Every finding on record at Together Homecare of Evansville LLC

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102. Survey Dates: 5/13/2024-5/17/2024 Active Census: 68 At this Emergency Preparedness survey, Team Select Home Care was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 484.102. QR Completed on 05/28/2024 by A4

This visit was for a Federal Recertification and State Re-Licensure survey of a Home Health Provider. Survey Dates: 5/13/2024-5/17/2024 Partially Extended on 5/16/2024 at 2:53 PM 12-Month Unduplicated Skilled Admissions: 44 This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Refer to State Form for additional State Findings.

Written instructions to patient include: CFR(s): 484.60(e) Standard: Written information to the patient. The HHA must provide the patient and caregiver with a copy of written instructions outlining: This STANDARD is not met as evidenced by: Based on record review, and interview the agency failed to ensure that all patients received education and had the ability to access written documentation such as the Plan of Care (POC), updates to the POC, medication list, updates or revisions, any treatments to be administered, and any other instructions related to the patient’s care via the agencies electronic health portal for 1 of 3 patient home visits. (Patient #7) Findings Include: During a home visit on 5/15/2024 at 12:15 PM, Patient #7’s home admission folder was reviewed. The folder failed to evidence a current written POC, any updates to the POC, a current or updated medication list, any treatments to be administered by the agency staff or other instructions related to the care provided by staff of the agency or acting on behalf of the agency. Patient #7 indicated they are not receiving mailed updates to the POC, medication list and/or updates, treatments administered, or instructions on any other care received and had no knowledge of the patient portal or how to use it. Home Health Aide 1 (HHA) also indicated these documents or anything else in the patient record are shared with Patient #7 during aide visits via HHA 1’s phone. During an interview on 5/15/2024 at 2:45 PM, the Director of Clinical Services indicated that since Team Select became the owner of the agency and the patient portal was implemented, documents have not been mailed or taken to patient homes, unless specifically requested, because patients have access to all documents through their patient portal anytime or anywhere. During an interview on 5/15/2024 at 12:35 PM after Patient #7’s home visit, the Registered Nurse Case Manager (RN 1) indicated that because the patient portal was being used documents had no longer been mailed or taken to the homes. RN 1 indicated the practice was being re-implemented because many patients either weren’t using the portal or were unable to use the portal.

An Emergency Preparedness Survey was conducted by the Indiana State Department of Health in accordance with 42 CFR 484.102. Survey Date: 9/13/2021 - 9/16/2021 Facility Number: 014390 Active Census = 68 At this Emergency Preparedness survey, Together Homecare of Evansville LLC, was found in compliance with Emergency Preparedness Requirements for Medicare Participating Providers and Suppliers, 42 CFR 484.102. QR completed 9/30/2021 A4

This visit was for a Federal recertification and State re-licensure survey of a home health agency. Partially Extended survey was announced on 9/14/2021 at 4:00 p.m. Survey Dates: 09/13/2021 - 09/16/2021 Facility ID: 014390 Unduplicated 12 month census: 108

