated 8/25/2019, signed by employee F, RN. This document had a subcategory titled, "Intervention Documentation", which stated, " ... Problem: Post-op care ... Goal: Care of wound drain Description: Patient / caregiver will demonstrate the ability to care for wound drains throughout episode of care. Intervention: Instruct on fall prevention Description: Instruct patient / caregiver in drain care...." The physical assessment failed to evidence the patient had a drain. Clinical record review evidenced a group of documents, identified by the administrator as the nurse's visit notes. The notes dated 6/26/2019 stated, " ... Goal: Care of wound drain Description: Patient / caregiver will demonstrate the ability to care for wound drains throughout episode of care. Intervention: Instruct on fall prevention Description: Instruct patient / caregiver in drain care...." The physical assessment on this note failed to evidence the patient had a drain. The nurse's notes dated 7/3/2019 and 7/4/2019 each stated, " ... Problem: Post-op care ... Goal: Care of wound drain Description: Patient / caregiver will demonstrate the ability to care for wound drains throughout episode of care. Intervention: Instruct on fall prevention Description: Instruct patient / caregiver in drain care.....". The physical assessment on each of these notes failed to evidence the patient had a drain. The nursing notes dated 6/27/2019, 7/1/2019, 7/3/2019, 7/8/2019, 7/9/2019, 7/11/2019, 7/13/2019, 7/15/2019, 7/18/2019, 7/22/2019, 7/25/2019, 7/29/2019, 8/1/2019 and 8/5/2019 each failed to evidence the patient had a drain. During an interview on 3/31/2021 at 12:13 p.m., the administrator indicated if a patient had a drain, it should be included in the physical assessment and in the nursing teaching and interventions. When queried, the administrator indicated patient #2 did not have a drain. When informed of the findings, the administrator reviewed the patient's electronic record (Epic) and stated, "Something's goofy. That's really strange. We'll have to call Epic." The administrator indicated the clinical record documentation was not clear. 3. Clinical record review on 3/29/2021 for patient #3, with start of care 2/18/2021, certification period 2/18/2021 to 4/18/2021, primary diagnosis of Covid-19, evidenced a group of documents, identified by the administrator as the nurse's visit notes. Each of the notes were signed by employee E, RN. These notes had a subcategory titled, "Communicable Disease Screening". This screening stated, " ... In the last month, have you been in contact with someone who was confirmed or suspected to have Coronavirus / COVID - 19? ...." The answers documented to this question were as follows: 2/18/2021 - yes, 2/19/2021 - no, 2/22/2021 - yes, 2/25/2021, 3/1/2021, 3/3/2021, 3/8/2021 - no, 3/11/2021 - yes, 3/15/2021, 3/18/2021, 3/22/2021, and 3/24/2021 - no. During an interview on 3/31/2021 at 10:12 a.m., the administrator indicated the Covid screening should be done by the clinician at the beginning of each visit. The administrator indicated the first question was to determine if the patient had been in contact with anyone potentially positive for Covid-19 in the past month. When informed of the findings, the administrator stated, "There are inconsistencies", and indicated the nurse's documentation was unclear. 17-15-1(a)(7)

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