Every finding on record at Together Homecare of Indianapolis, LLC

This visit was for a Federal Recertification and State Relicensure survey of a Home Health Provider. Survey Dates: 01-22-2023, 01-23-2023, 01-24-2023, and 01-25-2023 12-Month Unduplicated Skilled Admissions: 205 This deficiency report reflects State Findings cited in Accordance with 410 IAC 17. Refer to State Form for Additional state tags. QR Completed on 01/30/2024 by A4

Accessibility CFR(s): 484.50(f)(1,2) Standard: Accessibility. Information must be provided to patients in plain language and in a manner that is accessible and timely to- (1) Persons with disabilities, including accessible web sites and the provision of auxiliary aids and services at no cost to the individual in accordance with the Americans with Disabilities Act and Section 504 of the Rehabilitation Act. (2) Persons with limited English proficiency through the provision of language services at no cost to the individual, including oral interpretation and written translations.Standard: Accessibility Information must be provided to patients in plain language and in a manner that is accessible and timely to- This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure patients/caregivers were provided an option or given a preference in the way patient Plans of Care and Medication information and instructions were received, in 3 of 3 home visits. (Patients #3, #4, and #5) Findings include: 1. Review of an agency document dated 08-05-2023, titled '1.1 Patient Rights' stated, "... The plan of care must be provided to the patient and/or his/her authorized representative (if any) no later than the next visit after the plan of care has been approved by the physician... Clear written communication between the HHA and the patient and the patient's caregiver and authorized representative (if any) helps ensure that patients and families understand what services to expect from the HHA, the purpose of each service and when to expect the services ..." Review of an undated agency document titled 'CubHub Patient Portal Instructions' provided a web address with instructions to gain access to the agency's EMR and it's patient portal and create a password and username. Review of an undated agency document titled 'Client Portal CubHub Systems' contained 11 pages of detailed instructions on how to gain access to specific patient documents which included, but were not limited to: plan of care, assessments, and medication list. 2. On 01-22-2024 at 3:30 PM, during a home visit for Patient #3, Person A (a family member) when queried, indicated there was no current plan of care in the home, was aware of a patient portal that could be accessed on the internet to view patient documents from the agency, but had not yet accessed this. On 01-23-2024 at 1:10 PM, during a home visit for Patient #5, Person B (a family member) when queried, indicated there was no current plan of care in the home provided by the agency. Person B indicated was aware of a patient portal that could be accessed on the internet to view patient documents from the agency, but had not yet accessed this. On 01-23-2023 at 4:45 PM, during a home visit for Patient #4, the patient when queried, indicated there was no current plan of care in the home provided by the agency. Patient #4 indicated had recently become aware of the patient portal that could be accessed online to view their documents from the agency, but had not accessed this yet. 3. On 01-24-2024 at 3:58 PM with the Administrator and Director of Nursing, when queried regarding the lack of recent plans of care in the home, indicated the agency had provided access to a patient portal for patients/family use, but could not force them to utilize it. On 01-25-2024 at 10:22 AM, the Director of Nursing indicated the transition to their new agency and new electronic medical records (EMR) system led to a change in the way plans of care were delivered to patients. This transition to the new EMR started approximately June 1, 2023 and since then, all new patients had been presented with a printed booklet (which contained, but was not limited to: patient rights, notice of privacy practices, advanced directive information, state hotline number to lodge complaints, administrator contact number, individualized emergency plan, and consent forms). Along with this booklet, an instruction sheet had been provided which explained how to access the patient portal. For existing patients who transitioned over to the new agency and new EMR, the Director of Nursing indicated during recertification or resumption, the nurses were "taking everything" out to the patients at those visits.