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 record review and interview, the agency failed to ensure the patient received all services outlined in the plan of care for 2 of 7 records reviewed (Patient 5 & 6). Findings include: 1. A December 30, 2020 policy titled, "Admission Policy C-120" was provided by the Administrator on 9/15/2021 at 8:39 a.m. The policy indicated, but was not limited to, "Patients are accepted for treatment in the home on the basis of reasonable criteria and under the expectation that the patient's medical, nursing, and social needs can be met adequately by Agency in the patient's place of residence.... 10. Agency services must be ... available to meet the specific needs and requests of the patient and caregiver." 2. A December 30, 2020 policy titled, "Plan of Care C-580" was provided by the Administrator on 9/15/2021 at 8:39 a.m. The policy indicated, but was not limited to, "Planning for care is a dynamic process that addresses ... services to be provided. The plan will be consistently reviewed to ensure that patient needs are met ..." 3. An undated document titled, "Rights and Responsibilities" was provided by the Administrator on 9/15/2021 at 8:39 a.m. The document indicated, but was not limited to, “10. Establishing and revising the plan of care … 21. To receive all services outlined in the Plan of Care.” 4. The clinical record for patient 5 was reviewed on 9/13/2021, SOC date 8/16/2021, for certification period 8/16/2021 to 10/14/2021. The clinical record evidenced the following: The plan of care indicated SN (skilled nurse) services 5-9 hours/day x 4-6 days/week. A 8/24/2021 missed visit note indicated: "Missed Visit Date: 8/24/2021. Discipline for Service: SN. Reason for Cancellation/Missed Visit: Cancelled By Client-Family to Provide Services. Describe How the Patient's Needs Was Met: Family to provide care. Dates August 24th through 27th, 2021." An 8/25/2021 Client Logging Report indicated: "LATE LOGGING ... no staffing available today." An 8/26/2021 Client Logging Report indicated: "LATE LOGGING ... no staffing available today." An 8/27/2021 Client Logging Report indicated: "LATE LOGGING ... no staffing available today." *During the week of 8/22/2021 to 8/28/2021, patient 5 received SN services x one, seven-hour visit from the agency. There were no physician orders within the clinical record to modify the plan of care. A 9/1/2021 missed visit note indicated: "Missed Visit Date: 9/1/2021. Discipline for Service: SN . Reason for Cancellation/Missed Visit: Cancelled By Agency-No Available Staff. Describe How the Patient's Needs Was Met: Family to provide care. Dates August 30th through September 3rd, 2021." *During the week of 8/29/2021 to 9/4/2021, patient 5 received no SN services from the agency. There were no physician orders within the clinical record to modify the plan of care. A 9/7/2021 cancel schedules note indicated: "Service Type: RN Hourly. DOS [date of service] Start: 9/7/2021 8:00 a.m. DOS End: 9/7/2021 3:00 p.m. Cancellation Type: Cancelled by Agency. Cancellation Reason: No Available Staff. Remarks: Client family to provide care." A checkmark was noted in the box next to the words "This is a Missed Visit." During an interview on 9/15/2021 at 12:12 p.m., the Administrator acknowledged the 8/24/2021 missed visit note incorrectly indicated the client/family had cancelled the SN visits for 8/25/2021 to 8/27/2021. The Administrator indicated the family cancelled the 8/24/2021 SN visit, but the agency cancelled the SN visits scheduled for 8/25/2021, 8/26/2021, and 8/27/2021 due to no staff available. 6. During an interview on 9/14/2021 at 3:54 p.m., the Administrator confirmed the agency had trouble with staffing some of its services. 7. The clinical record for patient 6 was reviewed on 9/13/2021, SOC date 10/26/2020, for the certification period 12/25/2020 to 2/10/2021, with orders for home health aide 1-2 visits/day, 6-10 hours/day times 5-7 days/week for 9 weeks. Review of patient 6’s Missed Visit Notes indicated cancelled visits due to no available staff for the following dates: 1/5/2021, 1/11/2021, 1/12/2021, 1/13/2021, 1/14/2021, 1/15/2021, 1/16/2021, 1/18/2021. The agency failed to ensure all services were provided as outlined on the plan of care. Review of patient 6’s clinical record failed to evidence Missed Visit Note documentation and physician notification for the home health aide for the following dates: 1/19/2021, 1/20/2021, 1/21/2021, 1/22/2021, 1/25/2021, 1/26/2021, 1/27/2021, 1/28/2021, 1/29/2021, 2/1/2021, 2/2/2021, 2/3/2021, 2/4/2021, 2/5/2021, 2/8/2021, and 2/10/2021. The agency failed to ensure all services were provided as outlined on the plan of care. Review of patient 6's Client Logging Report indicated the agency was looking for staffing for the following dates: 1/5/2021, 1/6/2021, 1/7/2021, 1/8/2021, 1/11/2021, 1/13/2021, 1/14/2021, 1/18/2021, 1/19/2021, 2/3/2021, 2/4/2021, and 2/5/2021. The agency failed to ensure all services were provided as outlined on the plan of care. During an interview on 9/15/2021 at 1:50 p.m. the Clinical Manager confirmed there were no visits made on the above dates and the agency was looking for staffing. The Clinical Manager indicated that staffing depends on the location and if staff are willing to go to the area.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the plan of care accurately included all medications and treatments for 3 of 7 records reviewed. (Patient 2, 3, & 4) Findings include: 1. A December 30, 2020 policy titled, "Plan of Care C-580" was provided by the Administrator on 9/15/2021 at 8:39 a.m. The policy indicated, "2. The Plan of Care shall be completed in full to include: ... j. All medications ... 10. Professional staff shall promptly alert the physician to any changes that suggest a need to alter the Plan of Care...." 2. An undated document titled, "Position: Registered Nurse" was provided by the Administrator on 9/15/2021 at 8:39 a.m. The document indicated, but was not limited to, "c. Develops and/or follows and individualized Plan of Care.... e. Reports ... information necessary to modify and update the care plan ... " 3. The clinical record for patient 3 was reviewed on 9/13/2021, SOC (start of care) date 1/21/2019, for the certification period 7/9/2021 to 9/6/2021 and evidenced the following: The plan of care indicated an order for Humalog to be administered as a scheduled dose of insulin at 11:30 a.m. plus a correction dose of insulin as needed: "Humalog (insulin) KwikPen Subcutaneous Solution Pen-injector 100 UNIT/ML / 1.5 ml (milliliter) / Subcutaneous / Twice a day 1.5 units at 1130 ... plus correction dose if needed treatment of diabetes/hyperglycemia ..." The plan of care indicated an order for Novolog as a correction dose of insulin at 11:30 a.m. as needed: " NovoLOG FlexPen Subcutaneous Solution Pen-injector 100 UNIT/ML / # of units = (blood sugar - 150) / 200 / Subcutaneous / Once a Day at 1130 ONLY! Correction insulin to be combined with prandial [with meals] insulin and given after 1130 meal. Do not give if feeding is held treatment of diabetes/hyperglycemia" The medication profile indicated the Novolog Flexpen correction dose of insulin scheduled for 11:30 a.m. was discontinued on 8/2/2021. An 8/20/2021 physician-signed revision to the plan of care order indicated "HumaLOG KwikPen Subcutaneous Solution Pen-Injector 100 UNIT/ML-Subcutaneous-# of units =blood sugar-150)/100 - 12/9/2020 -0730-1130-2000. Correction insulin to be combined with prandial insulin and given after each meal at these specified times. Do not give if feeding held. - 3 times every 1 Day(s)." 4. During an interview on 9/16/2021 at 9:19 a.m., the Clinical Manager indicated the order for Humalog KwikPen twice a day at 11:30 a.m. and 3:30 p.m. plus correction, read as the correction dose was intended to be that of Humalog, and not Novolog as indicated on the plan of care. The Clinical Manager indicated Novolog was discontinued on 8/2/2021 and the reason was unclear. The Clinical Manager indicated Humalog was ordered as a correction dose insulin for 11:30 a.m. dosing on 8/20/2021. 17-13-1(a)(1)(D)(i-xiii) 5. The clinical record for patient 2 was reviewed on 9/13/2021, SOC 8/9/2021, for the certification period 8/9/2021 - 10/7/2021, with orders for "Other Service Providers ... [Name of Physical Therapy agency, phone, and contact information]" The agency failed to indicate the frequency, duration, and reason for therapy services. 5. The clinical record for patient 4 was reviewed on 9/13/2021, SOC date 1/4/2021, for the certification period 9/1/2021-10/30/2021, with orders for "Granulotion / 1 application / Topical / Every 6 [hours] Apply to skin with q-tip 4 times daily remove granulation tissue / ... Other Service Providers ... OT/PT [Name of therapy agency] every Thursday [phone number] PT with [Name of therapy agency] once a week {Name of contact and phone number]". The agency failed to indicate the anatomical location of where Granulotion (medicated lotion for itching) was to be applied and failed to indicate the duration and reason for therapy services. 6. During an interview on 9/15/2021 at 11:20 a.m. the Clinical Manager indicated the agency does not recognize PT/OT services. The therapy services are separate and there will be no PT/OT documentation. On 9/16/2021 at 9:37 a.m. the Clinical Manager indicated PT/OT frequency and duration do not affect our care. The agency does not address PT/OT goals or progress because it was not a part of patient care. The Clinical Manager indicated the agency was not affiliated with the 2 other PT/OT providers and it was up to the physician and family to order therapy services.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on observation, record review, and interview, the agency failed to follow written physician orders on the plan of care for 2 of 7 records reviewed (Patient 1 & 5) and for 1 of 3 home visit observations (Patient 2). Findings include: 1. A December 30, 2020 policy titled, "Plan of Care C-580" was provided by the Administrator on 9/15/2021 at 8:39 a.m. The policy indicated, but was not limited to, “Purpose To provide guidelines for agency staff to develop a plan of care individualized to meet specific identified needs. 2. The Plan of Care shall be completed in full to include: ... n. Patient-specific interventions ... 10. Professional staff shall promptly alert the physician to any changes that suggest a need to alter the Plan of Care. 11. Verbal/telephone orders shall be obtained from the patient’s physician for changes in the Plan of Care … " 2. An undated document titled, "Position: Registered Nurse" was provided by the Administrator on 9/15/2021 at 8:39 a.m. The document indicated, but was not limited to, "ESSENTIAL FUNCTIONS/AREAS OF ACCOUNTABILITY 1. Assumes responsibility and accountability for the practice of professional nursing ... c. ... follows an individualized Plan of Care.... d. Provides skilled interventions ..." 3. An undated document titled, "Position: Home Health Aide" was provided by the Administrator on 9/16/2021 at 9:45 a.m. The document indicated, but was not limited to, "Reports to: Clinical Supervisor/Case Manager Position Summary Provides personal care services under the direction of the Registered Nurse ... The Home Health Aide ... performs services for clients as necessary to maintain their personal comfort.... 6. Documents care provided and completes the forms required for the client's records. Completes the appropriate records to document care given ... " 4. The clinical record for patient 1 was reviewed on 9/13/2021, SOC (start of care) date 5/20/2021, for the certification period 5/20/2021 to 7/18/2021. The clinical record evidenced the following: The plan of care indicated HHA (home health aide) services 4-8 hours/day x 4-6 days/week x 9 weeks. The plan of care indicated, but was not limited to, "Risk for Skin Breakdown ... Notify agency for any skin changes, including redness, bruising, discoloration, pain, bleeding, rash, or any other signs of breakdown.... HOME HEALTH AIDE: ACTIVITY ... Turn every: 2 hours; remind to change positions. every visit.... " A 5/20/2021 aide care plan completed by the Clinical Manager, indicated to turn the patient every 2 hours at every visit and remind the patient to change positions. A 5/20/2021 comprehensive assessment completed by a registered nurse indicated "dry, cracking skin but no openings. No wounds. Does the patient have wounds? No." Twenty-nine HHA (home health aide) visit notes dated 5/20/2021 to 7/9/2021 failed to evidence completed tasks of turning the patient every 2 hours, and reminding the patient to change positions. Five HHA visit detail reports for completed HHA visits - 7/5/2021 (7 hours, 15 mins), 7/6/2021 (8 hours, 43 mins), 7/7/2021 (8 hours, 37 mins), 7/8/2021 (8 hours, 32 mins), and 7/9/2021 (8 hours) - indicated there were no skin changes for patient 1 reported to the agency. The agency's client logging report indicated no notification of skin changes for patient 1 during the week of 7/5/2021 to 7/9/2021, or prior, by the HHA. A 7/16/2021 client logging report entry indicated patient 1 was taken to the emergency room on 7/10/2021 and admitted to the hospital with pressure ulcers to his/her coccyx (tailbone) and left calf. During an interview on 9/15/2021 at 2:21 p.m., the Clinical Manager confirmed the plan of care indicated the HHA was to turn patient 1 every 2 hours and remind the patient to change positions. The Clinical Manager indicated the HHA was to notify the agency of any skin changes. The Clinical Manager confirmed patient 1 was hospitalized on 7/10/2021, the agency staffed patient 1 from 7/5/2021 to 7/9/2021, and there were no reports of skin issues received by the agency prior to patient 1's hospitalization. 5. The clinical record for patient 5 was reviewed on 9/13/2021, SOC date 8/16/2021, for certification period 8/16/2021 to 10/14/2021 and evidenced the following: The plan of care indicated: "Orders for Disciplines and Treatments: ... Skilled Nurse: 5-9 hours/day x 4-6 days/week ... Problems and Interventions: ... BOWEL PREP/PROGRAM ... clean stoma with soap and warm water daily and PRN [as needed] soiled...." A 9/6/2021 nursing visit note indicated "Bowel Ostomy Stoma Care (verify orders on POC [plan of care] before performing) N/A - Stoma care not ordered to be performed this visit...." A 9/8/2021 nursing visit note indicated "Bowel Ostomy Stoma Care (verify orders on POC [plan of care] before performing) N/A - Stoma care not ordered to be performed this visit...." A 9/9/2021 nursing visit note indicated "Bowel Ostomy Stoma Care (verify orders on POC [plan of care] before performing) N/A - Stoma care not ordered to be performed this visit...." A 9/10/2021 nursing visit note indicated "Bowel Ostomy Stoma Care (verify orders on POC [plan of care] before performing) N/A - Stoma care not ordered to be performed this visit...." A 9/13/2021 nursing visit note indicated "Bowel Ostomy Stoma Care (verify orders on POC [plan of care] before performing) N/A - Stoma care not ordered to be performed this visit...." During an interview on 9/15/2021 at 2:02 p.m., the Clinical Manager indicated colostomy care for patient 5 was ordered on the plan of care. The Clinical Manager indicated he/she would discuss with the skilled nurse why care not ordered was documented in the nursing visit notes. 17-13-1-(a) 6. The clinical record for patient 2 was reviewed on 9/13/2021, SOC (start of care) date 8/9/2021, for the certification period 8/9/2021 to 10/7/2021. The plan of care indicated orders for “Kate Farms Ped Standard 1.2 Oral Liquid/250 mL/G-tube/5 times every 1 Day(s) 250 mL via G-tube 5 times daily at 0530, 1030, 1530, 1615, and 2030 nutritional intake … Tap Water/100-200 mL/G-tube/5 times every 1 Day(s) 5-10 mL g-tube flush before each tube feeding G-Tube Flush … Tap Water / 100-200 mL/G-Tube/ 5 times every 1 Day(s) 100-200 mL water via G-tube 15-20 minutes after each tube feeding (5 per day) hydration … SN to check residual before administering the feeding. If residual amount exceeds half of previous feeding wait and re-check in 1 hour. If residual still exceeds this amount, hold feeding and notify MD.” During a home visit on 9/14/2021 at 2:30 p.m. RN (registered nurse) F was observed to provide care to patient 2. RN F indicated the patient was to receive 285 ml (milliliters) of K (potassium) Formula feeding and receive no free water. RN F failed to check for residual prior to administering the gastric feedings and failed to flush the gastric tube with tap water as indicated on the current plan of care. At that time, RN F was interviewed and indicated the family did not want to flush the feeding tube and was in the process of adjusting the feedings based on a goal. The agency failed to follow written orders based on the plan of care to accurately reflect the gastric feeding orders and flushes at the time of the home visit. During an interview on 9/15/2021 at 11:45 a.m. the Clinical Manager confirmed the orders on the plan of care should have been followed.

