Every finding on record at Union Healthcare Services Inc

This visit was for a Federal Complaint survey of a Deemed Home Health Agency. Survey Dates: 07-01, 07-02, and 07-03-2024 12-month unduplicated skilled admission: 123 Complaint # 107917 with unrelated findings Union Healthcare Services INC was found in compliance with Conditions of Participation 484.58,484.70, and 484.100 as related to the complaint.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on record review and interview the Agency failed to notify the physician of missed visits in 3 of 5 active records reviewed. ( Patients # 3, 4, and 6) Findings include: 1. A policy titled “MISSED VISITS Policy No.4-069.1” indicates but was not limited to “ If a visit is missed for any reason, the clinician should attempt to reschedule it . . . Notify the physician . . . including date, time, physician name, method of notification and the staff reporting the information.” 2. A review of the clinical record of Patient #3 with a start of care 06-21-2024 and a Certification period of 06-21-24 through 08-19-2024 with physician orders for skilled nursing one time a week for wound care to left lower extremity evidenced no visits scheduled or completed for the week of 06-23-2024. During an interview with the Administrator on 07-02-2024 at 9 AM, related to the missed skilled nursing visit during the week, they reported Registered Nurse 2 (RN) did not do “our process”, by not contacting scheduling, and the visit was missed and the physician was not notified. 3. A review of the clinical record for Patient #4 evidenced a start of care 06-14-2024 and a certification period of 06-14-2024 through 08-12-2024 with orders for an occupational therapy (OT) evaluation on 06/14/2024. The record evidenced no OT evaluation had been completed and no evidence of physician notification. During an interview on 07-02-2024 at 10:45 AM, the Alternate Administrator, OT, reported not sure if the patient requested an alternative date but reported they could not locate a physician's order or note to explain the missed OT evaluation and no evidence of physician notification. 4. A review of the clinical record for Patient # 6 with a Certification period of 05-06-2024 through 07-04-2024 evidenced home health aide (HHA) orders for 5 days a week for 6 hours per day. The HHA record evidenced 2 HHA missed visits the week of 05-06-2024, 2 missed visits the week of 05-19-2024, 1 HHA visit missed for the week of 05-26-2024, one HHA missed visit the week of 06-16-2024, and 2 missed HHA visits missed for the week of 06-23-2024. The record failed to evidence the physician was notified of the missed visits. 5. Interview on 07-03-2024 at 11:20 AM the administrator reported the agency notifies the physician of missed visits by faxing them but had not .