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 patients' medication, weight, and safety measures to protect against injury were accurately reflected on the Plan of Care/485, in 2 of 5 active charts reviewed. (Patient #1 and #3) Findings include: 1. Review of an agency policy dated 08-05-2023, titled '2.6 - Plan of Care' stated, "POLICY Service will be provided in accordance with a written Care Plan based on the patient's diagnoses and assessment of immediate and long-range needs and resources ... PROCEDURE There is a written Plan of Care established based on the assessment of the patient ... The plan of care includes: ... nutritional requirements, medications and treatments ... Education and safety measures ..." 2. Review of the clinical record for Patient #1, certification period of 01-18-2024 through 03-17-2024. Non-skilled home health aide services were ordered 4-6 days per week for nine weeks. The plan of care dated 01-16-2024 contained a list of the patient’s current medications which included, but not were limited to: “… baclofen 10 mg Oral 1-2 tablets TID (three times daily) Muscle Relaxer Take 1-2 tablets TID – 6/20/2023”, “baclofen 20,000 mcg/ 20 ml (1,000 mcg/ ml intrathecal (injection into the spinal canal) 36 mcg/day (1.5mcg/ hr) Daily Pain from muscle spasms Baclofen pump to be injected intrathecally in MD office. – 7/25/2023 …”. The medication list also contained, “… Docusate [Colace] 100 mg 1 capsule BID (twice daily) Constipation – 6/10/2023 …” and, “… docusate sodium 100 mg Oral 1 tablet BID Constipation – 6/10/2023 …” A section titled 'Nutritional Requirements' stated, "16. Current Weight: 170" and failed to evidence a unit of measurement. A section titled '15. Safety Measures' failed to evidence a protocol/action plan for the patient's Autonomic Dysreflexia. A section titled '21. Orders for Disciplines and Treatments stated, "Autonomic Dysreflexia Action Plan - Follow up with Neurology and use Nitro Paste (nitroglycerin in paste form, the recommended initial emergency treatment of severe hypertension in patients with autonomic dysreflexia) PRN". The action plan failed to evidence further instruction on the use of Nitro Paste (found in the medication list, "nitroglycerin 0.02 mg/mg Topical Apply 1-inch SBP (systolic blood pressure) >180 and remove when SBP decreases to 140 PRN (as needed) 2-3 times in 45 minutes Autonomic Dysreflexia Apply to a 1-inch space on the forehead". The plan failed to evidence other interventions to remove/reduce triggers, and failed to evidence further instructions should the 3 attempts to use Nitro Paste fail to resolve the emergent episode. In total, the plan of care failed to evidence an explanation for duplicate instances of the same drugs, failed to include a unit of measurement for the patient's weight, and failed to contain a completed protocol/action plan for the patient's autonomic dysreflexia. 3. Review of the clinical record for Patient #3, certification period of 12-07-2023 through 02-04-2-24 included but was not limited to: Skilled private-duty nursing was ordered five (5) times per week for nine (9) weeks. The plan of care dated 12-06-2024 contained a medication list which included but was not limited to: “… Haleigh’s Hope CBD oil (15:1) 1gm/1ml Enteric – GB (gastrostomy button) 2ml QD seizures – 6/7/2023 …” And, “… Haleigh’s Hope CBD oil (15:1) 1gm/1ml Enteric – GB (gastrostomy button) 1.5 ml QD seizures – 10/6/2023 …” The plan of care also evidenced, "... Current Weight: 50 ..." The record failed to evidence an explanation for duplicate instances of the same medication and failed to include a unit of measurement for the patient's body weight. 4. In an interview on 01-23-2024 at 3:30 PM, during a home observation for Patient #3, Person A, the primary caregiver, when queried as to the duplicated entries of CBD oil appearing on the plan of care, indicated knew the difference and explained the 2ml dose was to be administered with the patient’s afternoon feeding and the 1.5 ml should be given with the night feeding. 5. On 01-24-2024 at 11:37 AM, the Alternate Administrator/Director of Nursing and Alternate Director of Nursing indicated were unaware of duplicated medications and the lack of a unit of measurement for body weight for Patient #1 and Patient #3 being carried over inaccurately to the plan of care from the comprehensive assessment, and indicated they suspected this to be a glitch in the new EMR (Electronic Medical Records) system but would investigate further and put in a ticket with the EMR vendor. Both indicated these discrepancies should have been caught. 6. On 01-24-2024 at 1:41 PM when queried as to what should be expected in an Autonomic Dysreflexia protocol/action plan for Patient #1, the Alternate Administrator/Director of Nursing indicated this patient was receiving only home health aide services, and would expect the aide would not apply medications, would notify any family present in the home and/or other pertinent family members, would call the nurse in the office to report any changes in the patient, and the aide could call 911. 7. On 01-25-2024 at 11:45 AM when queried regarding Patient #1 and the duplicate entries of baclofen and docusate on Patient #1’s Plan of Care medication list, Registered Nurse (RN) 2 indicated had also noticed duplications of medication appearing on patient's plans of care. Also indicated there should have only been one (1) instance of Docusate, confirmed the two (2) instances of Baclofen were accurate, and indicated there should be a further explanation as to why the medications appeared twice. Regarding Patient #1's autonomic dysreflexia protocol/action plan, RN 2 indicated patient's family member/primary caregiver is the one who would administer the Nitro Paste to the patient and RN 2 had already placed a call to the provider for further orders and instructions regarding next steps after the Nitro Paste is given and the episode remains unresolved, for example whether to call an ambulance or the doctor. Indicated further would be including instructions to ensure the home health aide is not to touch nor administer any medication. Reiterated the family member knows how to administer the medication and how to take the patient's blood pressure as well. 410 IAC 17-13-1(D)(viii,ix,x)

