Every finding on record at Together Homecare of Fort Wayne LLC

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102. Survey Dates: March 6, 7, 10, and 11, 2025 Active Census: 97 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.

This visit was for a Federal Recertification and State Re-Licensure survey of a Home Health Provider. Survey Dates: March 6, 7, 10, and 11, 2025 12-Month Unduplicated Skilled Admissions: 23 Partially extended on 03/07/2025 at 4:35 PM. This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Refer to State Form for additional State Findings. Abbreviations: RN Registered Nurse POC Plan of Care CM Clinical Manager SOC Start of Care SN Skilled Nurse QR 3/13/25 A2

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 home health agency failed to ensure patients received all services as ordered in the POC for 2 of 5 active patient records reviewed (Patient #2, 4). Findings include: 1.The Visit Schedule / Missed Visit policy, revised 06/25/2024, indicated “In the event of employee illness, vacation, holidays and unexpected voluntary or involuntary termination of employment, the Agency will provide alternate, qualified personal care worker(s) to complete the required visits… The Agency will coordinate with the patient or patient’s authorized representative to reschedule a missed visit whenever possible…” 2. Review of Patient #4’s clinical record included a SOC date of 03/11/2020, a POC for certification period 12/15/2024 to 02/12/2024 with orders including but not limited to SN visits four to six days per week, and a POC for certification period 02/13/2025 to 04/13/2025 with orders including but not limited to SN visits four to six days per week. Review of Patient #4’s SN visit notes indicated Patient #4 received two SN visits the week of 01/05/2025 and three SN visits the weeks of 01/12/2025, 01/19/2025, 01/26/2025, 02/02/2025, 02/09/2025, 02/16/2025, and 02/23/2025. Patient #4 received no SN visits the week of 03/02/2025. Missed visits notes indicated a reason of “Caregiver Cancelled” for missed visits on 01/09/2025, 01/10/2025, 01/16/2025, 01/17/2025, 01/23/2025, 01/24/2025, 01/30/2025, 01/31/2025, 02/06/2025, 02/07/2025, 02/13/2025, 02/14/2025, 02/20/2025, and 02/21/2025. The agency failed to ensure Patient #4 received SN visits four to six times per week any week from 01/05/2025 through 03/07/2025. During an interview on 03/07/2025 at 4:11 PM, the CM indicated she was Patient #4’s RN case manager and indicated “caregiver cancelled” meant the agency employee cancelled the visit. The CM further indicated Patient #4 did not receive their SN frequency as ordered in the POC due to the following missed visits which were all documented as “caregiver cancelled”: 01/06/2025, 01/09/2025, 01/10/2025, 01/16/2025, 01/17/2025, 01/23/2025, 01/24/2025, 01/30/2025, 01/31/2025, 02/06/2025, 02/07/2025, 02/13/2025, 02/20/2025, and 02/21/2025. The CM indicated the missed visit documentation was not yet there for the missed SN visits on 02/27/2025, 02/28/2025, 03/03/2025, 03/04/2025, 03/05/2025, 03/06/2025, and 03/07/2025. During an interview on 03/07/2025 at 4:18 PM, the Administrator indicated the reason there were no SN visits the week of 03/02/2025 was because the regular nurse had surgery, and another nurse is in training that will provide services to that patient. 3. Review of Patient #2’s clinical record included a SOC date of 11/28/2023 and a POC for certification period 01/21/2025 to 03/21/2025 with orders for SN visits, one to two visits, five to seven days per week. Review of Patient #2’s SN visit notes indicated the patient received four SN visits the week of 02/16/2024. Missed visit notes indicated the reason for the missed visit on 02/16/2025 was “Caregiver Cancelled.” During an interview on 03/11/2025 at 11:45 AM, the Alternate CM indicated she was Patient #2’s RN case manager. The Alternate CM further indicated the reasons Patient #2 did not receive their SN frequency as ordered in the POC for the week of 02/16/2025 through 02/22/2025 were the nurse called off sick for the 02/16/2025 shift, and the agency was unable to find a replacement. The Alternate CM indicated on 02/17/2025 it looked like the nurse was unavailable and indicated for the 02/21/2025 visit a member of the patient’s family cancelled the visit because they were going to be with the patient and would provide 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 home health agency failed to ensure infection control precautions were performed related to bag technique for 1 of 2 home visit observations of RNs (RN 2). Findings include: 1 .The Exposure Control Plan: OSHA Regulations policy, revised 06/25/2024, indicated “…Nursing Bag Technique… Upon entering the home, place the bag on a clean surface; paper towels, barriers or plastic bag must be used to create a clean area…” 2. A home visit observation of RN 2 providing care for Patient #3 was conducted on 03/07/25 beginning at 9:33 AM. Observed RN 2’s nurse bag open and directly on floor with no barrier underneath. 3. During an interview on 03/07/2025 at 10:00, RN 2 indicated that the area the bag was located on the floor was the designated area for his bag in the patient’s home. 4. During an interview on 03/07/2025 at 4:23 PM, the CM indicated the nurse bag should not be left open in the patient’s home when not being accessed and indicated the nurse bag should not be placed directly on the floor. The CM further indicated the nurse bag should be placed on barrier or hung from a chair.