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on record review, observation, and interview the agency failed to follow all ordered visits ordered by the physician in the plan of care in 3 of 5 active records reviewed. (Patients # 3, 4, and 6) Findings include: 1. A policy titled “MISSED VISITS Policy No.4-069.1” indicates but was not limited to “ If a visit is missed for any reason, the clinician should attempt to reschedule it . . . so that the physician ordered frequency is maintained . . . .” 2. A review of the clinical record of Patient #3 with a start of care 06-21-2024 and a Certification period of 06-21-24 through 08-19-2024 with physician orders for skilled nursing one time a week for wound care to left lower extremity evidenced no visits scheduled or completed for the week of 06-23-2024. During an interview with the Administrator on 07-02-2024 at 9 AM, related to the missed skilled nursing visit during the week, they reported Registered Nurse 2 (RN) did not do “our process”, by not contacting scheduling, and the visit was missed. 3. A review of the clinical record for Patient #4 evidenced a start of care 06-14-2024 and a certification period of 06-14-2024 through 08-12-2024 with orders for an occupational therapy (OT) evaluation on 06/14/2024. The record evidenced no OT evaluation had been completed. During an interview on 07-02-2024 at 10:45 AM, the Alternate Administrator, OT, reported not sure if the patient requested an alternative date but reported they could not locate a physician's order or note to explain the missed OT evaluation. 4. A review of the clinical record for Patient # 6 with a Certification period of 05-06-2024 through 07-04-2024 evidenced home health aide (HHA) orders for 5 days a week for 6 hours per day. The HHA record evidenced 2 HHA missed visits the week of 05-06-2024, 2 missed visits the week of 05-19-2024, 1 HHA visit missed for the week of 05-26-2024, one HHA missed visit the week of 06-16-2024, and 2 missed HHA visits missed for the week of 06-23-2024. During a home visit to Patient #6’s residence on 07-03-2024 at 12:50 PM observed RN 2 and the absence of a scheduled home health aide (HHA). Patient #6 reported the HHA was to be there but did not show up and has had car trouble lately missing some visits. During an interview on 07-03-2024 at 2:12 PM the Administrator reported the HHA had car trouble a few times and the aide is supposed to phone them and report if they are absent.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on record review and interview, the agency performed services for 8 of 15 active home health patients without physician orders. (Patients: #1, 3, 4, 6, 12, 13, 10, and 16) Findings Include: 4. A focused review of the clinical record for Patient #6 was completed on 06-20-2023. Patient #6’s clinical record with a start of care 10-24-2022, evidenced an agency document titled, “Physician Order.” The signed physician order indicated a verbal order for evaluation for Skilled Nursing, Physical Therapy, and Home Health Aide services. The clinical record failed to evidence a physician order for Attendant care services to be provided by Union Healthcare Services. 5. A focused review of the clinical record for Patient #12 was completed on 06-20-2023. Patient #12’s clinical record with a start of care 07-01-2022, failed to evidence a physician order for Attendant care services to be provided by Union Healthcare Services. 6. A focused review of the clinical record for Patient #13 was completed on 06-20-2023. Patient #13’s clinical record with a start of care 05-23-2022, failed to evidence a physician order for Attendant care services to be provided by Union Healthcare Services. 7. A focused review of the clinical record for Patient #16 was completed on 06-22-2023. Patient #16’s clinical record with a start of care 09-08-2022, failed to evidence a physician order for Attendant care services to be provided by Union Healthcare Services. During an interview on 06-22-2023 at 3:35 PM, the DON and Administrator confirmed they could not provide the physician orders for Patients #6, 12, 13, and 16. They further indicated they were in the process of getting orders for all the Attendant care patients. 1. November 2021, Union Healthcare Services Incorporated (Inc) policy titled, “Physician Participation in Plan of Care”, Policy No. 4-002.1 was provided by the Director of Nursing (DON) on 06-21-2023 at 3:15 PM. The policy indicated but was not limited to, “… 6. The attending physician… recertification will be obtained in intervals of at least every 60 days when the patient’s plan of care is reviewed, the patient recertified…”. 2. On 06-21-2023 at 11:25 AM, Patient #3’s clinical record was reviewed. Patient #3 had a start of care date of 04-19-2023. The most current plan of care had a certification period of 04-19-2023 to 06-17-2023. A comprehensive assessment was conducted on 06-21-2023. The agency failed to perform a recertification assessment within the time frame listed in their policy and failed to produce a current plan of care. During an interview with the Director of Nursing (DON) on 06-21-2023 at 11:40 AM, when queried regarding Patient #3’s recertification assessment and plan of care, they indicated the recertification and comprehensive assessment would be late. The DON indicated there was no current plan of care. 3. On 06-21-2023 at 12:25 PM, Patient #10’s clinical record. Patient #10 had a start of care date of 06-03-2023. The most current plan of care had a certification period from 03-30-2023 through 05-28-2023. A comprehensive assessment was conducted on 06-12-2023. The agency failed to perform a recertification assessment within the time frame listed in their policy and failed to produce a current plan of care. During an interview with the Administrator on 06-21-2023 at 12:44 PM, they indicated Patient #10 had no current plan of care. The Director of Nursing indicated the previous plan of care expired and they had initiated a start-of-care assessment on 06-12-2023.

An Emergency Preparedness survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102, for a Medicare participating deemed Home Health Agency. Date of survey: 01-03-2023 through 01-11-2023 Facility #: 014867 CCN: 157715 QR by Area 3 on 1-26-2023 Census: 42 Unduplicated Skilled Admissions: 21 At this Emergency Preparedness survey, Union Healthcare Services, was found to have been out of compliance with the requirements of Emergency Preparedness for Medicare and Medicaid participating providers and suppliers, including staffing and implementation of staffing during a Pandemic, at 42 CFR 484.102. The cumulative effect of these systemic problems resulted in Union Healthcare Services, Inc, being found out of compliance with the condition: 42 CFR 484.102. The requirement is NOT MET as evidenced by: Findings include: 1. On 01-09-2023 at 11:10 AM, Administrator #1 (Admin #1) provided a November 2021, Union Healthcare Services policy titled, “Emergency Management Plan, Policy No. 6-037.1.” The policy indicated but was not limited to, “Purpose … To establish a plan which will allow for continuation of services in the event of a disaster, natural or man-made, affect the organization or community and to ensure the safe management of staff while securing patient and employee records …” 2. On 01-09-2023 at 2:30 PM, Administrator #1 provided a binder titled, “Emergency Preparedness”. The pages held within the binder were blank with the exception of an Employee list that was undated and contained former employee names. There was no evidence of the COVID Pandemic Emergency Readiness Response. There was no evidence an active drill or tabletop exercise was ever completed. 3. On 01-06-2023 at 9:15 AM, Administrative Staff #3 (Admin #3) provided employee records for review. Admin #3 was queried about the education provided annually for staff. Admin #3 indicated the only education provided was related to Dementia training. QR by Area 3 on 1-26-2023