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 patients/caregivers received their most recent plans of care for 3 of 3 home visits observed. (Patients #3, #4, and #5) Findings include: 1. Review of an agency document dated 08-05-2023, titled '1.1 Patient Rights' stated, "... The plan of care must be provided to the patient and/or his/her authorized representative (if any) no later than the next visit after the plan of care has been approved by the physician... Clear written communication between the HHA and the patient and the patient's caregiver and authorized representative (if any) helps ensure that patients and families understand what services to expect from the HHA, the purpose of each service and when to expect the services ..." 2. On 01-23-2024 at 3:30 PM, during a home visit for Patient #3, Person A (a family member) when queried, indicated there was not a current plan of care in the home, was aware of a patient portal that could be accessed on the internet to view patient documents from the agency, but had not yet accessed this. On 01-23-2024 at 1:10 PM, during a home visit for Patient #5, Person B (a family member) when queried, indicated there was not a current plan of care in the home provided by the agency. Person B indicated was aware of a patient portal that could be accessed online to view patient documents from the agency, but had not yet accessed this. On 01-23-2023 at 4:45 PM, during a home visit for Patient #4, the patient when queried, indicated there was not a current plan of care in the home provided by the agency. Patient #4 indicated had recently become aware of the agency's patient portal that could be accessed online to view their own documents, but had not yet accessed this. 3. On 01-25-2024 at 10:22 AM, the Alternate Administrator/Director of Nursing indicated the recent transition to their new agency and new electronic medical records (EMR) system led to a change in the way plans of care were delivered to patients. This transition to the new EMR started approximately June 1, 2023, and since then all new patients had been presented with a printed booklet (which contained, but was not limited to: patient rights, notice of privacy practices, advanced directive information, state hotline number to lodge complaints, administrator contact number, individualized emergency plan, and consent forms). Along with this booklet, an instruction sheet had been provided which explained how to access the patient portal. For existing patients who transitioned over to the new agency and new EMR, the Director of Nursing indicated upon recertification or resumption, the nurses were "taking everything" out to the patients at those visits so patients could have access to their own documents which included but were not limited to: plans of care and medication lists.

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 ensure patients/caregivers had received a recent medication list, in 3 of 3 home visits observed. (Patients #3, #4, and #5) Findings include: 1. Review of an agency policy dated 08-05-2023, titled '2.6 - Plan of Care' stated, "POLICY Service will be provided in accordance with a written Care Plan based on the patient's diagnoses and assessment of immediate and long-range needs and resources ... PROCEDURE There is a written Plan of Care established based on the assessment of the patient ... The plan of care includes: ... nutritional requirements, medications and treatments ..." 2. On 01-23-2024 at 3:30 PM, during a home visit for Patient #3, Person A (a family member) when queried, indicated there was not a current medication list in the home, was aware of a patient portal that could be accessed on the internet to view such patient documents from the agency, but had not yet accessed this. 3. On 01-23-2024 at 1:10 PM, during a home visit for Patient #5, Person B (a family member) when queried, indicated there was not a current medication list in the home provided by the agency. Person B indicated was aware of a patient portal that could be accessed on the internet to view such patient documents from the agency, but had not yet accessed this. 4. On 01-23-2023 at 4:45 PM, during a home visit for Patient #4, the patient when queried, indicated there was not a current medication list in the home provided by the agency. Patient #4 indicated had recently become aware of the patient portal which could be accessed via the internet to view their documents from the agency, but had not accessed this yet. 5. On 01-25-2024 at 10:22 AM, the Alternate Administrator/Director of Nursing indicated the transition to their new agency and new electronic medical records (EMR) system led to a change in the way plans of care were delivered to patients. This transition to the new EMR started approximately June 1, 2023 and since then all new patients have been presented with a printed booklet (which contained, but was not limited to: patient rights, notice of privacy practices, advanced directive information, state hotline number to lodge complaints, administrator contact number, individualized emergency plan, and consent forms). Along with this booklet, an instruction sheet was provided which explained how to access the patient portal where the patient's plan of care and medication list can be viewed. For existing patients who transitioned over to the new agency and new EMR, the Director of Nursing indicated upon recertification or resumption, the nurses were "taking everything" out to the patients at those visits so patients could have access to their documents which included but were not limited to: plans of care and medication lists.