This survey was for a Federal and State complaint of a Home Health Agency Provider. Survey Dates: May 30, 31, June 01, 02, and 05, 2023 Complaint: 98819 was investigated; related and unrelated Federal and State deficiencies were cited. 12-month unduplicated skilled census: 156 Survey was Fully Extended 06/02/2023. During this Federal and State Complaint Survey, Team Select was found to be out of compliance with Conditions of Participation 484.55 Comprehensive Assessment of Patients and the Conditions of Participation 484.60, Care Planning, Coordination of Services, and Quality of Care. Based on the Condition-level deficiencies during the 06/05/2023 survey, your home health agency was subject to an extended survey pursuant to section 1891(c)(2)(D) of the Social Security Act on 06/02/2023. Therefore, and pursuant to section 1891(a)(3)(D)(iii) of the Act, your agency is precluded from operating a home health aide training, skills competency and/or competency evaluation programs for a period of two years beginning June 5, 2023, and continuing through June 4, 2025. This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Refer to State Form for additional State Findings. QR: Area 2 6/13/23

Be free from abuse CFR(s): 484.50(c)(2) Be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect and misappropriation of property; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure Patients were free of abuse, in 1 of 1 one complaint / incident reviewed of registered nurse (RN), (RN 1), with the potential to affect all patients in which RN provided care. Findings include: 1. CMS defines Abuse, and includes the willful infliction of injury, intimidation, resulting in physical harm and or mental anguish. Abuse may be verbal, mental, physical. Verbal abuse refers to and includes abuse perpetrated through any use of disrespectful and or oral language directed toward and in the presence of the Patient. Mental abuse is a type of abuse that includes, but is not limited to, threats of intimidation (e.g. living in fear in one's own home). Physical abuse refers to abuse perpetrated through any action intended to cause physical harm or pain, trauma or bodily harm. 2. Review of agency policy dated 12/30/21 and titled “Incident Reporting B-340” indicated the agency will immediately suspend an employee, pending the agency investigation, who is involved in an incident with alleged, suspected, or actual abuse. 3. Review of the agency’s undated personnel policy titled “Safety,” indicated any use or possession of a firearm while on company business can result in an employee being disciplined, up to and including termination. 4. The agency's incident log included an incident, reported by RN 1 and occurred on 5/23/23 at 9:35 PM; incident involved RN 1, Patient 1, and Patient #1's family members. The incident revealed RN 1 reported that a family member entered the home, RN 1 was holding a firearm, and asked the family member to leave the premises. The unsigned investigative narrative, dated 5/24/23, was provided by the clinical director; the narrative relayed RN 1 was informed by the director of nursing, that RN 1 they should not have handled a firearm, of any kind, during the provision of care and in a patient's home. The narrative included a response from RN 1, that at the time of the reported incident, he / she was trying to reassemble the firearm that belonged to the primary caregiver of Patient # 1. Incident investigation indicated agency notified child protective services, adult protective services, police department, physician office, and case management group. The investigation revealed the agency failed to follow their policy, Incident Reporting B - 340; 5/23/23 was the reported date of the incident, RN #1 provided skilled nurse services to Patient #1 on 5/24/23; the agency did not suspend RN 1 until 5/25/23 at 3:00 PM. 5. A review of clinical record for Patient #1 evidenced RN 1 provided skilled nursing care services for multiple hours, on 5/24/23. 6. Other Roster 3, was interviewed, by phone, on 5/30/2023 at 4:30PM. They relayed that on 05/23/23, they entered the residence of Patient #1; upon entry, RN 1 was standing to the side of Family Member 2, holding a gun, Glock 9mm, which belonged to Family Member 2. Other Roster 3 indicated Patient #1 and Family Member 3, a minor, were present, and indicated RN #1 threatened Other Roster 3 with the gun, as they told Other Roster 3 to leave the home. 7. During an interview on 6/01/23 at 2:49 PM, the director of clinical service indicated RN #1 was placed on suspension on 05/25/2023 and the investigation moved to their corporate level human resource. 8. At 3:35 PM, the administrator indicated the agency will terminate RN #1 due to handling a gun and violating professional boundary line with a patient / caregiver.

Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient's eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This CONDITION is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the skilled nurse completed an assessment with an accurate representation of the patient's current status (See G528), failed to ensure the comprehensive assessment included a medication review to identify potential medication issues requiring physician input (See G536), and failed to ensure a recertification comprehensive assessment was conducted during the last 5 days of every 60 days (See G546). The cumulative effects of these systemic problems resulted in the home health agency being found out of compliance with Conditions of Participation 42 CRF 484.55 Comprehensive Assessment of Patients.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the skilled nurse completed an assessment with an accurate representation of the patient's current status in 1of 2 patients with a comprehensive assessment, following a hospitalization (Patient # 6), with the potential to affect all patients. Findings include: 1. Review of an agency wound policy indicated wound assessments should include the location, size, color, status of the wound edges, and type of new skin growth. 2. A review of the clinical record for Patient #6, included a comprehensive assessment, dated 4/03/23, completed by registered nurse (RN) 4 with notation that the assessment was for the resumption of care, following a hospitalization on 4/01/23, and to stand for the recertification assessment. The assessment relayed Patient was admitted to the hospital for a planned surgical intervention on 03/29/23 and was discharged 4/01/23. The assessment included documentation that described the healing status of a surgical wound as with new tissue growth and intact wound edges (the edges meet, are flush with surrounding skin) and included documentation that indicated the wound was not observable because it was covered with a dressing, applied the day of surgery, and the dressing was not to be removed until Wednesday, (April 05, 23). 3. Review of the plan of care, for the certification period 4/6/23 – 6/04/23, completed by RN 4, included a summary of Patient and relayed Patient #6 had clear breath sounds with rhonchi (sounds like snoring, indicating fluid in the lower airway), present during the assessment. 4. During an interview on 6/05/23 at 2:04 PM, the Clinical Supervisor indicated the wound must not be covered to assess healing status and breath sounds are not clear if rhonchi are present. 410 IAC 17 - 14 - 1(a)(1)(B)

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment included a medication review to identify potential medication issues requiring physician input in 2 of 6 (Patients #2, #5) active records reviewed, with the potential to affect all patients. Findings include: 1. Review of an agency policy titled “Medication Reconciliation C – 709,” indicated the purpose of the policy was to prevent potential medication errors. The policy indicated the medications should be reviewed at the start of the patient’s care. 2. Review of an agency policy on comprehensive assessments indicated a medication review was to be completed to identify potential adverse reactions, significant side effects, significant drug interactions, duplicate therapy, and issues with medication compliance. 3. Review of the clinical record for Patient #2, start of care 10/26/2022, evidenced the medication review was conducted on 11/9/2022, 12 days after the date of the comprehensive assessment. 4. Review of the clinical record for Patient #5 evidenced a comprehensive assessment dated 4/02/2023; the date of a medication review was 5/09/2023, 16 days later. 5. During an interview on 5/31/2023 at 4:15 PM, the Clinical Supervisor indicated staff will sometimes complete the medication review a “couple of days” after the comprehensive assessment. The Clinical Supervisor confirmed Patient #2’s and Patient #5’s medications were reviewed 12 and 16 days respectively after the start of care, indicated was not conducted as part of the comprehensive assessment. 410 IAC 17 - 14 - 1(a)(1)(B)

Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure a recertification comprehensive assessment was conducted during the last 5 days of every 60 days, in 1 of 3 active pediatric records reviewed (Patient #4). Findings include: Review of an undated agency policy titled "Patient Reassessment/Update of Comprehensive Assessment C-155" indicated the comprehensive assessment will be updated and revised the last 5 days of every 60 days. Clinical record review of Patient #4 on 05/31/2023 revealed the patient received skilled nurse services on 05/26/2023, 05/28/2023, 05/30/2023 and 05/31/2023 for the administration of medications and tube feeding, and provided caregiver education. The clinical record failed to evidence a comprehensive assessment prior to the end of the plan of care for the certification period ending 5/25/23. During an interview on 05/31/2023 at 2:00 PM, the director of clinical services indicated the comprehensive assessment was not conducted. 410 IAC 17-14-1(a)(1)(B)

