Every finding on record at Together Homecare of Northwest Indiana LLC

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR §484.102. Survey Dates: 2/26 - 3/01/24, and 3/04/24. The exit date was extended to 3/06/24, as pertinent information related to the survey findings was requested during the survey process and received after exit. Active Census: 46 During this Emergency Preparedness survey, Team Select Home Care was found to be out of compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR §484.102. QR: A 1 3/15/24

Establishment of the Emergency Program (EP) CFR(s): 484.102 §403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.542, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must establish and maintain a [comprehensive] emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements: * (Unless otherwise indicated, the general use of the terms "facility" or "facilities" in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This CONDITION is not met as evidenced by: Based on record review and interview the agency failed to develop a process for collaboration with state and local emergency preparedness officials (E-0009), the communication plan failed to include names and contact information for physicians (E-0030), the agency failed to provide alternate means of communication per policy (E-0032), the communication plan failed to address a method of sharing information with other healthcare providers (E-0033), the communication plan failed to include a process for sharing information with emergency preparedness authorities (E-0034). The Findings Include: An undated policy titled “Emergency Management Policy,” indicated secondary methods of contact to be walkie-talkie and satellite telephone. A review of their Emergency Preparedness Plan (EPP) on 02/29/24 failed to evidence a process for cooperation and collaboration with emergency preparedness officials or documented attempts of collaboration; failed to evidence contact information for patient's attending physicians and their other providers of care; failed to evidence a secondary method to contact their staff in the event of emergency; failed to evidence a secondary method of communication in the event of electronic failure; failed to evidence a method of communication with authorities that have jurisdiction in the event of an emergency. On 02/29/24 beginning at 4:22pm during an interview with the Administrator and the Clinical Manager (CM), they indicated they have not made attempts to collaborate with emergency preparedness officials. The CM indicated the physician and other provider's information was maintained in each of their Patient’s homes and was not in the EPP. The CM indicated they did not have a walkie-talkie or satellite telephone as per policy, nor indicated another means was available for communication from the agency to others and added that staff and patients could listen to the radio. The CM indicated that they would drive to and deliver any necessary documents to communicate with other providers of care and that this was not included included in their EPP.

This visit was for a Federal Recertification and State Re-Licensure survey of a Home Health Provider. Survey Dates: 2/26 - 3/01/24, and 3/04/24. The exit date was extended to 3/06/24, as pertinent information related to the survey findings was requested during the survey process and received after exit. 12-Month Unduplicated Skilled Admissions: 58 Survey was fully extended on 2/27/24 An Immediate Jeopardy was identified and the administrator was notified on 02/29/24 at 12:30 PM at 42 CFR 484.50. The immediacy was abated prior to exit on 3/04/24 at 11:29 AM. During this Federal Recertification and State Re-licensure Survey, Team Select Home Care was found to be out of compliance with the Condition of Participation at 42 CFR §484.50: Patient Rights, 42 CFR §484.60: Care Planning, Coordination of Services, and Quality of Care, §484.65: Quality Assessment and Performance Improvement (QAPI), and 42 CFR §484.80: Home Health Aide Services. Based on the Condition-level deficiencies during the 3/06/24 survey, your HHA was subject to a partial or extended survey pursuant to section 1891(c)(2)(D) of the Social Security Act on 3/06/24. 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 3/06/24 and continuing through 3/05/26. This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Refer to State Form for additional State Findings. QR: 3/14/24 A 1

Patient rights CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient's rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This CONDITION is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure the Patient Rights were maintained when the agency failed to ensure Patient's safety during the provision of care when home health aide [HHA] 1 neglected to ensure a safe environment during the provision of patient care (G0430) (Patient #1). Findings include: A home visit occurred on 2/28/24 beginning at 12:18 PM with Patient #1, the Clinical Manager, and Home Health Aide (HHA) 1. Upon arrival to this visit, the patient was being offloaded from an ambulance, and into the residence. A family member indicated they just got home from an appointment in which x-rays were taken due to falling on 2/26/24. HHA 1 assisted the patient into the shower, and the patient sat on the shower chair. While the patient was still seated on the shower chair, HHA 1 removed his/her gloves and left the room. The patient, was left unattended with water running, and attempted to stand unassisted. The Surveyor called out to family and agency staff for assist. The family member went into the bathroom and assisted the patient back into a seated position. During this time, the Clinical Manager instructed HHA 1 twice to return to the bathroom. HHA 1 returned to the bathroom to complete the patient’s personal care. The record for Patient #1 included a hospital document dated 11/29/23 which indicated Patient had a history of falls and a right hip fracture, Parkinson’s Disease and unspecified dementia. During an interview with the Clinical Manager on 02/28/24 at 1:06 PM, the Clinical Manager indicated they observed HHA 1 leave the Patient unattended and was concerned. 410 IAC 17-12-3(b)(4)(A)