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 staff adhered to infection prevention standards in 2 of 3 home visits observed. (Patients #3 and #5) Findings include: 1. Review of an agency document dated 08-06-2023, titled '3.5 Standard Precautions' stated, "POLICY Blood and body fluid precautions will be followed for all patients. PURPOSE To prevent transmission of communicable diseases ... Standard Precautions include the following procedures: All health care workers will routinely use appropriate barrier precautions to prevent skin and mucous membrane exposure when contact with blood or any other body fluids of any patient is anticipated. Gloves will be worn before touching body blood and body fluids, mucus membranes or non-intact skin of all patients: for handling items or surfaces soiled with blood and body fluids; ..." Review of an agency document dated 08-06-2023, titled '3.6 - Hand Hygiene / Hand Washing / Hand Cleansing' stated, "POLICY Hand Hygiene / Hand Washing / Hand Cleansing will be done by all employees to reduce the transfer of microbes to patients and to prevent the growth of microorganisms on the nails, hands and forearms. PURPOSE To prevent transfer of germs and transmission of infections to patients and caregivers. PROCEDURE 1. Indications for Hand Hygiene / Hand Washing / Hand Cleansing are: before and after direct patient care, before and each procedure ... When hands are soiled ... After any contact with contaminated materials ... 2. All employees are responsible for implementing Hand Hygiene / Hand Washing / Hand Cleansing procedures in an on-going attempt to prevent and/or contain infectious processes and communicable diseases ..." 2. On 01-22-2024 at 3:30 PM during a home visit for Patient #3, Registered Nurse (RN) 2 was observed preparing medications for gastrotomy tube (G-tube: a tube inserted directly into the belly that brings nutrition directly to the stomach) administration by prefilling liquid medications into empty, needless syringes. Gloves were donned and the filled syringes were brought to the patient's chairside. Using a gloved right hand to grasp the underside of the seat of a rolling stool, the nurse pulled this stool closer to the patient's chair to sit near them. Using the same gloved right hand, the nurse proceeded to attach a length of extension tubing to the feeding port of the G-tube, proceeded to administer all the prepared medications, and ended with a water flush. The nurse then disconnected the extension tubing and closed the feeding port using the same gloved right thumb and forefinger. 3. On 01-23-2024 at 1:10 PM during a home visit for Patient #5, Certified Nurse Assistant (CNA) 1 was observed preparing to provide a bed bath for the patient. The CNA properly washed and dried their hands then a single basin of reportedly warm water was prepared for the patient. The basin was brought into the room and placed alongside the patient. The CNA donned gloves. The CNA took a light-colored washcloth, dipped into the water-filled basin, and began to cleanse the patient's eyes, working their way down the front of the torso, applying soap to the washcloth with each new section of the body cleansed, finishing with the patient's back, the basin becoming increasingly foamy. The CNA continued the bed bath, transitioning to a dark washcloth for the patient's perineal area and lower body. The basin's water was not exchanged for fresh water and the aide's gloves were not changed for the duration of the bed bath. 4. On 01-24-2024 at 3:58 PM, the Administrator and Alternate Administrator/Director of Nursing indicated were aware of the infection control breach during the visits with Patient #3 and RN 1, and indicated they would have expected the nurse would have washed their hands and re-gloved after touching the chair. Indicated further they were also aware of the infection control breach with Patient #5 and CNA 1, and indicated would have expected the use of two basins during a bed bath (one for rinse water), and that gloves would have been changed more frequently and at appropriate intervals. 5. On 01-24-2024 at 6:08 PM in a returned phone call, RN 1, indicated after handling Patient #3's stool/chair, should have taken a moment to remove gloves, sanitize hands, re-glove, then start again. 6. On 01-25-2024 at 12:00 PM, CNA 1 indicated knew two basins were needed for Patient #5, but the patient is normally taken to the shower for their bathing. Indicated would have ideally changed their gloves more often during the visit but had been very nervous, had already received re-education and been able to perform an extensive bed bath with reinforcement from the case managing nurse. 410 IAC 17-12-1(m)

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure a discharge summary was completed and sent to the physician within 5 days upon discharge, in 1 of 2 closed records reviewed. (Patient #6) Findings include: 1. Review of an agency document dated 08-06-2024, titled '2.24 - Discharge Summary' stated, "POLICY A discharge summary will completed for all patients discharged from the Agency. PURPOSE To record a summary of care received by the patient from the start of care through discharge. PROCEDURE 1. The discharge summary form will be completed by the Skilled Nurse ... The Discharge Summary will included but us not limited to: Discharge date ... reason for discharge ... Status of problems identified throughout the course of care ... Patient's overall status ... Instructions given to the client ... A summary of care or services provided ... 2. The physician will be informed of the availability of the Discharge Summary. 3. The Discharge Summary Form from each service, as applicable, will be filed in the medical record and a copy forwarded to the physician upon request." 2. Review of the closed clinical record for Patient #6 evidenced a start of care date of 02-17-2022 with a discharge date of 12-06-2023. The record failed to evidence a discharge summary had been completed. 3. On 01-25-2024 at 10:26 AM, when queried as to the discharge summary for Patient #6, the Alternate Administrator/Director of Nursing indicated after further review it appeared the nurse on the case, Registered Nurse (RN) 3 had not completed this discharge summary timely, but had communicated with the patient's provider and case manager upon discharge. Also informed RN 3 was working to complete the document and the resulting discharge summary would be sent to the provider, and indicated an audit of all discharged patients would ensue. 410 IAC 17-15-1(a)(6)