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on record review, observation and interview, the home health agency failed to ensure the medical care provided was established in consultation with the attending physician, and within an individualized written plan of care (See G572), failed to ensure the plan of care was individualized and included all pertinent diagnoses and accurate medications (See G574), and failed to notify the physician of changes in the patient need for services (See G590). The cumulative effect of these systemic problems resulted in the home health agency's inability to ensure the provision of quality health care for the condition of participation at 42 CFR 484.60 Care planning, coordination, and quality of care.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to ensure the medical care provided was established in consultation with the attending physician, and within an individualized written plan of care in 1 of 3 active pediatric records reviewed (Patient #4). Findings include: 1. A review of the clinical record review for Patient #4 on 5/31/23 revealed Patient received skilled nurse services on 05/26/23, 05/28/23, 05/30/23 and 05/31/23 for the administration of medications and tube feeding, and caregiver education. The clinical record failed to evidence a plan of care, nor written or verbal orders for the medical care provided. During an interview on 5/31/23 at 2:00 PM, the director of clinical services indicated they had not contacted the attending physician nor developed a plan of care, nor do they have physician orders for the care provided after 5/25/23. 2. A clinical record review of Patient #3, included a plan of care for the certification period 04/11/2023 to 06/09/2023 with orders for home health aide services 1/2 to 4 hours a day, 1-3 days a week, and for 4-8 hours a day, for 4-6 days a week for 9 weeks. The clinical record failed to evidence home health aide visits were provided as ordered. Review of agency documents titled “Client Logging Report” included documentation that the agency could not provide staff for the ordered home health aide visits from 04/04/2023 to 05/20/2023. During an interview on 6/05/23 at 2:04 PM, the administrator indicated the last home health aide visit for Patient #3 was made on 4/01/23 and no further. The director of clinical services indicated the agency thought another daughter of Patient would be hired to provide the ordered home health aide services, which did not occur.

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, interview, and observation the agency failed to ensure the plan of care was individualized and included all pertinent diagnoses and accurate medications for 4 of 7 patient records reviewed (Patient #3, 4, 5, 7). Findings include: Review of an agency policy titled “Plan of Care C – 580” indicated the plan of care is developed based on the current assessment of the patient and must include all pertinent diagnoses and medications, including dosage and route of administration. Review of the clinical record for Patient #5, certification period 4/24/2023 – 6/22/2023, evidenced a plan of care which identified a diagnosis of spastic quadriplegic cerebral palsy (a disorder affecting muscles and movement of all four limbs, face, and torso). No other diagnoses were identified. Review of clinical information from Entity A included documentation of Patient #5’s diagnoses of spastic quadriplegic cerebral palsy, pancreatic cyst, constipation, gastroesophageal reflux disorder (GERD), intellectual disability, severe osteoporosis, and the presence of a gastrostomy tube (a tube inserted into the stomach that brings nutrition and medication directly to the stomach). Documentation included history of multiple lower limb fractures, recurrent bouts of pneumonia, and recurrent abdominal abscesses. During an interview on 6/1/2023 at 3:55 PM, the Clinical Supervisor indicated the plan of care was missing pertinent diagnoses that could impact Patient #5’s care. Review of an agency policy dated 12/30/2022 and titled “Plan of Care C-580” indicated the plan of care will include all pertinent diagnoses and all medications. Review of an agency policy dated 12/30/2022 and titled “Physician Orders C-635” indicated all orders for medications must include the route of administration. Clinical record review of Patient #3 revealed the plan of care for the certification period of 04/11/2023 to 06/09/2023 indicated the oral route for administration of cyanocobalamin solution (treats Vitamin B12 deficiency) that failed to evidence the correct route as intramuscular (injection into a muscle). During an interview on 06/05/2023 at 11:40 AM, the director of clinical services indicated the route of administration should be intramuscular. Clinical record review of Patient #4 revealed the plan of care for the certification period of 03/27/2023 to 05/25/2023 that indicated the pertinent diagnosis of dependence on a ventilator (machine that moves air in and out of the lungs). During an observation visit with Patient #4 on 05/31/2023 at 10:00 AM, observed a stoma (surgical opening) on the front of patients’ neck without tubing that would be connected to a ventilator machine. Registered nurse (RN) 3 indicated the patient pulled out the tubing in January of 2023 and was never replaced. During an interview on 05/31/2023 at 4:25 PM, the director of clinical services indicated would remove a diagnosis from the plan of care that was no longer applicable for a patient. 410 IAC 17-13-1 (a)(1)(C), 17-13-1 (a)(1)(D)(ix)