Investigate complaints made by patient CFR(s): 484.50(e)(1)(i) (i) Investigate complaints made by a patient, the patient's representative (if any), and the patient's caregivers and family, including, but not limited to, the following topics: This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to identify and investigate complaint with caregiver report of home health aide missed shift for 1 of 1 records reviewed. (Patient #1) The Findings Include: The record for Patient #1 included a document titled, “Missed Shift Log” which included an entry date of 01/9/24, which indicated Patient #1's caregiver called the agency on 01/10/24 to report Home Health Aide 1 (HHA 1) did not report to their scheduled shift on 01/9/24. The note further indicated the agency contacted HHA 1 to verify employee status to which HHA 1 relayed they had taken the day off. A review of the complaint log on 02/27/24 failed to evidence the complaint. During an interview with the administrator on 02/27/24 at 11:40 am indicated the reason the complaint was not in the complaint log was because they did not consider it a complaint.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to conduct an initial assessment visit within 48 hours of referral for 2 of 7 active records reviewed (Patient #1 and #3). Findings Include: The clinical record or Patient #1 indicated a referral date of 10/26/23. The Plan of Care indicated a start of care date of 11/10/23.. The clinical record for Patient #3 failed to evidence a referral. The record included a Plan of Care with a start of care date of 11/7/23. During an interview on 02/29/24 beginning at 2:00 PM, the Administrator indicated when a referral is received the operations team verify the insurance, then pass to the clinical team to schedule. During an interview with the Clinical Manager on 03/4/24 beginning at 2:40 PM, they indicated the referral for Patient #3 was received in July 2023 and was on hold until November due to lack of available staff. 410 IAC 17-14-1 (a)(1)(A)