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 the skilled nurse administered medications and gastric feedings as ordered by the physician on the plan of care for 2 of 7 records reviewed. (Patient 2 & 5) 5. The clinical record for patient 2 was reviewed on 9/13/2021, SOC (start of care) date 8/9/2021, for the certification period 8/9/2021 to 10/7/2021. The plan of care indicated orders for “Kate Farms Ped Standard 1.2 Oral Liquid/250 mL/G-tube/5 times every 1 Day(s) 250 mL via G-tube 5 times daily at 0530, 1030, 1530, 1615, and 2030 nutritional intake … Tap Water/100-200 mL/G-tube/5 times every 1 Day(s) 5-10 mL g-tube flush before each tube feeding G-Tube Flush … Tap Water / 100-200 mL/G-Tube/ 5 times every 1 Day(s) 100-200 mL water via G-tube 15-20 minutes after each tube feeding (5 per day) hydration … SN to check residual before administering the feeding. If residual amount exceeds half of previous feeding wait and re-check in 1 hour. If residual still exceeds this amount, hold feeding and notify MD.” During a home visit on 9/14/2021 at 2:30 p.m. RN (registered nurse) F was observed to provide care to patient 2. RN F indicated the patient was to receive 285 ml (milliliters) of K (potassium) Formula feeding and receive no free water. RN F failed to check for residual prior to administering the gastric feedings and failed to flush the gastric tube with tap water as indicated on the current plan of care. At that time, RN F was interviewed and indicated the family did not want to flush the feeding tube and was in the process of adjusting the feedings based on a goal. The agency failed to follow written orders based on the plan of care to accurately reflect the gastric feeding orders and flushes at the time of the home visit. During an interview on 9/15/2021 at 11:45 a.m. the Clinical Manager confirmed the orders on the plan of care should have been followed. Findings include: 1. A December 30, 2020 policy titled, "Medication Administration C-708" was provided by the Administrator on 9/15/2021 at 8:39 a.m. The policy indicated, but was not limited to, "Together Homecare staff will administer medications as ordered by the physician...." 2. An undated document titled, "Position: Registered Nurse" was provided by the Administrator on 9/15/2021 at 8:39 a.m. The document indicated, but was not limited to, "ESSENTIAL FUNCTIONS/AREAS OF ACCOUNTABILITY ... c. ... follows an individualized Plan of Care ... 2. Consistently demonstrates competency with technical nursing skills according to personal and legal scope of practice: ... c. Medication administration...." 3. The clinical record for patient 5 was reviewed on 9/13/2021, SOC date 8/16/2021, for certification period 8/16/2021 to 10/14/2021 and evidenced the following: The plan of care indicated: "Medications/Dose/Route/Frequency ... Famotidine Oral Suspension 40 MG[milligram]/5ML[milliliter] ... 5ml / Oral / Once a Day 5ml treatment for GERD [reflux].... MEDICATION ADMINISTRATION: SN [skilled nurse] to administer all medications per physician orders during scheduled shift times...." The SN visit frequency was indicated as 5-9 hours/day x 4-6 days/week. An 8/16/2021 to 9/14/2021 medication administration report indicated the SN administered Famotidine 5 ml during the SN visit on 9/6/2021 at 8:20 a.m. No further administration of Famotidine was indicated on the report for SN visits that occurred during the time period of 8/16/2021 to 9/14/2021. 4. During an interview on 9/15/2021 at 2:02 p.m., the Clinical Manager indicated there were no times specified for medication administration on the plan of care or medication profile. Medication administration responsibilities between the caregiver and the skilled nurse were not clearly defined. Once medications were administered by the SN over the course of a month, a pattern developed which was then used to perform the monthly audit for compliance with the plan of care. The Clinical Manager acknowledged the SN did not administer medication as ordered on the plan of care, and indicated he/she would call the nurse to discuss why the medication was missed. 17-13-1-(a)