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to notify the physician of changes in the patient need for services for 1 of 1 discharged patient records reviewed (Patient #3). Findings include: Review of an agency policy dated 12/30/2022 and titled “Plan of Care C-580” indicated professional staff will promptly report to the physician any changes that suggest a need to alter the plan of care. Clinical record review of Patient #3, included a plan of care for the certification period 04/11/23 to 06/09/23, with orders for aide visits. The record failed to evidence home health aide visits were provided after 04/01/23. The clinical record evidenced the patient was discharged on 5/25/23. Review of home health aide visits indicated the last visit made was on 04/01/23 for 2 hours by home health aide (HHA) 1. Documentation failed to evidence notification to the physician that Patient was not receiving home health aide services, as ordered. During an interview on 6/05/23 at 2:04 PM, the administrator indicated the last home health aide visit for Patient #3 was made on 4/01/23 and no further. The director of clinical services indicated the agency thought another daughter of Patient would be hired to provide the ordered home health aide services. 410 IAC 17-13-1 (a)(2)

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 record review, observation, and interview, the agency failed to ensure staff used proper hand hygiene (handwashing or use of alcohol based hand rub) to prevent the spread of infection in 1 of 2 skilled nurse home visit observations (Registered nurse (RN) 2, and with the potential to affect all patients in which RN 2 provided direct care or supervised direct care. Findings include: 1. Review of an agency policy on hand hygiene, indicated hand hygiene must be completed prior to providing patient care and before putting on gloves. 2. During a home observation visit of RN 2, during the provision of direct care with Patient #2 on 5/31/23, RN 2 used a catheter to suction (insertion of a tube to remove thick mucus from the trachea) Patient. Prior to performing the procedure, RN 2 failed to complete hand hygiene (no handwashing or use of an alcohol based hand rub) prior to donning gloves. During an interview at the visit, RN 2 indicated she did not realize she did not complete hand hygiene. 3. During an interview on 6/2/2023 at 12:47 PM, the Clinical Supervisor indicated hand hygiene (handwashing or the use of an alcohol based hand rub) was to be performed before providing care to the patient as well as before putting on gloves. 410 IAC 17 - 12 - 1(m)

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the licensed practical nurse (LPN) completed an assessment, as part of the interdisciplinary team, with an accurate representation of the patient's status in 2 of 4 (Patients #5, 6) active patients who received LPN care, with the potential to affect all patients receiving care from an LPN. Findings include: 1. Review of an agency wound policy indicated wound assessments should include the location, size, color, status of the wound edges, and type of new skin growth. 2. Review of the clinical record for Patient #5, with start of care 4/24/2023, evidenced documentation of a nurse visit performed by licensed practical nurse (LPN) 1 on 5/5/2023, which identified an open area of skin on Patient #5’s left buttock. The clinical record failed to include documentation of notification to the registered nurse regarding this finding. The clinical record evidenced LPN 2 performed the skilled nurse visits prior to and after LPN 1’s visit; LPN 2’s visit notes failed to identify the open wound. Review of a skilled nurse visit note, dated 5/11/2023, indicated LPN 2's skilled nurse visit was 9 hours in length with Patient #5; the visit ended at 3:30 PM. The visit note included documentation of a low - grade fever of 99.4 Fahrenheit; other findings were documented as normal. Review of clinical documentation from Entity A, dated 5/11/23, indicated Patient arrived at the Emergency Room (ER) on 5/11/2023 at 6:36 PM, 3 hours after LPN 2 left their shift. Patient #5 arrived at the ER with a fever (102 F), respiratory failure (increased oxygen demand), high pulse rate, low blood pressure, and pain (symptoms of sepsis, an overwhelming response to infection that can cause organ failure and death). Patient #5 was admitted to the hospital with diagnoses of sepsis, pneumonia, abdominal abscess (a pocket of infection), possible pancreatic abscess, and a possible femur (thigh) fracture. LPN 2 failed to identify and document symptoms other than a low - grade fever. 3. Review of a nursing visit note for Patient #6, completed by LPN 3 on 4/04/2023, indicated the healing status of a surgical wound, including type of skin growth, however the note indicated the wound was not visible as it was covered with a dressing. 4. During an interview on 6/01/2023 at 3:55 PM, the Clinical Supervisor indicated LPN 2 should have recognized Patient # 5’s symptoms. 5. During an interview on 6/05/2023 at 2:04 PM, the Clinical Supervisor indicated the wound must not be covered with a dressing to assess healing status. 410 IAC 17 - 12 - 2(g)