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 ensure an Emergency Preparedness program was in place as noted over 7 of 7 survey days. Findings include: 1. On 01-09-2023 at 11:10 AM, Administrator #1 (Admin #1) provided a November 2021, Union Healthcare Services policy titled, “Emergency Management Plan, Policy No. 6-037.1”. The policy indicated but was not limited to, “Purpose…To establish ha plan which will allow for continuation of services in the event of a disaster, natural or man-made, affect the organization or community and to ensure the safe management of staff while securing patient and employee records…”. 2. On 01-09-2023 at 2:30 PM, Administrator #1 provided a binder titled, “Emergency Preparedness”. The pages held within the binder were blank with the exception of an Employee list that was undated and contained former employee names. There was no evidence of the COVID Pandemic Emergency Readiness Response. There was no evidence of an active drill or a tabletop exercise was ever completed. 3. On 01-06-2023 at 9:15 AM, Administrative Staff #3 (Admin #3) provided employee records for review. Admin #3 was queried about the education provided annually for staff. Admin #3 indicated the only education provided was related to Dementia training.

This visit was for a Federal Complaint Survey of a deemed Home Health Provider. A fully extended complaint investigation was announced on 01-09-2023 at 1:40 PM. Complaint #: 95101 Survey dates: 01-03-2023, 01-04, 01-05, 01-06, 01-09, 01-10 and 01-11-2023 Census: 42 Unduplicated Skilled patients: 27 An Immediate Jeopardy was announced on 1-10-2023, at 42 CFR 484.60, Care Planning, Coordination of Services, and Quality of Care, when it was identified the last skilled nursing visit for Patient #7, who had wound care orders for right lower extremity, was made on 10-7-2022, the Immediate Jeopardy began at that time, when the agency failed to provide services, notify the attending physician, seek to coordinate care with the involved insurance provider, or assist Patient #7 to find another home health agency to provide wound care and then discharge Patient #7. This patient had an amputation of the right lower extremity sometime prior to 1-9-23, and was recovering in a rehabilitation facility at the time of the survey. The Immediate Jeopardy was found to affect 16 active patients and 2 inactive patients, for whom the home health agency had not met their care needs. The Administrator confirmed the home health agency had failed to provide visits as ordered on the plan of care and failed to coordinate with the physician and insurance providers for some patients. These deficient practices had the potential to affect all 42 patients who received agency services. The Administrator was notified of the Immediate Jeopardy (IJ) on 01-10-2023 at 2:54 PM. The agency submitted a removal plan for the immediacy component of the IJ at 42 CFR 484.60, Care Planning, Coordination of Services, and Quality of Care on 1-11-2023, at 10:00 AM. This removal plan was found to be unacceptable because at least one action had not been completed when the removal plan was presented. Additionally, the immediacy component removal plan failed to identify and take action for all patients at risk of serious harm, it only addressed new admissions. The Immediate Jeopardy was not abated by the end of the exit conference on 01/11/2023 at 3:00 PM. On 1-23-2023, an immediacy component plan of correction for the Immediate Jeopardy was received and found to be unacceptable because the plan submitted did not clearly identify all agency interventions to identify patients who are likely to suffer serious adverse outcomes as a result of the identified non-compliance and failed to ensure the interventions/actions the agency proposed had all been completed. QR by Area 3 on 1-14, 1-15, 1-16, 1-17, 1-24, 1-25, and 1-26-2023