This visit was for a Federal Recertification and State Re-Licensure Survey of a Medicaid Home Health provider in conjunction with 2 complaints. Complaint #: IN 00319604 Unsubstantiated Complaint #: IN 00343773 Unsubstantiated. Survey Date: 6/4/2021, 6/7/21, 6/8/21, 6/9/21, 6/10/21 and 6/14/21 Facility #: 013608 Provider #: 15K128 Medicaid #: 201279300 Quality Review completed on 6/24/2021 by Area 3

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 all patients received an age-appropriate comprehensive assessment that accurately reflected the patient's health, psychosocial, functional, and cognitive status in 2 of 4 active records reviewed. (Patients #1, 3) Findings include: 1. The clinical record for patient #1 was reviewed and contained a plan of care for the certification period (make sure when you are referring to the plan of care that you are using all the language in red, this is a standard practice taught by CMS) of 5/11/21 - 7/9/21, which revealed patient #1 had with a primary diagnosis of Bronchopulmonary Dysplasia (A form of chronic lung disease that affectss newborns, most often those who are born prematurely, where the lungs and the airways [bronchi] are damaged, causing tissue destruction [dyplasia] in the tiny aidr sacs of the lung [alveoli]) need to describe all diagnoses and secondary diagnoses of postsurgical malabsorption (a condition or defect that occurs during the digestion and absorption of food nutrients by the gastrointestinal [GI] tract following GI surgical procedures), chronic respiratory disease (progressive destruction of the air sacs in the lungs and loss of repiratory membrane for oxygen exchange) ...; do not use the dots unless it is a quote chronic respiratory failure (a condition in which your blood doesn't have enough oxygen or has too much carbon dioxide); white matter disease (A disease that affects the nerves that link various parts of the brain to each other and to the spinal cord); diarrhea; nutritional deficiency (Occurs when the body doesn't absorb or get from food the necessary amount of nutrients); delayed milestone in childhood (A condition where a child does not reach one of the states at the expected age); incisional hernia with obstruction (Happens when a weakness in the muscle of the abdomen to protrude through the muscle of the abdomen allows the tiessues of the abdomen to protrude through the muscle, appears as a bulge under the skin and can be painful or tender to the touch. Complications are bowel obstruction and strangulation with can cause tissue death in the intestine) ...; gastrostomy (G-tube) status (tube inserted surgically into the stomach so liquid nutrition and fluids can be provided); dehydration; hyperosmolality (loss of water makes the blood more concentrated than normal such as high sodium, gloucose and other substances) and hypernatremia (high levels of sodium in the blood-not enough water); and tracheostomy (trach) status (opening created at the front of the neck so a trbe can be inserted into the windpipe [trachea] to help you breathe). Review of a comprehensive assessment titled "ROC/ RCT (Resumption of care/ Recertification) Assessment - Non-OASIS", dated 5/6/21 at 5 PM - 5:30 PM. The Non-Oasis assessment document are used for adults, 18 years and older. The assessment revealed the patient was a mobile, 2 year old toddler The patient's risk for hospitalization included polypharmacy only. Patient #1 lived with parents and sister on the ground floor of a 2 story house with steps, which were gated, and the patient was active, ambulatory without devices other than bilateral AFOs (Ankle Foot Orthosis). Patient #1 was fully dependent for all needs and was unable to speak due to the presence of a tracheostomy. (trach) Heart rate, respirations, and temperature were "WNL (Within Normal Limits." The Braden Scale evidenced "little risk." Patient #1 experienced oral aversion and was fed via G-tube (gastrostomy tube) but could have pleasure foods. The patient was receiving speech, physical, and occupational therapy, and the fall risk assessment evidenced that a continued fall prevention program was in place. Patient #1 had moderate strength in all extremities, a steady gait, and used a stroller for distances. The patient had impaired speech and developmental delay, and emotional/behavioral status was "WNL". The assessment identified no suicide risk. The patient had granulation tissue removed from the trachea on 5/5/21 and the trach stoma was "WNL". The assessment failed to be specific for pediatric patients and failed to evidence any diagnoses, including diagnoses related to the reason for home health care. (see plan of care entry below) The hospital risk assessment failed to include significant risk factors including the patient's fragile respiratory status resulting from the trach and bronchopulmonary dysplasia (BPD) diagnosis, potential for failure to thrive and poor nutritional status related to malabsorption and diarrhea, dehydration related to diarrhea, high risk of emergencies related to decannulation (accidental dislodgement of the trach) and dislodgement of the G-tube, and emergencies and/or illness of a toddler aged child. The assessment failed to address fall prevention specific to a 2 year old (i.e. gates, lack of proprioception, developmental safeguards, use of car seat), failed to identify a specific fall prevention program being used and what education was provided. The assessment failed to use an appropriate pressure sore assessment (as the Braden scale is used in the adult population vs the Braden Q for pediatric patients). Physical assessment failed to evidence that a blood pressure was obtained with standard vital signs, included a head circumference, and included review of the male genitals, including presence of descended testes and absence of inguinal hernia, both standard in pediatric assessments. The assessment failed to define or identify specific pleasure foods, including how they should be prepared, offered, and encouraged. (i.e. finger food, pureed, small bites). The neurological assessment evidenced impaired speech and developmental delay but failed to evidence how the patient communicated, why and when the patient wore AFOs, and exercises/tools recommended by therapy to address speech, development, and motor skills. Review of patient #1's emotional/ behavioral status evidenced WNL, but failed to identify what was normal for a 2 year old the existing diagnoses. The patient was not at risk for suicide risk, and assessment not appropriate for a 2 year old. The assessment failed to assess standard behavior and emotional development and response of a 2 year old, and failed to include address the patient's ability to self soothe, sleep patterns, ability to socialize, or the quality of his behavior, including discipline, anxiety, separation from parents, and fears related to hospitalization and medical treatment. The assessment failed to evidence the quality of the trach and G-tube stomas (pink, healed, granulating, drainage, etc.) and failed to include complete and accurate assessment for patient #1's overall health, psychosocial, functional, and cognitive status. 