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 the Registered Nurse (RN) completed a comprehensive reassessment during the last 5 days of the certification period for 1 of 1 active clinical record reviewed of an adult patient who received skilled nursing services (Patient #4). The findings include: The clinical record for Patient #4 evidenced a comprehensive reassessment was due between 12/24/2023 to 12/28/23 (the last 5 days of the certification period); the comprehensive assessment was completed on 01/11/24. A communication note dated 12/15/23 evidenced Patient’s schedule would remain the same over Christmas and New Year’s. A Nursing Supervisory visit dated 12/19/23 evidenced the agency did not have staff to provide services for Patient. A communication note dated 01/10/24 evidenced an error was made; the comprehensive reassessment visit was missed due to the holidays. During an interview on 02/27/24 at 4:58 PM, the Clinical Manager indicated the comprehensive reassessment visit was missed, they were 2 weeks late; the Case Manager forgot to schedule the assessment and was overlooked. 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 and interview, the home health agency failed to ensure the patient was accepted for treatment on the reasonable expectation that the agency could meet the patient's needs, or received an individualized written plan of care (POC) (G0570), ensure the patient received all services as ordered in the POC (G0572), the POC failed to include all required elements (G0574), failed to ensure the Registered Nurse (RN) obtained a verbal order to establish or update the POC (G0580), and failed to ensure the Patient's POC was reviewed and revised by the certifying physician once every 60 days (G0588). The findings include: The cumulative effect of these systemic problems resulted in the agency's inability to ensure patients received appropriate care and services, which could result in the agency not providing quality health care, thus being out of compliance with the Condition of Participation 42 CFR §484.60: Care Planning, Coordination of Services, and Quality of Care. Based on record review and interview, the home health agency failed to ensure the patient was accepted for treatment on the reasonable expectation that the agency could meet the patient's needs, or received an individualized written plan of care (POC), for 1 of 3 skilled pediatric patients who experienced an unplanned hospitalization within the first 5 days after admission (Patient #9). The findings include: The clinical record for Patient #9 included the initial comprehensive assessment was completed by RN 1 on 01/23/24, and subsequently signed by Corporate Staff 3 (quality assurance [QA] RN) on 01/29/24, (6 days after admission) evidenced a section titled "nutrition," which indicated Patient had no nausea or vomiting, and required skilled nursing interventions to remain safe in the home, due to family unable to provide all of the care needed for Patient. The initial POC was initially signed by RN 1 on 01/23/24, and subsequently signed by RN 1 and Corporate Staff 3 on 01/29/24 (6 days after admission). The POC evidenced skilled nursing was ordered 6 - 10 hours daily, 4 - 6 days per week. The clinical record failed to evidence any nursing visits occurred from 01/24/24 through 01/28/24. A transfer summary note dated 01/29/24 evidenced Patient experienced an unplanned hospitalization on 01/28/24, for increased vomiting and dehydration. During an interview on 3/4/24 at 2:15 PM, RN 1 indicated there weren't any visits made after the start of care visit because the POC wasn't created yet, indicated this was a complex patient, how would the nurse know what to do without a POC, and they couldn't send out a nurse until the POC was completed.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the patient received all services as ordered in the plan of care (POC) in 2 of 3 active adult unskilled clinical records reviewed (Patient #2 and 7), 1 of 1 active adult skilled clinical record reviewed (Patient #4), and 1 of 2 discharged clinical records reviewed (Patient #5). The findings include: 4. Clinical record for Patient # 5 indicated home health aide visits during certification period 12/2/23 through 1/30/24 during week 3 of the certification period failed to meet minimum visit ordered in Patient's plan of care. The plan of care for this certification period indicated the agency was to provide home health aide services for six (6) to seven (7) visits per week. During an interview with HHA 3 on 02/28/24, beginning at 9:33 AM, HHA 3 verbalized while working with Patient #5 during the certification period of 12/2/23 through 01/30/24, when they left early due to sickness, HHA 3 notified the agency who would try to find a replacement. During an interview with Administrator beginning on 02/27/24 beginning at 4:24 PM, the Administrator verbalized when staff call in sick or miss a visit, agency attempts to offer the patient or family a substitute but sometimes that substitute is refused. THe record failed to evidence documentation Patient declined the replacement staff. 1. The clinical record for Patient #2 evidenced a POC for the certification period 02/06/24 – 4/05/24, that evidenced Patient to receive non-skilled Home Health Aide (HHA) services 7 days per week, 1-3 visits weekly for 7-11 hours and 2-4 visits weekly for 5-9 hours. During week #1 of the certification period, (5 days: 02/06/24 through 02/10/24), the record failed to evince HHA services were provided on as ordered; on 02/10/24, 2.25 hours of aide services were provided. During week #2, the record failed to evidence HHA services were provided at minimum number of hours on 02/11/24, during this visit 2.5 hours were provided. During an interview on 02/27/2024 at 1:44 PM, RN 1 indicated the HHA frequency was based on the POC which was “translated” as 9 hours per day for 2 days each week and 7 hours per day for 5 days per week, and indicated the frequencies could deviate from what was ordered.. During an interview on 02/27/24 at 3:55 PM, HHA 2 indicated he/she had no idea how many aide service hours he/she was to provide for each visit. 2. The active clinical record for Patient #4 evidenced a POC for the certification period 10/30/23 – 12/28/23, with orders for skilled nursing 6 – 10 hours daily for 1 – 3 days per week. The clinical record evidenced 2 visits were made during the 60 day certification period. During an interview on 02/27/24 at 4:55 PM, the Administrator indicated the assigned nurse got another job and the agency could not cover the shifts. 3. The clinical record for Patient #7 evidenced a POC for the certification period 02/17/24 - 4/16/24, with orders for non-skilled HHA services 0.5 - 3 hours per day, 4 - 6 days per week, Attendant services (ATTC) 1 - 5 hours daily, 1 - 3 days per week, and Homemaker services (HMKR) 1 - 5 hours daily, 2 - 4 days per week (5 hours daily, 4 days per week). The clinical record evidenced Patient received no services for week 1 of the certification period. During week 2, the total of combined services (HHA, ATTC, and/or HMKR) equaled 4 hours daily, from 02/19/24 - 02/23/24. During an interview on 02/28/24 at 10:30 AM, HHA 4 (the patient's regularly scheduled HHA) indicated Patient's regular schedule was for 4 hours daily, 5 days per week, and the services provided each day was dependent on the day of the week..

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 patient’s plan of care (POC) failed to include all required elements for 2 out of 3 unskilled clinical records reviewed (Patients #2 and # 5). The findings include: X. The clinical record for Patient # 5 revealed order for Bacitracin/Neomycin/Polymyxin B (Neosporin Ointment) to apply as needed twice daily to wounds on second (2nd) and third (3rd) toe until healed dated 10/20/2022. The plan of care for 1/31/24 through 3/30/24 included a medication Bacitracin / Neomycin / Polymyxin B (Neosporin Ointment) to apply as needed twice daily to wounds on second (2nd) and third (3rd) toe until healed, the order was dated 10/20/2022. Recertification assessment performed by RN 2 indicated that the complete head-to-toe assessment performed on 01/26/24 showed no skin breakdown. During an interview with RN 2, beginning on 2/28/24 at 2:26 p.m., RN 2 verbalized that Patient # 5 did not have wounds anywhere on body for last months of patient’s care. RN 2 verbalized that the order for the Neosporin Ointment should have been removed from the plan of care. X.The clinical record for Patient #2 evidenced the patient received non-skilled Home Health Aide (HHA) services, Registered Nurse (RN) 1 was the patient’s case manager, and HHA 2 provided care. A Plan of Care (POC) for certification period 2/06/24 – 4/05/24 evidenced but not limited to the patient’s activities included Passive Range of Motion (PROM) exercises (someone else manually moves a body part that would not independently be possible). The POC failed to include what body part(s) required PROM, the frequency, type(s), or quantity of repetitions to perform. During an interview on 2/27/2024 at 1:44 PM, RN 1 indicated the PROM exercises were “as tolerated”, and the patient told the HHA what to do. 410 IAC 17-13-1(a)(1)(D)(ix)