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to provide services, ordered by the physician and as indicated within the plan of care for 1 of 6 records reviewed (Patient # 6) with skilled nurse services. Findings include: Review of the clinical record for Patient #5, start of care 4/24/2023, evidenced a coordination note dated 5/3/2023, which documented a verbal physician order to resume care for the patient following hospitalization. Review of the comprehensive assessment dated 5/2/2023 confirmed care was provided without a physician order. Review of the coordination note dated 5/31/2023 at 2:40 PM indicated a verbal physician order was received to continue care. Review of a revision to the plan of care indicated Patient #5 was discharged home on 5/30/2023 and care was provided on 5/30/2023, one day before the verbal order was obtained. Review of Patient #5’s plan of care evidenced an order for the registered nurse (RN) to provide supervisory visits every 30 days. Review of the clinical record for Patient #6, certification period 4/6/2023 – 6/4/2023, evidenced a verbal physician order to resume care dated 4/4/2023. Review of the comprehensive assessment dated 4/3/2023 confirmed care was provided without a physician order. Review of nursing visit notes, completed by licensed practical nurse (LPN) 3, indicated postural drainage (positioning patient so airway secretions are removed by gravity) was completed. Licensed Practical Nurse 3 performed this procedure on 4/4, 4/5, 4/6, 4/7, 4/10, 4/18, 4/19, 4/20, 4/24, 4/25, 4/26, 4/27, 5/1, 5/2, 5/3, 5/4, 5/8, 5/9, 5/10, 5/11, 5/22, 5/23, 5/24, 5/25, 5/30, and 5/31/2023. Review of the plan of care for Patient #6 failed to evidence an order for postural drainage. During an interview on 6/5/2023 at 2:39 PM, the Clinical Supervisor confirmed LPN 3 completed the procedure without a physician order. Review of nursing visit notes for 4/5 and 4/6/2023, indicated LPN 3 completed wound care on Patient #6’s surgical wound. Review of the record failed to identify a physician order for wound care. During an interview on 6/5/2023 at 2:39 PM, the Clinical Supervisor confirmed there were no physician orders to provide wound care. 410 IAC 17 - 14 - 1(a)(1)(H) 410 IAC 17 - 14 - 1(a)(2)(F) Review of an undated RN job description indicated the RN provides skilled nursing care in accordance with physician orders and the plan of care. Review of an undated licensed practical nurse (LPN) indicated the LPN provides skilled nurse care in accordance with physician orders and the plan of care. Review of an agency policy dated 12/30/2022 and titled “Physician Orders C-635” indicated all medications, treatments and services provided to patients must be ordered by a physician. Clinical record review of Patient #3, included the plan of care for the certification period 04/11/2023 to 06/09/2023 that indicated orders for home health aide service for .5 to 4 hours a day, 1-3 days a week, and for 4-8 hours a day, for 4-6 days a week for 9 weeks. Review of agency documents titled “Client Logging Report” included documentation that indicated the agency could not provide staff for the ordered home health aide visits from 04/04/2023 to 05/20/2023. Documentation failed to evidence the agency provided services according to the plan of care. Clinical record review of Patient #4, included a plan of care for the certification period 03/27/2023 to 05/25/2023 that indicated orders for skilled nurse services for 6-10 hours a day, for 4-6 days a week. Record review failed to evidence a revised plan of care for the certification period beginning 05/26/2023. Review of skilled nurse visits indicated visits were made on 05/26/2023, 05/28/2023, 05/30/2023, and 05/31/2023 with no physician orders. Documentation failed to evidence services were provided according to a plan of care. During an interview on 05/31/2023 at 2:16 PM, when asked to see the physician orders to provide care to Patient #4, the director of clinical services indicated a nurse will go out today to complete a comprehensive assessment and then obtain a physician order to revise the plan of care with a retroactive order to be effective on 05/26/23. 410 IAC 17-14-1 (a)(1)(H) 17-14-1(a)(2)(F)

Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This ELEMENT is not met as evidenced by: Based on record review and interview, the registered nurse (RN) failed to supervise the care provided by the licensed practical nurse (LPN) for 1 of 6 active records reviewed (Patient # 5). Findings include: Review of an agency policy titled Supervisory Visit of Patient/ Staff C – 315 indicated the purpose of the visit was to ensure staff were competent in identifying and responding to patient needs. Review of the clinical record for Patient #5, start of care 4/24/2023, failed to evidence the licensed practical nurses (LPNs) received supervisory visits, in which the registered nurse (RN) ensured the LPN was providing appropriate care based on the plan of care. When the last supervisory visit note was requested, the Clinical Supervisor provided one dated 3/22/2023. During an interview on 6/2/2023 at 9:14 AM, the Clinical Supervisor confirmed supervisory visits were not done. Review of the employee record for LPN 2 evidenced an annual performance evaluation signed by LPN 2 on 3/6/2023. The evaluation was completed by an administrative staff person with no nursing education. The annual performance evaluation signed by LPN 2 on 2/25/2022 was completed by an administrative staff person with no nursing education. The record contained a competency form to assess LPN 2’s clinical skills, dated 3/21/2021. The form included LPN 2’s initials and signature but did not provide evidence of observation or education by an RN. There were no RN initials for the individual clinical skills and the form was not signed by an RN. During an interview on 6/1/2023 at 3:55 PM, the Clinical Supervisor confirmed the agency has a quality review of notes but once the staff person documents well, they are not reviewed any longer. The Clinical Supervisor confirmed LPN 2’s notes have not been reviewed and lack clinical elements. 401 IAC 17 - 14 - 1(a)(1)(J) Review of an undated LPN job description indicated the LPN provides skilled nursing care under the supervision of the RN. Clinical record review of Patient #1, included the plan of care for certification period 04/10/2023 to 06/08/2023 that indicated skilled nurse services for 6.5-10.5 hours a day, for 3-5 days a week, and for 5.5-9.5 hours a day, for 1-2 days a week. The plan of care indicated the RN to perform supervisory visits at least once every 30 days unless RN only care has been provided. Record review of skilled nurse visits made during the 04/10/2023 to 06/08/2023 certification period indicated LPN visits were made on 04/20/2023 and 05/07/2023. Documentation failed to evidence the RN supervised the LPN during this 60-day period. During an interview on 06/01/2023 at 4:30 PM, the director of clinical services indicated the RN did not make an LPN supervisory visit during this time. 410 IAC 17-14-1 (a)(1)(J)

Protection of records CFR(s): 484.110(d) Standard: Protection of records. The clinical record, its contents, and the information contained therein must be safeguarded against loss or unauthorized use. The HHA must be in compliance with the rules regarding protected health information set out at 45 CFR parts 160 and 164. This STANDARD is not met as evidenced by: Based on observation and interview, the home health agency failed to ensure patient's personal health information was stored in a locked, secure area in 1 of 1 home health agency. Findings include: On 05/30/2023 at 10:15 AM, entered the unlocked door to the entrance of the home health agency. During a tour of the home health agency office on 05/30/2023 at 11:50 AM, observed a room with no door. Observed patient paper charts on open shelves inside this room. During an interview on 05/30/2023 at 11:50 AM, the administrator indicated the front door to the office is locked at the end of the day. Indicated the door to the room with patient paper charts was removed last Friday by the property owner, because the office was being renovated; there was no door to this room.

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102. Survey Dates: 5/17, 5/18, 5/19, 5/20, and 5/23/2022. Census: 125 At this Emergency Preparedness survey, Together Homecare was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 484.102.

This visit was for a Federal Recertification and State Relicensure survey of Together Homecare with 3 complaints. Survey Dates: 5/17, 5/18, 5/19, 5/20, and 5/23/2022. Census: 125 Complaint #29494: Unsubstantiated, due to lack of sufficient evidence. Complaint #29806 - Unsubstantiated, due to lack of sufficient evidence. Complaint #29807 - Unsubstantiated, due to lack of sufficient evidence. These deficiencies reflect State Findings cited in accordance with 410 IAC 17.

Update of the comprehensive assessment CFR(s): 484.55(d) Standard: Update of the comprehensive assessment. The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient's condition warrants due to a major decline or improvement in the patient's health status, but not less frequently than- This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure a comprehensive re-assessments were completed in the home by a registered nurse for 1 of 2 skilled patients reviewed (Patient #7). Findings include: Clinical record review for Patient #7, with start of care date of 01/07/2022, included an agency document titled “Form Type: Recertification-OASIS D1”, dated 03/04/2022 and 05/04/2022. The recertification assessments each failed to include vital signs and noted that the visits were conducted via telemedicine, with an unknown staffer in the home conveying the information to the RN (assessment over the phone). During an interview on 5/20/2022 at 2:10PM, the director of nursing indicated when a nurse is in the home, caring for a patient, that nurse will provide patient information to the registered nurse, over the phone, who then completes the comprehensive re-assessment.