Review and revision of the plan of care CFR(s): 484.60(c) Standard: Review and revision of the plan of care. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure orders on the plan of care were accurate for 1 of 1 patients with a Baclofen (muscle relaxer) pump, a colostomy, and a central line (Patient 5); and for 1 of 2 patients with gastric tube feedings. (Patient 2) 6. The clinical record for patient 2 was reviewed on 9/13/2021, SOC (start of care) date 8/9/2021, for the certification period 8/9/2021 to 10/7/2021. The plan of care indicated orders for “Kate Farms Ped Standard 1.2 Oral Liquid/250 mL/G-tube/5 times every 1 Day(s) 250 mL via G-tube 5 times daily at 0530, 1030, 1530, 1615, and 2030 nutritional intake … Tap Water/100-200 mL/G-tube/5 times every 1 Day(s) 5-10 mL g-tube flush before each tube feeding G-Tube Flush … Tap Water / 100-200 mL/G-Tube/ 5 times every 1 Day(s) 100-200 mL water via G-tube 15-20 minutes after each tube feeding (5 per day) hydration … SN to check residual before administering the feeding. If residual amount exceeds half of previous feeding wait and re-check in 1 hour. If residual still exceeds this amount, hold feeding and notify MD.” During a home visit on 9/14/2021 at 2:30 p.m. RN (registered nurse) F was observed to provide care to patient 2. RN F indicated the patient was to receive 285 ml (milliliters) of K (potassium) Formula feeding and receive no free water. RN F failed to check for residual prior to administering the gastric feedings and failed to flush the gastric tube with tap water as indicated on the current plan of care. At that time, RN F was interviewed and indicated the family did not want to flush the feeding tube and was in the process of adjusting the feedings based on a goal. The agency failed to revise the plan of care to accurately reflect the gastric feeding / flush observation at the time of the home visit. 7. During an interview on 9/15/2021 at 11:50 a.m. the Clinical Manager confirmed the orders on the plan of care and agreed the plan of care should have been revised. Findings include: 1. A December 30, 2020 policy titled, "Plan of Care C-580" was provided by the Administrator on 9/15/2021 at 8:39 a.m. The policy indicated, but was not limited to, "Purpose To provide guidelines for agency staff to develop a plan of care individualized to meet specific identified needs.... 2. The Plan of Care shall be completed in full to include: ... j. ... treatments ... n. Patient-specific interventions ... r. Other appropriate items s. All of the above items must always be addressed on the Plan of Care.... 10. Professional staff shall promptly alert the physician to any changes that suggest a need to alter the Plan of Care...." 2. An undated document titled, "Position: Registered Nurse" was provided by the Administrator on 9/15/2021 at 8:39 a.m. The document indicated, but was not limited to: "ESSENTIAL FUNCTIONS/AREAS OF ACCOUNTABILITY ... c. Develops ... an individualized Plan of Care.... e. Reports changes and information necessary to modify and update the care plan ... 5. Initiates actions to improve the quality of patient care...." 3. The clinical record for patient 5 was reviewed on 9/13/2021, SOC date 8/16/2021, for certification period 8/16/2021 to 10/14/2021 and evidenced the following: The plan of care indicated: "Medications/Dose/Route/Frequency ... Baclofen Intrathecal [into the spine] Solution Prefilled Syringe 20000 MCG [microgram]/20ML [milliliter] / 750 mcg / Intrathecal / Once a Day once a day via automatic pump treatment of spasticity ... Orders for Disciplines and Treatments: ... Skilled Nurse: 5-9 hours/day x 4-6 days/week ... Problems and Interventions: ... MEDICATION ADMINISTRATION: SN (skilled nurse) to administer all medications per physician orders during scheduled shift times.... BOWEL PREP/PROGRAM ... clean stoma with soap and warm water daily and PRN [as needed] soiled.... Intravenous Therapy ... Size and type of line: Tunneled Groshong CBL [central line]. Site care and frequency sterile kit, weekly (Tuesdays). Change dressing every week (Tuesdays). Line changed every day. Line changes by: family. COLOSTOMY ... Empty drainage bag as needed...." An 8/16/2021 to 9/14/2021 medication administration report indicated the skilled nurse did not administer the Baclofen Intrathecal Solution during the SN visits that occurred during the time period of 8/16/2021 to 9/14/2021. 4. During an interview on 9/15/2021 at 11:19 a.m., the Clinical Manager indicated the Baclofen Intrathecal Solution would not show on the medication administration report if the caregiver was managing the medication. The Clinical Manager indicated he/she was unsure who was managing patient 5's colostomy, Baclofen infusion, and central line care, and would review the Plan of Care. 5. During an interview on 9/15/2021 at 2:54 p.m., the Clinical Manager stated the "plan of care is bare" in regards to the colostomy. The Clinical Manager indicated he/she spoke with patient 5's caregiver and the colostomy bag was emptied as needed, and the wafer changed once weekly by the skilled nurse. The Clinical Manager indicated the colostomy care was not on the plan of care and needed updated. The Clinical Manager indicated the central line dressing changes were changed by an outside entity with which care is coordinated at every recertification, and needed clarified on the plan of care. The Clinical Manager indicated the Baclofen pump was changed 3-4 times/year by the physician and needed clarified on the plan of care. Lastly, the Clinical Manager indicated the skilled nurse did not administer the Baclofen Intrathecal Solution, and it should not have been on the medication administration report.

Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient's updated comprehensive assessment, and contain information concerning the patient's progress toward the measurable outcomes and goals identified by the HHA and patient 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 the current comprehensive assessment and plan of care contained updated information for 1 of 3 home visit observations. (Patient 2) Findings include: A 12/30/20 policy titled Plan of Care C-580 was provided by the Administrator on 9/15/2021 at 8:39 a.m. The policy indicated, but was not limited to, "The plan will be consistently reviewed to ensure that patient needs are met ... 10. Professional staff shall promptly alert the physician to any changes that suggest a need to alter the Plan of Care." A 12/30/20 policy title Coordination of Patient Services C-360 was provided on 9/16/2021 at 8:47 a.m. The policy indicated, but was not limited to, "To modify the plan to reflect needs or changes identified by members of the team ... To identify needs to modify the plan of care" During a home visit on 9/14/2021 at 2:30 p.m. RN F indicated patient 2 was to receive 285 ml (milliliters) of K (potassium) Formula feeding and receive no free water. RN F failed to check for residual prior to administering the gastric feedings and failed to flush the gastric tube with tap water as indicated on the current plan of care. At that time, RN F was interviewed and indicated the family did not want to flush the feeding tube and was in the process of adjusting the feedings based on a goal. The clinical record for patient 2 was reviewed on 9/13 - 9/14 of 2021, SOC (start of care) date 8/9/2021, for the certification period 8/9/2021 to 10/7/2021. The plan of care indicated orders for “Kate Farms Ped Standard 1.2 Oral Liquid/250 mL/G-tube/5 times every 1 Day(s) 250 mL via G-tube 5 times daily at 0530, 1030, 1530, 1615, and 2030 nutritional intake … Tap Water/100-200mL/G-tube/5 times every 1 Day(s) 5-10 mL g-tube flush before each tube feeding G-Tube Flush … Tap Water / 100-200 mL/G-Tube/ 5 times every 1 Day(s) 100-200 mL water via G-tube 15-20 minutes after each tube feeding (5 per day) hydration … SN to check residual before administering the feeding. If residual amount exceed half of previous feeding wait and re-check in 1 hour. If residual still exceeds this amount, hold feeding and notify MD." Review of patient 2's Comprehensive Assessment dated 8/9/2021 failed to indicate specific goals related to gastric feedings/ flushes and checking for residual that reflected what was observed on the 9/14/2021 home visit. Review of patient 2's Plan of Care dated 8/9/2021 failed to be revised / altered based on the goals identified by the agency and parent that reflected the 9/14/2021 home visit observation. During an interview on 9/15/2021 at 11:45 a.m., the Clinical Manager confirmed the orders of the plan of care should have been followed. The Clinical Manager indicated the goal was for feedings at 285 ml, 5 times a day, and the doctor wanted the family to get as close to the goal as possible.

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the agency failed to integrate therapy goals into the plan of care for 2 of 3 home visit observations. (Patient 2 & 4) Findings include: 1. A 12/30/20 policy titled Coordination of Patient Services C-360 was provided by the Administrator on 9/16/2021 at 8:47 a.m. The policy indicated, but was not limited to, "All personnel furnishing services shall maintain a liaison to assure that their efforts are coordinated effectively and support objectives outlined in the Plan of Care ... To ensure services are coordinated among members of the interdisciplinary team. To ensure appropriate, quality care is being provided to patients ... To ensure the efforts of agency personnel effectively complement one another and support the objectives outlined in the Plan of Care ... To identify needs to modify the plan of care ... Special Instructions ... 2. Interdisciplinary care conferences shall be conducted as often as necessary to respond to changes in the patient's needs, services, care, or goals. ... 4. Ongoing care conferences shall be conducted to evaluate the patient's status and progress." 2. A 12/30/20 policy titled Plan of Care C-580 was provided by the Administrator on 9/15/2021 at 8:39 a.m. The policy indicated, but was not limited to, "... follow the plan designated to attain personal health goals." 3. The clinical record for patient 2 was reviewed on 9/13/2021, SOC date 8/9/2021, for the certification period 8/9/2021-10/7/2021, with orders for "Other Service Providers (8/16/2021 ...) Center for [Name of therapy agency and phone number]”. The agency failed to include the frequency and duration of therapy services and what the patient was to be seen for (such as strengthening training, balance, and mobility). Review of the Plan of Care indicated "Coordination of Care: Care is coordinated among patient''s mother [parent name and physician name] , The Center for Pediatric Therapy, and [Name] the Columbus Organization, and Together Homecare. Patient Participation: Patient's parents have participated in establishing goals and plan of care. Review of patient selected goals and Goals / Rehabilitation Potential / Discharge Plans failed to evidence specific goals established by therapy services and progress toward those goals. Review of the Start of Care Comprehensive Assessment dated 8/9/2021 indicated the names and phone numbers of OT (occupational therapy) and ST (speech therapy) services, but failed to indicate specific goals and orders set by therapy services. The Goal Planning and Progress section failed to indicate goals and progress set by therapy services. Review of the Client Logging Report dated 8/9/2021 and 9/2/2021, indicated Coordination of Care with therapy services, but failed to indicate specific goals set by therapy services and progress toward set goals. 4. The clinical record for patient 4 was reviewed on 9/13/2021, SOC date 1/4/2021, for the certification period 9/1/2021-10/30/2021, with orders for "Other: Assist appropriate pediatric musculoskeletal development tasks and PROM. Therapists from coordinating agency can offer suggestions as appropriate. Every visit. (Currently rolls from back to side only)." Review of the Plan of Care indicated "Coordination of Care: Care is coordinated among patient, parents [parents name and physician name] , Deaconess Highpoint PT/OT, First Steps Easterseals OT, and Together Homecare. Patient Participation: Patient's family has participated in ongoing establishment of goals and plan of care." Review of the Plan of Care "Current goals 08/31/2021" section and "Goals / Rehabilitation Potential / Discharge Plans" section, failed to evidence specific goals established by PT (physical therapy) and OT (occupational therapy) services. Review of the 60 day summary dated 8/31/2021 failed to evidence progress toward PT/OT goals. Review of the Recertification Comprehensive Assessment dated 8/31/2021 indicated the names and phone numbers of the other service providers, but failed to indicate specific goals set by PT/OT services and progress toward the set goals. Review of the Client Logging Report dated 9/1/2021, 9/2/2021, 9/3/2021, 9/10/2021, failed to indicate specific PT/OT goals or progress toward goals. During a home visit on 9/15/2021 at 9:00 a.m. RN H indicated there were two separate PT therapists that provide care for patient 4. Physical therapy comes to the home 3 times a week and another therapist comes in once a week. RN H indicated there was a hard copy of PT notes in the home but was not sure where the parent keeps it. RN H indicated he/she gives PT report and both are involved with patient 4. 5. During an interview on 9/15/2021 at 11:20 a.m. the Clinical Manager indicated the agency does not recognize PT/OT services. The therapy services are separate and there will be no PT/OT documentation. On 9/16/2021 at 9:37 a.m. the Clinical Manager indicated PT/OT frequency and duration do not affect our care. The agency does not address PT/OT goals or progress because it was not a part of patient care. The Clinical Manager indicated the agency was not affiliated with the 2 other PT/OT providers and it was up to the physician and family to order therapy services. The Clinical Manager indicated the agency does not have an agreement with therapy services. 17-12-2(g)