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the Registered Nurse (RN) obtained a verbal order to establish or update the Plan of Care (POC) in 1 of 1 active clinical record reviewed of an adult skilled patient (Patient #4) and in 1 of 2 clinical records reviewed with an adult patient who received unskilled services and a home visit observation occurred (Patient #7). The findings include: 1. The plan of care [POC] policy dated 02/07/24 evidenced all orders must contain sufficient information to carry out the order, the representative conferring the order to the agency, orders were written, signed, and dated with the date of receipt by the RN. 2. A policy on patient admission criteria/scope of services dated 8/05/23, evidenced verbal orders must be given by the referring physician and by others approved by law to prescribe. 3. The clinical record for Patient #4 evidenced a comprehensive reassessment was completed on 02/22/24 from 11:09 AM – 12:13 PM, and evidenced RN 2 spoke to Person A at Entity B (certifying physician’s office) regarding completion of home care recertification visit, that the Plan of Care (POC) would be faxed to the physician for signature. The clinical record failed to evidence a physician order was received on 02/22/24 to continue home health services, the discipline to be provided, the frequency, and duration. A communication note dated 02/22/24 at 10:24 AM indicated RN 2 left a message with Entity B to return a call to obtain verbal orders for recertification, this was prior to completion of the comprehensive reassessment visit. A communication note dated 02/23/24 at 2:57 PM indicated RN 2 received a verbal order from Person A to continue with home health services for the next certification period. The clinical record failed to evidence a documentation of a physician order. On 02/27/24 at 12:58 PM, the clinical record failed to evidence the presence of a verbal order or a POC for the certification period from 02/27/24 to 4/26/2024. During an interview on 02/27/24 at 3:05 PM, the Administrator indicated there was not a current POC nor documentation of a physician order for the services to be provided from 02/27/24 onward for 60 days. During an interview on 02/27/24 at 3:10 PM, the Clinical Manager indicated the comprehensive reassessment was still in the quality assurance (QA) process, still pending completion, after which time, the POC would generate. 4. A home visit occurred on 02/28/24 at 10:30 AM with Home Health Aide (HHA) 4, who performed non-skilled services for Patient #7. The clinical record for Patient #7 evidenced a comprehensive reassessment was completed on 02/16/24, which evidenced RN 1 spoke to Person C, staff at Entity D (certifying physician’s office) that the POC would be faxed to the physician for signature. The clinical record failed to evidence a physician order was received on 02/16/24 to continue home health services, the disciplines to provide the services, the frequency and duration of those services. A communication note dated 02/16/24 at 2:57 PM indicated RN 1 received a verbal order from Person C to continue with home health services for the next certification period. The clinical record failed to evidence the physician order was documented, for the services to be provided, the frequency, and duration of these services. During an interview on 02/27/24 at 2:59 PM, the Administrator indicated there was not a current POC nor documentation of a physician order. On 02/28/24 at 9:20 AM, the clinical record failed to evidence documentation of a verbal order nor a POC for certification period from 02/17/24 – 4/16/2024. During an interview on 02/28/24 at 9:37 AM, RN 1 indicated the POC was still in process, they had a 5 day window to complete it, then an order would be obtained.

Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient's condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the Patient's Plan of Care (POC) was reviewed and revised by the certifying physician once every 60 days, for 1 of 1 clinical record reviewed for an adult patient who received skilled nursing services (Patient #4), and 1 of 2 clinical records reviewed with adult patients who had unskilled services and a home visit (Patient #7). The findings include: 1. The clinical record for Patient #4 evidenced a completed update to the POC was due for review/revision by the certifying physician no later than 12/28/23 (the last day of the certification period), for certification period 12/29/23 - 02/26/24. The updated POC for certification period 12/29/23 - 2/26/24 was signed by RN 2 and the certifying physician on 01/16/24, 74 days since the last time the physician reviewed. During an interview on 2/27/24 at 3:50 PM, RN 2 indicated the updated POC for 12/29/23 - 02/26/24 was completed 2 weeks late. The subsequent update to the POC was due for review/revision by the certifying physician no later than 02/26/24 (the last day of the certification period), for the certification period dated 02/27/24 - 4/26/24. On 2/27/24 at 12:58 PM, the clinical record failed to evidence presence of an updated POC for the certification period 02/27/24 - 4/26/24. A comprehensive reassessment dated 02/22/24 evidenced RN 2 spoke with a non-clinical staff member at the certifying physician's office to confirm the updated POC for certification period 02/27/24 - 4/26/24, the new POC would be faxed to the physician for signature; the record failed to evidence the physician reviewed/approved an updated POC. The Administrator provided a POC for the certification period 02/27/24 - 4/26/24 on 2/28/24 at 9:30 AM, which evidenced RN 2 signed the document on 02/22/24, with additional signatures of Administrative Staff 3 (corporate quality assurance [QA]) and RN 2 on 02/27/24 at 4:16 PM. The POC failed to evidence documentation that a verbal order was received to indicate the certifying physician reviewed or approved an updated POC on 02/22/2024. During an interview on 02/27/24 at 4:48 PM, the Clinical Manager indicated verbal orders received for recertification were not documented, with the discipline and services to be provided, with frequency and duration. During an interview on 02/27/2024 at 3:05 PM, the Administrator indicated Patient #4's clinical record failed to include an updated POC nor a verbal order for recertification with the discipline and services to be provided, with frequency and duration, for the certification period 02/27/24 - 4/26/24. During an interview on 02/27/24 at 3:10 PM, the Clinical Manager indicated the comprehensive reassessment was in the QR process, still pending, and once approved, the POC would generate. During an interview on 02/27/24 at 3:50 PM, RN 2 indicated the POC for the certification period 02/27/24 - 4/26/24 was not complete. 2. On 02/28/24 at 9:20 AM, the clinical record for patient #7 evidenced RN 1 was the patient's nurse, and failed to evidence a POC for the certification period 02/17/24 - 4/16/24. During an interview on 02/28/24 at 9:37 AM, RN 1 indicated the comprehensive reassessment was still in the QR process, and once approved, a POC would be generated. The record failed to evidence the certifying physician reviewed the POC every 60 days. 410 IAC 17-13-1(a)(2)

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 promptly alert the physician of a change in the patient’s condition so that the provider may determine if care should be altered for 1 of 3 adult unskilled clinical record reviewed (Patient #1). The Findings Include: The record for Patient #1 included a comprehensive assessment dated 01/08/24 completed by Registered Nurse 1 (RN 1) revealed a blood pressure of 89/59. The record further indicated physician notification parameters for systolic blood pressure of less than 90 or diastolic blood pressure less than 60. The record failed to evidence notification was made to the physician. In an interview on 02/27/24 beginning at 11:40 AM with the Administrator and Clinical Manager (CM), the CM indicated they would have expected the RN to call the attending physician the same day. They further indicated they were not able to find documentation that notification was made to physician for Patient #1. During an interview with RN 1 on 02/27/24 beginning at 1:20 PM, they indicated they were unaware there was a specific time frame for notification. 410 IAC 17-13-1 (a)(2)

Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA's governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA's performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This CONDITION is not met as evidenced by: Based on record review and interview the agency failed to evidence data collected to monitor effectiveness of services and quality of care, nor approval from the governing body (G644), maintain performance improvement activities that focus on high risk, high volume, or problem prone areas (G648), maintain performance improvement activities that consider incidence, prevalence, and severity of problems (G650), maintain performance improvement activities that lead to immediate correction of any identified problems that directly or potentially threatens the health and safety of the patients (G652), or maintain performance improvement projects with measurable progress achieved (G658). The Findings Include: 1. A review of the Quality Assessment and Performance Improvement (QAPI) provided was completed on 3/01/24 failed to evidence the data used monitored the effectiveness of services nor frequency and detail of the data collected was approved by the Governing Body. On 3/01/24 during an interview beginning at 12:45 PM, the Administrator indicated they would need to check if they had documentation of the approval by the governing body on the frequency and data detail to be collected. 2. The review of the agency QAPI failed to evidence performance improvement activities with a focus on high risk, high volume, or problem-prone areas of increased falls, infections, or hospitalizations. During an interview on 3/01/24, the Clinical Manager (CM) indicated there was no report that tracks that information. 3. The review of the QAPI provided failed to identify the agency’s performance improvement activities considering incidence, prevalence, and severity of problems for falls, infections, or hospitalizations. During an interview on 3/01/24, the CM indicated they do not recall action plans for those items. 4. The QAPI provided for review on 3/1/24, failed to identify performance improvement activities that would provide correction of any identified problem(s) that directly or potentially threatens the health and safety of patients. During the interview on 3/1/24 conducted with the Administrator and the Clinical Manager (CM), the CM indicated there were no action plans. 5. The QAPI information provided for review on 3/1/24 failed evidence documentation of performance improvement projects (PIP) undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. During an interview with the CM on 3/1/24, they indicated they need to look at this and need to review their policy.