2. During a home visit on 6/8/21 from 9 AM - 11 AM, patient #3 was observed seated in the floor watching television. The patient's grandmother was present and was interviewed concerning diagnoses and care. The grandmother stated the patient was diagnosed with autism prior to the age of 3 years, and could play instruments, was verbal, and had a "photographic" memory. The patient's biological mother cohabitated with a man not related to the patient, who threw him against the wall and "dented" his skull when the patient was 3 years old. The patient is currently profoundly delayed, has left sided hemiparesis, is non-verbal, and is dependent for all care. All needs must be anticipated and patient #3 must be supervised at all times due to delays and seizures. The grandmother stated patient #3 vomits when anxious and with certain foods and once it starts it will go on all day. The patient can feed himself finger foods but must be watched constantly to avoid stuffing his mouth and/or choking. She stated the patient experiences atopic dermatitis "all over his body" but did not discuss treatment. The surveyor observed gates between the kitchen and living room area (where the patient spends most of the time) and the bedrooms and living room area. The grandmother stated the patient is non-ambulatory but was able to pull himself up to stationary objects, placing him at risk for falling and fractures due to significant osteoporosis caused from lack of use of the limbs. She stated the patient was no longer safe in the stander due to risk of fractures, therefore it was not used. The hoyer was also not used due to the patient's fear, however she stated the patient had become almost too heavy to lift and she was concerned about the nurses trying to transfer him. The clinical record for patient #3 was reviewed and contained a plan of care for the certification period 5/4/21 - 7/2/21 evidenced a primary diagnosis of post traumatic seizures (long-recognized complication of traumatic brain injury) and secondary diagnoses of autistic disorder (serious developmental disorder that impairs the ability to communicate and interact), quadriplegia (paralysis of all four limbs), tic disorder (compulsive, repetitive sound or movement that's often difficult to control), feeding difficulties (broad term used to describe a variety of feeding or mealtime behaviors perceived as problematic for a child or family), gastro-esophageal reflux (digestive disease in which stomach acid or bile irritates the food pipe lining), atopic dermatitis (itchy inflammation of the skin), laryngeal spasm (vocal cords suddenly seize or close when taking a breath, blocking airflow into the lungs, often happens at night,with people waking up from a sound sleep unable to speak or breathe), other osteoporosis (bones are weaker than normal but not so far gone that they break easily), nausea with vomiting. Review of the comprehensive assessment titled "ROC/ RCT Comprehensive Assessment - Non-OASIS", dated 4/29/21 from 9:10 AM - 10:00 AM. The Non-Oasis assessment document are used for adults, 18 years and older. The assessment revealed the patient was a 13 year old pediatric patient who lived with his grandmother, who was his legal guardian, and her significant other in a single family home with 4 dogs and 4 cats. The patient's grandmother worked full time. The patient's hospital risk included polypharmacy only. A fall risk assessment evidenced visual impairment, 3 or more co-existing diagnoses, environmental hazards, incontinence, and cognitive impairment. The assessment revealed a fall precautions plan continued, and fall education was provided. Review of living arrangements evidenced "NA, no environmental barriers/hazards." A FLACC pain assessment evidenced a score of zero, or no pain. Physical assessment evidenced a heart rate of 44 beats/minute with a history of chronic bradycardia. The patient scored at moderate risk for pressure sores based on use of the Braden Scale. The intervention guide for moderate risk included frequent turning with a planned schedule, pressure reduction support surface, foam wedges for 30 degree lateral positioning, manage moisture, offer bedpan/urinal and a glass of water in conjunction with turning schedules, increase protein intake, offer liquid diet supplement, manage friction and shear, and use lift sheet to move patient. Patient #3 was lactose intolerant and allergic to red dye, diphenhydramine, and tuberculosis serum. Review of nutritional requirements included a regular diet with soft foods. The patient wore briefs for incontinence of bowel and bladder, and had reflux/indigestion. Review of the male reproductive system evidenced "NA, no problems reported." Patient #3 was unable to ambulate and had paralysis to the left upper and lower extremities, was able to creep, roll, sit supported, and pull up to stationary objects. The patient used a manual wheelchair for primary mobility with AFOs in place when in the wheelchair. The patient was non-verbal with developmental delay, recognized family and caregivers, and his name. The patient had a VNS (Vagal Nerve Stimulator) and experienced over 1000 seizures per month. A detailed seizure plan was present. The PHQ-2 depression screen evidenced no depression or suicide ideation. The assessment failed to be appropriate for pediatric patients and failed to include the patient's diagnoses pertinent to the reason for home health. The fall risk assessment and risk