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 record review and interview, the agency failed to provide written instructions of which medications would be administered by the skilled nurse for 1 of 7 records reviewed (Patient 5). Findings include: 1. A December 30, 2020 policy titled, "Medication Administration C-708" was provided by the Administrator on 9/15/2021 at 8:39 a.m. The policy indicated, but was not limited to, "Together Homecare staff will administer medications as ordered by the physician...." 2. An undated document titled, "Position: Registered Nurse" was provided by the Administrator on 9/15/2021 at 8:39 a.m. The document indicated, but was not limited to, "2. Consistently demonstrates competency with technical nursing skills according to personal and legal scope of practice: ... c. Medication administration...." 3. The clinical record for patient 5 was reviewed on 9/13/2021, SOC date 8/16/2021, for certification period 8/16/2021 to 10/14/2021 and evidenced the following: The plan of care indicated: "Skilled Nurse: 5-9 hours/day x 4-6 days/week ... MEDICATION ADMINISTRATION: SN [skilled nurse] to administer all medications per physician orders during scheduled shift times. Patient/Caregiver is responsible for medications in absence of Together Homecare staff. Patient/Family/Caregiver may administer medications during scheduled SN [skilled nurse] shift per patient/family/caregiver request...." The medication profile listed the drug & package name, drug name, medication start date, discontinue date, dose, route, a box to indicate if the medication was prn (as needed), frequency, therapy class, a box to indicate if the medication was new/changed, and the type. The medication profile did not include times of medication administration or an administration schedule for the skilled nurse. The plan of care listed patient 5's medications but did not specify times of medication administration or an administration schedule for the skilled nurse. 4. During an interview on 9/15/2021 at 2:02 p.m., the Clinical Manager indicated there were no times specified for medication administration on the plan of care or medication profile. Medication administration responsibilities between the caregiver and the skilled nurse were not clearly defined. Once medications were administered by the SN over the course of a month, a pattern developed which was then used to perform the monthly audit for compliance with the plan of care.

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 standard infection control precautions were followed for 2 of 3 home visit observations. (Patient 2 & 3) 6. During a home visit on 9/14/2021 at 2:30 p.m. RN F was observed providing care to patient 2. RN F applied gloves, connected the gastric tubing to patient 2’s mini gastric button. RN F proceeded to punch in numbers on the Infinity pump while still gloved. RN F failed to remove gloves after direct patient contact and perform hand hygiene prior to touching the machine. 7. During an interview on 9/14/2021 at 4:15 p.m. the Clinical Manager, who was present on the home visit, confirmed the RN should have removed gloves and performed hand hygiene after direct patient contact. Findings include: 1. A revised October 2016 policy titled, "Universal Precautions and Patients’ Rights" was provided by the Administrator on 9/15/2021 at 8:39 a.m. The policy indicated, but was not limited to, “Protective Barriers Are Used – Includes the appropriate use of gloves for skin contact … Hand Hygiene – Hands are washed before and after each patient contact…” 2. A December 30, 2020 policy titled, "Handwashing/Hand Hygiene D-330" was provided by the Administrator on 9/15/2021 at 8:39 a.m. The policy indicated but was not limited to, "3. Indications for hand washing and hand antisepsis: a. Before performing invasive procedures.... d. Before tasks on the same patient.... f. After removing gloves.... g. After touching objects that are potentially contaminated...." 3. An undated job description titled, "Position: Registered Nurse" was provided by the Administrator on 9/15/2021 at 8:39 a.m. The document indicated, but was not limited to, "Essential Functions/Areas of Accountability.... 7. Promotes personal safety and a safe environment for clients ... a. Demonstrates knowledge of safety/infection control practices by complying with established policies and procedures...." 4. During a home visit on 9/14/2021 at 11:20 a.m., RN G was observed providing care to patient 3. RN G performed handwashing and donned gloves. RN G performed a glucose finger stick, wrote the result on a paper log sheet in the home, connected the gastric tubing to patient 3's gastric button, and turned on the machine for patient 3's gastric feeding. RN G then placed a needle on patient 3's insulin pen, primed the pen, cleansed patient 3's abdomen with an alcohol prep pad, and administered the insulin injection. RN G cleaned up supplies, completed a second paper log sheet, and then removed and disposed of the worn gloves. No glove changes or hand hygiene was observed during the home visit. 5. During an interview on 9/15/2021 at 11:45 a.m., the Clinical Manager indicated glove changes should be performed between: body parts, equipment, and processes. Hand hygiene and glove changes should be performed between each body area. The Clinical Manager indicated if the nurse was doing a blood sugar check during the home visit, the same pair of gloves should not have been worn to initiate the tube feeding. 17-12-1(m)

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 ordered by the physician as indicated in the plan of care were provided for 1 of 3 home observation visits. (Patient 2) Findings include: A December 30, 2020 policy titled, "Plan of Care C-580" was provided by the Administrator on 9/15/2021 at 8:39 a.m. The policy indicated, but was not limited to, “The plan will be consistently reviewed to ensure that patient needs are met … j. All medications and treatments … n. … measurable outcomes and goals … r. Other appropriate items.” An undated Registered Nurse job description was provided by the Administrator on 9/15/2021 at 8:39 a.m. The job description indicated, but was not limited to, “The Registered Nurse … Assumes responsibility and accountability … c. Develops and / or follows an individualized Plan of Care … " The clinical record for patient 2 was reviewed on 9/13/2021, SOC (start of care) date 8/9/2021, for the certification period 8/9/2021 to 10/7/2021. The plan of care indicated orders for “Kate Farms Ped Standard 1.2 Oral Liquid/250 mL/G-tube/5 times every 1 Day(s) 250 mL via G-tube 5 times daily at 0530, 1030, 1530, 1615, and 2030 nutritional intake … Tap Water/100-200 mL/G-tube/5 times every 1 Day(s) 5-10 mL g-tube flush before each tube feeding G-Tube Flush … Tap Water / 100-200 mL/G-Tube/ 5 times every 1 Day(s) 100-200 mL water via G-tube 15-20 minutes after each tube feeding (5 per day) hydration … SN to check residual before administering the feeding. If residual amount exceeds half of previous feeding wait and re-check in 1 hour. If residual still exceeds this amount, hold feeding and notify MD.” During a home visit on 9/14/2021 at 2:30 p.m. RN (registered nurse) F was observed to provide care to patient 2. RN F indicated the patient was to receive 285 ml (milliliters) of K (potassium) Formula feeding and receive no free water. RN F failed to check for residual prior to administering the gastric feedings and failed to flush the gastric tube with tap water as indicated on the current plan of care. At that time, RN F was interviewed and indicated the family did not want to flush the feeding tube and was in the process of adjusting the feedings based on a goal. The agency failed to follow written orders based on the plan of care to accurately reflect the gastric feeding orders and flushes at the time of the home visit. During an interview on 9/15/2021 at 11:45 a.m., the Clinical Manager confirmed the nurse should have followed the orders on the plan of care. 17-14-1(a)(1)(H)