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 and interview, the agency failed to ensure agency personnel practiced standard/universal precautions to prevent transmission of infections for 1of 1 home visit observation of a home health aide (Patient #1). The findings include: Upon arrival of a home health aide observation on 2/28/24 beginning at 12:18 pm for Patient #1, it was noted Home Health Aide 1 (HHA 1) was wearing gloves upon entry to the home. HHA 1 was observed to stand up from the couch using gloved hands to push off of their legs. It was observed HHA 1 went to bathroom in preparation of assisting Patient #1 with a bath. It was noted HHA 1 wearing same gloves as they prepared the bathroom for Patient #1 shower. HHA 1 then returned to Patient #1, grabbing the handles of Patient #1 wheelchair and wheeling Patient #1 to bathroom doorway. HHA assisted Patient #1 to stand and transfer to shower bench. Continuing with same gloves, HHA 1 assisted Patient #1 to remove clothing and sit on the bench. It was noted HHA1 checked the water temperature with gloved hand. HHA 1 then provided moistened loofa to Patient #1. Patient #1 proceeded to bathe areas they could reach independently. It was observed HHA 1 bathed Patient #1 back and lower extremities. HHA 1 then stood up, removed gloves and left bathroom. It was observed HHA 1 put on new gloves as they returned to the bathroom. HHA 1 turned off the water and proceeded to assist Patient #1 with drying and dressing. Wearing the same gloves, HHA 1 then assisted Patient #1 to wheelchair. HHA 1 then brushed Patient #1 hair and turned wheelchair to take Patient #1 to living room. Continuing to wear same gloves, HHA 1 assisted Patient #1 to recliner, pulled bedside table to Patient #1 and placed over turned bottle of water upright. HHA 1 then removed gloves and performed hand hygiene in dish filled kitchen sink. While washing hands, it was observed HHA 1 hands coming in contact with soiled dishes in the sink. In an interview with HHA 1 on 1/28/24 at 1:05 pm HHA 1 indicated they change their gloves anytime they touch anything. In a interview with the Clinical Manager (CM) on 2/28/24 at 1:06 pm the CM indicated they observed HHA 1 wearing the same gloves throughout the visit and was concerned.

Home health aide services CFR(s): 484.80 Condition of participation: Home health aide services. All home health aide services must be provided by individuals who meet the personnel requirements specified in paragraph (a) of this section. This CONDITION is not met as evidenced by: Based on observation, record review, and interview, the home health agency failed to ensure the Home Health Aide (HHA) was assigned to a specific patient by a Registered Nurse (RN) (See G0798), failed to ensure the HHA provided services that were ordered by the physician, included in the plan of care, and/or consistent with HHA training (See G0800), failed to provide interdisciplinary communication to the RN (See G0804), and failed to ensure home health aide supervision ensured the aide followed the plan of care and furnished care as assigned by the registered nurse (See G 818). The findings include: The cumulative effect of these systemic problems resulted in the agency's inability to ensure patients received appropriate care and services, which could result in the agency not providing quality health care, thus being out of compliance with the Condition of Participation 42 CFR §484.80: Home Health Aide Services.

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 observation, record review, and interview, the home health agency failed to ensure the Home Health Aide was assigned to a specific patient by a Registered Nurse (RN) in 2 of 3 active clinical records reviewed with adult patients who received non-skilled Home Health Aide (HHA) services only (Patient #2 and 7), and 1 of 1 discharged clinical record reviewed with an adult patient (Patient #5). The findings include: Findings include: 1. The clinical for Patient # 5 included a medical plan of care for the certification period 1/31/24 through 3/30/24 that delineated the home health aides were to provide active range of motion (ROM) to bilateral upper extremities. 2. The home health aide care plan dated 02/01/24 directed the aide to provide passive range of motion. 3. The aide visit notes dated 02/01/24, 1/31/24, and 1/30/24 included documentation the completed passive range of motion during their visit. 4. During an interview with Clinical Manager on 2/28/24, beginning at 2:00 p.m., Clinical Manager verbalized that the home health aide plan of care for range of motion (ROM) activities should exactly match the medical plan of care, and this was an error missed in quality review. The Clinical Manager indicated that the home health aide plan of care for passive range of motion was erroneous and should have indicated active range of motion to match the medical plan of care as ordered by the physician. 5. The medical plan of care indicated activities permitted included assistance with mobility in medical stroller / Barton chair. The recertification assessment completed on 01/26/24 by RN 2 indicated that Patient # 5 was unable to ambulate. 6. Aide plan of care on visit note dated on 2/1/24 indicated assist with ambulation and failed to identify the device to be used for safe mobility. 7. During an interview with Clinical Manager, beginning on 2/28/24 at 2:00 p.m., Clinical Manager verbalized that the aide care plan during certification period 1/31/24 to 3/30/24 was incorrect regarding assist with ambulation for Patient # 5 and quality review missed aligning this with the medical plan of care for the home health aide care plan in correction. 1. The clinical record for Patient #2 evidenced the patient received non-skilled Home Health Aide (HHA) services, Registered Nurse (RN) 1 was the patient’s case manager, and HHA 2 provided care. During an interview on 2/27/2024 at 1:44 PM, RN 1 indicated “Operations” (non-clinical office staff) assigned the aides to a patient, the Administrator (non-clinical) let the nurses know how many hours were approved, then the referral went to nursing for the admission visit. During an interview on 2/27/24 at 3:55 PM, HHA 2 indicated the office staff assigned the patients to the HHAs. 2. A home visit occurred on 2/28/24 at 10:30 AM with Patient #7 and HHA 4. During the visit, HHA 4 indicated she provided 4 hours of care each visit, about an hour a day for HHA services (personal care), and then the rest of the day on either Prior Authorization (PA) HHA care or homemaker services, it depended on the day, and the Administrator or other office assigned aides to patients. 3. During an interview on 2/27/2024 at 4:37 PM, the Administrator (non-clinical) indicated he/she asked potential patients to walk him/her through a typical day to enable him/her to establish the needs for home health services, assigned a HHA and assured availability, obtained insurance verification, then the RN admitted the patient for service(s). 410 IAC 17-14-1(m)