Coordination of Care CFR(s): 484.60(d) Standard: Coordination of care. The HHA must: This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to coordinate care for 1 of 2 patients reviewed with orders for skilled nursing care (Patient #1). Findings include: 1. Clinical record review for Patient #1 evidenced a Plan of Care for certification period 3/20/2022 – 5/18/2022, with an order for “… Ferrous sulfate [to improve the iron level] … on hold until labs are drawn reported per SN [skilled nurse] 10/1/2021 ….” 2. During an interview at the exit conference on 5/23/2022 at 3:53 PM, the Director of Clinical Services confirmed the agency did not know if the lab tests were completed or if the medication was current or on hold. He / She further confirmed that coordination of care was not completed.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on record review and interview, the registered nurse (RN) failed to ensure the home health aide (HHA) care plan was patient specific for 1 of 4 clinical records reviewed with orders for HHA care services (Patient #2). Findings include: Clinical record review for Patient #2, with start of care date of 02/15/2022, included a Plan of Care for the certification period of 4/16/22 to 6/14/22 with orders for aide services to assist with bathing at a sink with each visit. The plan of care identified Patient 2s functional limitations included ambulation and endurance, utilized a wheel chair for mobility, utilized a Hoyer [mechanical lift to assist to transfer a patient from surface to surface] transfer for transfers from their hospital bed to other surfaces, and Patient # 2 was on continuous oxygen at 3 liters / minute per nasal canula. The Aide Care Plan, dated 02/15/2022, included the home health aide task of a sink bath, with every aide care visit. A review of eleven home health aide visit care notes, dated from 5/02/2022 through 5/18/2022, each evidenced aide documentation that they assisted Patient #2 with bed baths, during each of the eleven aide care visits reviewed. During an interview on 5/18/2022 at 4:00PM, the director of clinical services indicated the home health aide is to follow the aide care plan and a sink bath takes place with patient sitting in front of a sink.

Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure staff were qualified or competent to complete the assigned tasks in 1 of 3 home visit observations (Registered Nurse (RN) #1). Findings include: 1. During a home visit observation on 5/18/2022, Registered Nurse (RN) #1, performed suctioning of Patient #1’s tracheostomy tube (a tube inserted into the windpipe to assist with breathing). When queried about the tracheostomy care he / she provided for Patient #1, RN #1 relayed he / she completed suctioning and that the tracheostomy tube was changed on his / her scheduled day off and that the daily tracheostomy care was provided by the patient's primary care giver. RN #1 indicated he / she was the primary nurse for Patient #1 and provided skilled nurse care 4 days a week, 8 hour shifts. 2. A chart review was completed for Patient #1 on 5/18/2022, included physician orders “… inner cannula [a tube that acts as a liner to the main tracheostomy tube] care daily and PRN (as needed) … change trach [tracheostomy] ties [ties hold the phalange in place; the phalange holds the tracheostomy tube in place] … every other day….” 3. Review of the agency complaint log revealed documentation of a complaint, dated 4/7/2022 regarding Patient #1. The complaint indicated Patient #1’s primary caregiver called the agency at 2:48 PM and spoke with the Director of Clinical Services and relayed that they believed “… [RN #1] does not know how to change [Patient #1’s] trach ….” 4. Review of the personnel record for RN #1 revealed a “Skilled Competency Form” dated 12/23/2020. The skill section included care of a tracheostomy, which was blank. 5. A review of an undated agency policy titled “Performance Evaluation D-260” identified the purpose, among others, “… to determine need for further training….” 6. Review of an agency job description for a registered nurse revealed “Essential Functions/ Areas of Accountability” of “… Consistently demonstrates competency with technical nursing skills …” and “Demonstrates competency in areas of assignment or identifies the need for additional training….” 7. During an interview on 5/19/2022 at 3:15 PM, the Administrator confirmed RN #1 was not checked for competency in managing a tracheostomy.

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 observation, record review, and interview, the agency failed to ensure the clinician's documentation included the actual time and duration of a service in 1 of 3 home visits observations conducted (Registered Nurse #2). Findings include: 1. A home visit observation was scheduled for 5/18/2022 at 10:30 AM at the residence of Patient # 1, to observe a registered nurse [RN] complete a recertification assessment. Upon arrival to the visit at 10:25 AM, the Director of Clinical Services stated, “The assessment was completed earlier today.” Registered Nurse (RN) #1 was present in the home, to provide patient care, and did not complete the recertification reassessment during the home visit observation. RN #2 was not present in the home during the home visit observation. 2. Review of Patient #1's recertification assessment revealed the assessment was completed on 5/18/2022, by RN #2; the document was dated and time of visit as “5-18-2022 / 10:00 – 11:00.” 3. During an interview on 5/20/2022 at 3:06 PM, both the Administrator and the Director of Clinical Services confirmed documentation of the home visit and patient assessment should include the actual time of the visit. 4. Review of an undated agency policy titled “Clinical Documentation C-680” stated documentation for each visit should include “… Actual time and length of the patient visit….” 410 IAC 17 - 15 - 1(a)(7)