Aides are members of interdisciplinary team CFR(s): 484.80(g)(4) Home health aides must be members of the interdisciplinary team, must report changes in the patient's condition to a registered nurse or other appropriate skilled professional, and must complete appropriate records in compliance with the HHA's policies and procedures. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure a HHA (home health aide) reported changes in a patient's skin condition to the registered nurse as indicated on the plan of care for 1 of 7 records reviewed (Patient 1). Findings include: 1. An undated document titled, "Position: Home Health Aide" was provided by the Administrator on 9/16/2021 at 9:45 a.m. The document indicated, but was not limited to, "Reports to: Clinical Supervisor/Case Manager Position Summary Provides personal care services under the direction of the Registered Nurse ... Essential Functions/Areas of Accountability 5. Reports any observed ... changes in the client's condition ... to the Registered Nurse ... Follows reporting guidelines in the Care Plan." 2.The clinical record for patient 1 was reviewed on 9/13/2021, SOC (start of care) date 5/20/2021, for the certification period 5/20/2021 to 7/18/2021 and evidenced the following: A 5/20/2021 plan of care indicated HHA (home health aide) services 4-8 hours/day x 4-6 days/week x 9 weeks. The plan of care indicated, but was not limited to, "Risk for Skin Breakdown ... Notify agency for any skin changes, including redness, bruising, discoloration, pain, bleeding, rash, or any other signs of breakdown...." A comprehensive assessment completed by a registered nurse on 5/20/2021 indicated "dry, cracking skin but no openings. No wounds. Does the patient have wounds? No." Five HHA visit detail reports for completed home health aide visits were reviewed - 7/5/2021 (7 hours, 15 mins), 7/6/2021 (8 hours, 43 mins), 7/7/2021 (8 hours, 37 mins), 7/8/2021 (8 hours, 32 mins), and 7/9/2021 (8 hours) - and indicated no skin changes for patient 1 were reported to the agency. The agency's client logging report indicated no notification of skin changes for patient 1 during the week of 7/5/2021 to 7/9/2021, or prior, by the HHA. A 7/16/2021 client logging report entry indicated patient 1 was taken to the emergency room on 7/10/2021 and admitted to the hospital with pressure ulcers to her coccyx (tailbone) and left calf. 3. During an interview on 7/15/2021 at 2:21 p.m., the Clinical Manager confirmed patient 1 was hospitalized on 7/10/2021, the agency staffed patient 1 from 7/5/2021 to 7/9/2021, and there were no reports of skin issues received by the agency prior to patient 1's hospitalization. The Clinical Manager indicated the HHA was to notify the agency of any skin changes.

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 facility failed to ensure clinical record documents were accurate, legible, clear, and appropriately authenticated, dated and timed for 3 of 7 records reviewed (Patient 4, 5 & 6). Findings include: 1. A December 30, 2020 policy titled, "Clinical Record Maintenance C-870" was provided by the Administrator on 9/15/2021 at 8:39 a.m. The policy indicated, but was not limited to, “Clinical records are legal documents … 6. All documentation must be legible …” 2. An undated document titled, "Position: Registered Nurse" was provided by the Administrator on 9/15/2021 at 8:39 a.m. The document indicated, but was not limited to, "d. Documents legibly and according to Agency documentation guidelines and standards...." 3. The clinical record for patient 5 was reviewed on 9/13/2021, SOC (start of care) date 8/16/2021, for the certification period 8/16/2021 to 10/14/2021 and evidenced the following: The record included photocopies of Nursing Notes dated 8/16/2021, 8/18/2021, 8/19,2021, and 8/20/2021 that were not legible or clear. 4. During an interview on 9/14/2021 at 10:29 a.m., the Clinical Manager indicated the illegible nursing notes were photocopies of skilled nursing notes sent to the Administrator until the agency could get the original copies incorporated into patient 5's clinical record. The Clinical Manager acknowledged the original copies should have already been been received by the agency and incorporated into the clinical record. 5. During an interview on 9/14/2021 at 3:54 p.m., the Administrator indicated if the agency were to receive illegible photocopies of documentation, the agency would request new copies. 6. During an interview on 9/15/2021 at 11:54 a.m., the Administrator confirmed the photocopies of skilled nursing notes for patient 5 were not legible. 17-15-1(a)(7) 2. A 12/30/20 policy titled Clinical Documentation C-680 was provided by the Administrator on 9/15/2021 at 8:39 a.m. The policy indicated, but was not limited to, "To ensure that there is an accurate record of the services provided, patient response and ongoing need for care ... 1. All skilled services provided by Nursing, Therapy ... will be documented in the clinical record ... 6. The reason for the missed visit will be documented in the clinical record." 3. A 12/30/20 policy titled Clinical Management C-870 was provided by the Administrator on 9/15/2021 at 8:39 a.m. The policy indicated, but was not limited to, "7. Any person who gives patient care or who is professionally involved in the management and/or coordination of patient services may make an entry into the clinical record." 4. The clinical record for patient 4 was reviewed on 9/13/2021, SOC date 1/4/1/2021, for the certification period 9/1/2021-10/30/2021, with orders for "Other: Assist appropriate pediatric musculoskeletal development tasks and PROM. Therapists from coordinating agency can offer suggestions as appropriate. Every visit. (Currently rolls from back to side only)." During a home visit on 9/15/2021 at 9:00 a.m. RN H indicated there were two separate PT therapists that provide care for patient 4. Physical therapy comes to the home 3 times a week and another therapist comes in once a week. RN H indicated there was a hard copy of PT notes in the home but was not sure where the parent keeps it. RN H indicated he/she gives PT report and both are involved with patient 4. During an interview on 9/15/2021 at 11:20 a.m. the Clinical Manager indicated the agency does not recognize PT/OT services. The therapy services are separate and there will be no PT/OT documentation. On 9/16/2021 at 9:37 a.m. the Clinical Manager indicated PT/OT frequency and duration do not affect our care. The agency does not address PT/OT goals or progress because it was not a part of patient care. The Clinical Manager indicated the agency was not affiliated with the 2 other PT/OT providers and it was up to the physician and family to order therapy services. 6. The clinical record for patient 6 was reviewed on 9/13/2021, SOC date 10/26/2020, for the certification period 12/25/2021 to 2/10/2021. The record included a photocopy of the POST (Physician Order for Scope of Treatment) that was not legible or clear. Review of patient 6’s clinical record failed to evidence Missed Visit Note documentation and physician notification for the home health aide for the following dates: 1/19/2021, 1/20/2021, 1/21/2021, 1/22/2021, 1/25/2021, 1/26/2021, 1/27/2021, 1/28/2021, 1/29/2021, 2/1/2021, 2/2/2021, 2/3/2021, 2/4/2021, 2/5/2021, 2/8/2021, and 2/10/2021. The agency failed to follow agency policy and include documentation for the missed visits. During an interview on 9/15/2021 at 2:25 p.m. the Administrator confirmed the document was not legible and indicated the State department required the use of pink paper for the POST document and that was why it looked distorted.