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the home health agency failed to ensure the Home Health Aide (HHA) provided services that were ordered by the physician, included in the plan of care, and/or consistent with HHA training, for 2 of 3 active clinical records reviewed with adult patients who received non-skilled HHA services only (Patient #2 and 7). The findings include: 1. The clinical record for Patient #2 evidenced Patient received non-skilled Home Health Aide (HHA) services, Registered Nurse (RN) 1 was Patient’s case manager, and HHA 2 provided care. A Plan of Care (POC) for the certification period 02/06/24 – 4/05/24 evidenced but not limited to the patient’s activities included Passive Range of Motion (PROM) exercises (someone else manually moves a body part that would not independently be possible). The POC failed to evidence specific instructions for the administration of PROM exercises by the aide. The HHA visit notes dated 2/06/24, 2/10/24, 2/13/24, 2/15/24, 2/16/24, 2/18/24, 2/20/24, 2/22/24, 2/23/24, 2/24/24, 2/27/2024, and visit notes with 2 visits on the same day, dated 2/07/24, 2/08/24, 2/11/24, 2/12/24, 2/19/24, 2/21/24, 2/25/24, and 2/26/2024, each evidenced tasks included but was not limited to PROM to upper and lower body, and evidenced the HHA provided PROM exercises to the upper and lower body, and failed to evidence the specific exercises administered by the HHA, or number of repetitions. During an interview on 02/27/2024 at 1:44 PM, RN 1 indicated the HHA care plan was imbedded in every visit note, and included PROM exercises to upper and lower extremities, the PROM exercises were “as tolerated” by the patient, and the patient told the HHA what to do. 2. A home visit occurred on 02/28/24 at 10:30 AM with Patient #7 and HHA 4. During the visit, Person E (staff) at Entity F (a hospice agency) arrived to provide a home visit, and provided wound care to Patient's left foot. When asked, Person E indicated she didn't know how the home health agency's HHAs protected the dressing when they did showers. HHA 4 indicated he/she cut the old dressings off, showered the patient, then handed the patient the supplies needed to re-dress the left foot wound. HHA 4 indicated the patient needed some touch for ROM to the left leg, but the other extremities were independent (active range of motion [AROM]), and they did whatever Patient tolerated. Oxygen equipment was observed. HHA 4 indicated Patient didn't presently use oxygen, he/she knew how to apply it if it was needed, but didn't know what the setting would be. The clinical record for Patient #7 evidenced a communication note dated 2/07/24, authored by the Administrator, which indicated HHA called the agency to report he/she administered a COVID-19 test to Patient due to a slight fever. The current POC failed to evidence orders to administer a COVID-19 test, ROM exercises, nor the removal of soiled wound dressings prior to showering. During an interview on 3/01/24 at 9:58 AM, the Administrator indicated he didn't think testing for COVID-19 was something they competency tested for, he would need to check into this. During an interview on 3/01/24 at 10:01 AM, HHA 4 indicated he/she took it upon him/herself to administer the COVID-19 test, and just felt like it needed to be done. During an interview on 3/01/24 at 10:10 AM, the Administrator indicated HHA 4's personnel file did not include a competency evaluation for administration of COVID-19 test.