for hospitalization failed to include risks related the patient's developmental delays, osteoporosis, hemiparesis (mild or partial weakness or loss of strength on one side of the body), pulling up to objects, and poor mobility, and evidenced environmental hazards followed but evidenced no environmental hazards in another section. It also failed to address how the patient was transferred safely, the specific fall prevention plan, and the education provided. The assessment failed to evidence an appropriate assessment tool for a 2 year old, as the FLACC pain assessment tool is indicated for use with newborns through age 7, and failed to utilize an appropriate pressure sore assessment as the Braden Scale is indicated for use with adults vs the Braden Q Scale for pediatric patients. The interventions for skin integrity failed to be appropriate for the patient based on age, development, mobility, and nutritional intake. The assessment failed to include the symptoms and interventions for the patient's listed allergies and failed to include the patient's atopic dermatitis interventions. The assessment failed to include assessment of the patient's genitals related to age and onset of puberty, failed to include how patient #3 communicated and made needs known, whether the patient could propel the wheelchair, what type of seizures the patient had and how to respond to the individual types, whether the patient was able to perform any personal care/dressing/grooming. It failed to address the patient's educational status and developmental, cognitive, and emotional needs and failed to address age/developmental appropriate behavior and discipline, and exercise/therapy required to assist the patient in continued milestones. The nutritional assessment failed to include foods/reasons associated with vomiting (see interview below) and how to stop the vomiting if it started. The assessment failed to assess an accurate weight and height, and failed to address the growth and development for pediatric patients, and failed to include complete and accurate assessment for patient #1's health, psychosocial, functional, and cognitive status. 3. On 6/9/21 at 3:30 PM, the administrator and clinical manager were interviewed concerning pediatric comprehensive assessments. When queried if the agency used pediatric assessments, they stated the agency used a non-OASIS (Outcome and Assessment Information Set) and tailored it for pediatric patients via their electronic medical record software. When queried whether that included items specific to pediatric growth and development (example: head circumference, developmental play, language development, toilet training) they stated it did not, but they were now aware of the difference between adult and pediatric assessments and would review content and availability of assessments designed for pediatric patients. No further information was provided. 410 IAC 17-14-1(a)(1)(B)

Strengths, goals, and care preferences CFR(s): 484.55(c)(2) The patient's strengths, goals, and care preferences, including information that may be used to demonstrate the patient's progress toward achievement of the goals identified by the patient and the measurable outcomes identified by the HHA; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure all patients received an age-appropriate comprehensive assessment that accurately reflected the patient's health, psychosocial, functional, and cognitive status in 2 of 4 active records reviewed. (Patients #1, 3) Findings include: 1. Review of the clinical record for patient #1 revealed a comprehensive assessment titled "ROC/RCT (Resumption of care/Recertification) Assessment - Non-OASIS, dated 5/6/21 at 5 PM - 5:30 PM. The assessment revealed the patient was a mobile, 2 year old toddler The assessment failed to evidence specific care preferences including, but not limited to favorite toys, preferred methods of soothing, daily schedules, likes and dislikes, appropriate discipline, and favorite "pleasure foods", favorite and allowed television shows and movies, and favorite music. 2. During a home visit on 6/8/21 from 9 AM - 11 AM, patient #3 was observed seated in the floor watching television. The patient's grandmother (his legal guardian and referred to as his mother), was present in the home and was interviewed during this visit. The surveyor observed gates securing the patient from the kitchen and bedroom area, as well as many appropriate toys in the room. The patient's grandmother stated patient #3 required snacks every 2 hours, had a history of poor weight gain, and was able to feed himself finger foods but was always supervised because he would stuff his mouth and vomit or choke. Grandmother stated she prepared the patient's food for each day prior to leaving for work so she could manage portions. The patient had a special "spinning chair" used during eating. The grandmother stated the patient had just received new AFOs, worn only with shoes, however the patient would not wear shoes and socks. When able to make him wear shoes, he required zip shoes. The patient was observed scooting on his bottom as a preferred means of mobility. The patient's grandmother stated she bathed the patient and did not have the nurses do it so that she could "control the drying" due to the atopic dermatitis. The patient had a Hoyer lift but was frightened of it and "fights it". The grandmother stated the patient received services 7 - 11 hours per day depending on her work schedule and the number of appointments patient #3 had that week, including medical and therapy appointments. The grandmother stated the nurses must watch the patient's face and body for cues to how the patient feels because the patient was unable to make needs known in any other way. Review of the clinical record for patient #3 revealed a "ROC/RCT Comprehensive Assessment - Non-OASIS, dated 4/29/21 from 9:10 AM - 10:00 AM. The assessment failed to include the specific care preferences stated by the grandmother during the home visit including, but not limited to, appropriate toys and developmental activities, specific therapy/exercises, special shoes, the patient's fear of the Hoyer lift, favorite toys or items that sooth, the need for gates to be secured, that only grandmother bathed patient #3, the spinning chair, the preferred means of mobility at home, and facial and body cues which evidenced patient #3's needs.