This visit was for a Federal and State complaint investigation of a home health agency. Complaint IN00343273 - substantiated with findings Survey Date: January 5, 2021 Facility ID: 014390 Provider ID: 15K169 Unduplicated Skilled Census: 51 Skilled Patients: 23 Home Health Aide Only Patients: 81 Personal Service Only Patients: 1 Total: 105 Total Active Patients: 51 Records Reviewed: 4 Home Visits: 0 These deficiencies reflect State Findings cited in accordance with 410 IAC 17. Quality Review completed on 1/7/2021

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 record review and interview, the agency failed to ensure all services in the plan of care were provided for 2 of 4 patients. (Patients 1 and 3) Findings include: 1. A 1/5/21 policy titled Patients' Rights and Responsibilities was provided by the Alternate Administrator on 1/5/2021 at 3:11 p.m. The policy indicated, but was not limited to, "Your Rights You or your legal representative have the right to be informed of your rights through effective means of communication ...21. To receive all services outlines in the Plan of Care ..." 2. The complete clinical record for patient 1 was reviewed on 1/5/2021 for the certification period 11/18/2020 to 1/16/2021, start of care date 3/23/2020. The record included a plan of care with orders for home health aide services for 1 time a day for 4-6 days a week for 9 weeks, PA 4-8 hours a day for 4-6 weeks and Waiver 0.5-4 hours a day for 4-6 weeks. The record indicated the following: A review of visits for 11/29/20-12/5/20, 12/6/20-12/12/20, and 12/13/20-12/19/20 indicated the agency did not meet the minimum hours a day per week as ordered on the plan of care. The missed visit reports stated the visits were canceled due to no staff available and that the patient/family would provide care. The agency failed to provide services as indicated on the plan of care. An order written on 12/23/20 stated that the agency wanted to place the patient services on hold effective 12/23/20 due to lack of staffing and was signed by the doctor on 12/28/20. The agency was unable to meet the needs of the patient as indicated on the plan of care. 3. The complete clinical record for patient 3 was reviewed on 1/5/2021 for the certification period 8/2/2020 to 9/30/2020, start of care date 10/7/2019. The record included a plan of care with orders for home health aide services for 1 visit/day for 5-7 days/week for 9 weeks; Medicaid PA Program Hours (HHA): 2-6 hours/day times 4-6 days/week, 1-5 hours/day times 1-2 days/week, 0.5-4 hours/day times 1-2 days/week. The plan of care included Medicaid Waiver hours (HHA) for 4-8 hours/day times 5-7 days/week and 5-9 hours/day times 1-2 days/week. The record indicated the following: A review of visits for 9/5/20 - 9/11/20 indicated the agency did not meet the minimum hours a day per week as indicated on the plan of care A review of missed visit notes dated 8/3/20, 9/5/20, 9/6/20, 9/7/20, and 9/17/20 indicated the agency canceled the visits due to no staff available and that the patient/family would provide care. The agency failed to provide services as indicated on the plan of care. A review of the Client Logging Report for patient 3 dated 9/4/2020 indicated a caregiver would not be able to attend his/her shifts for 9/5-9/7 (Saturday - Monday). 4. During an interview on 1/5/2021 at 3:30 p.m. the Alternate Administrator indicated the agency had issues with staffing home health aides off and on, but tried to meet the needs of patients to the best of their abilities. 17-13-1(a)

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 refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to provide all services as written on the plan of care for 2 of 4 patients. (Patients 1 & 3) Findings include: 1. A 1/5/21 policy titled Plan of Care was provided by the Administrator on 1/5/2021 at 11:00 a.m. The policy indicated, but was not limited to, "Home care services are furnished under the supervision ...SPECIAL INSTRUCTIONS 2. d. Frequency and duration of visits to be made ..." 2. A 1/5/21 policy titled Patients' Rights and Responsibilities was provided by the Alternate Administrator on 1/5/2021 at 3:11 p.m. The policy indicated, but was not limited to, "Your Rights Your or your legal representative have the right to be informed of your rights through effective means of communication ...21. To receive all services outlines in the Plan of Care ..." 3. The complete clinical record for patient 1 was reviewed on 1/5/2021 for the certification period 11/18/2020 to 1/16/2021, start of care date 3/23/2020. The record included a plan of care with orders for home health aide services for 1 time a day for 4-6 days a week for 9 weeks, PA 4-8 hours a day for 4-6 weeks and Waiver 0.5-4 hours a day for 4-6 weeks. The record indicated the following: A review of visits for 11/29/20-12/5/20, 12/6/20-12/12/20, and 12/13/20-12/19/20 indicated the agency did not meet the minimum hours a day per week as ordered on the plan of care. The missed visit reports stated the visits were canceled due to no staff available and that the patient/family would provide care. The agency failed to provide services as indicated on the plan of care. An order written on 12/23/20 stated that the agency wanted to place the patient services on hold effective 12/23/20 due to lack of staffing and was signed by the doctor on 12/28/20. The agency was unable to meet the needs of the patient as indicated on the plan of care.4. The complete clinical record for patient 3 was reviewed on 1/5/2021 for the certification period 8/2/2020 to 9/30/2020, start of care date 10/7/2019. The record included a plan of care with orders for home health aide services for 1 visit/day for 5-7 days/week for 9 weeks; Medicaid PA Program Hours (HHA): 2-6 hours/day times 4-6 days/week, 1-5 hours/day times 1-2 days/week, 0.5-4 hours/day times 1-2 days/week. The plan of care included Medicaid Waiver hours (HHA) for 4-8 hours/day times 5-7 days/week and 5-9 hours/day times 1-2 days/week. The record indicated the following: A review of visits for 9/5/20 - 9/11/20 indicated the agency did not meet the minimum hours a day per week as indicated on the plan of care A review of missed visit notes dated 8/3/20, 9/5/20, 9/6/20, 9/7/20, and 9/17/20 indicated the agency canceled the visits due to no staff available and that the patient/family would provide care. The agency failed to provide services as indicated on the plan of care. A review of the Client Logging Report for patient 3 dated 9/4/2020 indicated a caregiver would not be able to attend his/her shifts for 9/5-9/7 (Saturday - Monday). 5. During an interview on 1/5/2021 at 3:30 p.m. the Alternate Administrator indicated the agency had issues with staffing home health aides off and on, but tried to meet the needs of patients to the best of their abilities. 17-13-1(a)