Aides are members of interdisciplinary team CFR(s): 484.80(g)(4) Home health aides must be members of the interdisciplinary team, must report changes in the patient's condition to a registered nurse or other appropriate skilled professional, and must complete appropriate records in compliance with the HHA's policies and procedures. This ELEMENT is not met as evidenced by: Based on record review and interview, the Home Health Aide (HHA) failed to provide interdisciplinary communication to the Registered Nurse (RN) with regard to frequent refusals from the patient to allow performance of tasks assigned by the RN, in 2 of 3 active clinical records reviewed of an adult who were ordered unskilled services (Patient #2 and 7). The findings include: 1. A Home Health Aide (HHA) job description dated 2/2023 evidenced the HHA would complete all work assigned by the Registered Nurse (RN), and report incomplete assignments to the RN. 2. The clinical record for Patient #2 evidenced the patient received non-skilled Home Health Aide (HHA) services, Registered Nurse (RN) 1 was the patient’s case manager, and HHA 2 provided care. The HHA visit notes dated 2/06/24, 2/07/24, 2/08/24, 2/10/24, 2/11/24, 2/12/24, 2/13/24, 2/14/24, 2/15/24, 2/16/24, 2/17/24, 2/18/24, 2/19/24, 2/20/24, 2/21/24, 2/22/24, 2/23/24, 2/25/24, 2/26/24, and 2/27/2024 all evidenced the patient refused to allow the HHA to perform 1 or more tasks assigned by the RN, and evidenced the RN was not notified of the uncompleted task(s). During an interview on 2/27/2024 at 1:44 PM, when asked what circumstances would require the aide to notify a RN, RN 1 indicated they told the aides to call them for skin issues. During an interview on 2/27/24 at 3:55 PM, when asked what should occur when the patient refused to allow the HHA to provide/perform tasks assigned on the care plan, HHA 2 indicated he/she asked the patient a lot of times before marking the task as “refused”. 3. The clinical record for Patient #7 evidenced the patient received non-skilled Home Health Aide (HHA) services, Registered Nurse (RN) 1 was the patient’s case manager, and HHA 4 provided care. The HHA visit notes dated 2/19/24, 2/20/24, 2/21/24, 2/22/24, 2/23/24, 2/26/24, and 2/27/2024 all evidenced the patient refused to allow the HHA to perform 1 or more tasks assigned by the RN, and evidenced the RN was not notified of the uncompleted task(s). During an interview on 3/01/2024 at 10:01 AM, HHA 4 indicated she didn't notify the RN when patients refused care, and the patients directed the care to be performed during visits.

HH aide supervision elements CFR(s): 484.80(h)(4)(i-vi) Home health aide supervision must ensure that aides furnish care in a safe and effective manner, including, but not limited to, the following elements: (i) Following the patient's plan of care for completion of tasks assigned to a home health aide by the registered nurse or other appropriate skilled professional; (ii) Maintaining an open communication process with the patient, representative (if any), caregivers, and family; (iii) Demonstrating competency with assigned tasks; (iv) Complying with infection prevention and control policies and procedures; (v) Reporting changes in the patient's condition; and (vi) Honoring patient rights. This ELEMENT is not met as evidenced by: Based on record review, observation, and interview the agency failed to ensure home health aide supervision ensured the aide followed the plan of care and furnished care as assigned by the registered nurse for 1 of 3 adult unskilled patients. (Patient #1) The Findings Include: The record evidenced aide visit notes dated 02/05/24 through 02/26/24, which indicated the aide was assigned to make 3 hour visits daily, from 9:00 am to 12:00 pm, to provide aide services. The aide was then to provide attendant care services 6 to 7 days a week throughout the certification period; these services were scheduled 12:00 pm to 1:00 pm The aide then provided homemaker services at varying times in the evening, beginning at 4:00 pm to 10:00 pm. The record indicated the home health aide is scheduled 9:00 am to 10:00 pm on weekend days. A review of these aide visit notes revealed HHA 1 clocked in late and adjusted the time of services on 2/5/24, 2/7/24, 2/8/24, 2/9/24, 2/10/24, 2/11/24, 2/12/24, 2/14/24, 2/15/24, 2/16/24, 2/17/24, 2/18/24, 2/19/24, 2/21/24, 2/22/24, 2/23/24, 2/24/24, 2/25/24, and 2/26/24. In an interview with Home Health Aide 1(HHA1) on 3/1/24 beginning at 1:19 pm, HHA indicated they begin their shift begins at 9:00 AM continuing to work until 2:00 pm. They leave and return at 7:00 pm continuing to work until 10:00 pm. On 3/6/24 during an interview beginning at 11:46 pm with Patient #1 caregiver, they indicated during the weekdays the HHA arrives around 10:30 pm, continuing to work until 2:30 pm, with the exception of Tuesdays, which the caregiver indicated they have agreed to give the HHA that time off. The caregiver indicated HHA 1 returns in the evening to help put Patient #1 to bed but was unsure of the hours. The caregiver indicated HHA 1 works 5 hours per day on Saturday and Sunday but the hours of work vary. During an interview with the Administrator on 3/4/24 beginning at 11:30 AM, they indicated the discrepancy could be due to the Home Health Aide forgetting to clock in and further indicated the Home Health Aide does not self-schedule. 410 IAC 17-14-1 (n)