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 observation, record review and interview, the agency failed to ensure plan of care was individualized for 1 of 4 active records reviewed (Patient 2). Findings include: Review of an agency policy dated 12/30/20 titled, "Plan of Care C580" stated, "...Special Instructions ... 2. The Plan of care shall be completed in full to include: ... d. Frequency and duration of visits to be made .... " The clinical record of Patient #2 was reviewed on 6/7/21 and indicated a start of care date of 10/7/15. The record contained a plan of care for the recertification period of 5/8/21 to 7/6/21 with orders for skilled nursing 11-15 hours/day x 4-6 days/week. During an interview on 6/8/21 at 9:10 AM, when queried about her time, Employee E, Skilled Nurse for Patient #2 stated, "I get here everyday Monday through Friday form 5:30 AM to 6:00 PM." During an interview on 6/8/21 at 9:40 AM, with the caregiver of Patient #2, when queried about staffing hours, stated, " I did drive the bus but I hurt my back so I am here [at home] accept for appointments. My daughters help me on the weekends." During an interview with the clinical manager and administrator on 6/9/21 at 4:25 PM, when queried about frequency not being specific and ranges stated, " That is in case they leave early or stay late we have a 2 off range." When queried where the information came from, the administrator reported from their deemed accrediting agency. 410 IAC 17-13-1(a)(1)(D)(iii)

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure verbal orders were complete and contained specific duties/ services to be provided and failed to ensure the physician was notified after the completion of the comprehensive assessment in 2 of 4 active patients reviewed. (Patients #1, 3) Findings include: 1. A review of the clinical record for patient #1 revealed a document titled "Physician Order for Re-Certification of Services", signed by the clinician and dated 5/6/21 at 10:01 AM. The order evidenced the physician "has been notified of the assessment findings from the recertification visit on 5/5/21. The physician, patient/caregiver, and nurse have collaborated in the development and revision of the plan of care." The document evidenced a verbal order for discipline, frequency, and duration of 1 visit/day x 3-5 days/week x 9 weeks, with no changes to the previously signed plan of care. Review of the a recertification assessment dated 5/6/21 evidenced the assessment was completed at the patient's home from 5 PM - 5:30 PM. The order failed to include the specific duties and care to be provided during service. The order also evidenced it was established prior to the completion of the comprehensive assessment findings. 2. A review of the clinical record for patient #3 revealed an order for recertification, signed by the clinician and dated 4/28/21 at 12:15 PM. The order evidenced the physician "has been notified of the assessment findings form the certification visit on 4/29/21. The physician, patient/caregiver, and nurse have collaborated in the development and revision of the plan of care." The document evidenced a frequency of 1 visit/day x 3-5 days/week x 9 weeks with no changes to the previous signed plan of care. Review of the recertification assessment dated 5/6/21 evidenced the assessment was completed at the patient's home on 4/29/21 from 9:10 AM - 10 AM. The order failed to include the specific duties and care to be provided during service. The order also evidenced it was established prior to the completion of the comprehensive assessment finding. 3. On 6/14/21 at 3:30 PM the administrator and clinical manager were interviewed concerning the process for obtaining orders for recertification. The clinical manager stated the clinician obtains an order for recertification, then completes the comprehensive assessment, then develops a plan of care which is sent to the physician for signature. When queried concerning the point where the clinician reviews the comprehensive assessment findings with the physician, the clinical manager stated it occurs after the assessment and before the plan of care generates. When queried concerning the above orders which showed the clinician contacted the physician to review the assessment findings prior to completing the assessment, the administrator and clinical manager stated they would speak with the case manager concerning why that was done. No further information was provided. 410 IAC 17-14-1(a)(H)