Reporting OASIS information CFR(s): 484.45 Condition of participation: HHAs must electronically report all OASIS data collected in accordance with §484.55. This CONDITION is not met as evidenced by: Based on record review and interview, the agency failed to have in place a current written contract for the CEO (Chief Executive Officer), Corporate Staff #1, acting on behalf of the agency, to ensure the confidentiality of all patient identifiable information included in the clinical record and failed to transmit any skilled Medicaid patients utilizing federally funded health plans not meeting the exceptions to the transmittal requirement in 1 of 1 agency. The cumulative effect of this systemic problem resulted in the home health agency's inability to ensure the provision of quality health care in a safe environment for the Condition of Participation of 42 CFR 484.45, Reporting of OASIS information. Findings include: 1. During the entrance conference meeting on 01-03-2023 at 9:15 AM, the Administrator/Director of Nursing, Admin 1, indicated the agency did not have any contracted staff. 2. On 01-03-2023, received from Admin 1, an agency booklet titled, “Home Health Admission Booklet.” A review of page 6, the section titled “ Medical Records,” indicated but was not limited to, “ …Your records are kept strictly confidential by our staff and are protected against loss, destruction, tampering, or unauthorized use….” 3. During an interview on 01-06-2023 at 11:34 AM, the CEO, Corp Staff 1, stated, “I do all the submissions on Medicare patients only.” When asked to provide the OASIS submission validation for the past year, they confirmed they would send a copy to Admin 1 to provide via email. 4. On 01-06-2023 at 12:07 PM, the Administrator/Director of Nursing, Admin 1, provided an agency document titled, “ OASIS (The Outcome and Assessment Information Set) (a comprehensive assessment designed to collect information related to a home care recipient’s demographic, clinical, functional and service needs) Agency Final Validation.” The document was for the reporting period of the year to date, which indicated that Inactive Patients #6, 30, and 31 had a section titled “RFA (Reason For Assessment) listed as 01, indicating a start of care OASIS assessments were submitted on 11-14-2022.

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to submit OASIS (outcome and assessment information set) within 30 days of assessment completion for 12 of 16 qualified active skilled records reviewed (Patients: #1, 2, 3, 4, 10, 15, 18, 20, 21, 22, 23, and 24), and 4 of 7 qualified inactive records reviewed (Patients: # 8, 14, 29, and 31) where OASIS information was collected and transmitted. Findings include: 1. A review of a Union Healthcare Services Inc. policy revised date November 2021, titled, “OASIS Data Transmission” Policy No. 3-020.1, was received from the Administrator on 01-06-2023. The policy indicated, “…Policy: The organization will adhere to all OASIS data transmission requirements as outlined in the Medicare Conditions of Participation…1. The organization will encode and transmit completed OASIS data for each applicable patient within thirty (30) days of the M0090 date, date assessment completed…” 2. A review of the OASIS submission reports, indicated the agency failed to provide evidence of any skilled OASIS submissions for 2023 and only 3 patients with Medicare-funded starts of care submissions in 2022. 3. A review of the active clinical record for Patient #1 was reviewed, with the start of care date of 12-12-2022. The OASIS certification assessment was to be submitted for transmission on 01-11-2023. The record failed to evidence that OASIS submission occurred within 30 days of completion. 4. A review of the active clinical record for Patient #2 was reviewed, with the start of care date of 10-27-2022. The OASIS certification assessment was to be submitted for transmission on 11-26-2022. The record failed to evidence that OASIS submission occurred within 30 days of completion. 5. A review of the active clinical record for Patient #3 was reviewed, with the start of care date of 06-29-2021. The OASIS certification assessment was to be submitted for transmission on 07-29-2021. The record failed to evidence that OASIS submission occurred within 30 days of completion. 6. A review of the active clinical record for Patient #4 was reviewed, with the start of care date of 10-11-2022. The OASIS certification assessment was to be submitted for transmission on 11-10-2022. The record failed to evidence that OASIS submission occurred within 30 days of completion. 7. A review of the inactive clinical record for Patient #8 was reviewed, with the start of care date of 07-22-2021 and the discharge date of 09-16-2021. The OASIS certification assessment was to be submitted for transmission for the start of care on 08-21-2021, and the discharge assessment on 10-16-2021. The record failed to evidence that OASIS submission occurred within 30 days of completion. 8. A review of the active clinical record for Patient #10 was reviewed, with the start of care date of 11-25-2022. The OASIS certification assessment was to be submitted for transmission on 12-25-2022. The record failed to evidence that OASIS submission occurred within 30 days of completion. 9. A review of the inactive clinical record for Patient #14 was reviewed, with the start of care date of 10-4-2022, and discharge date of 12-28-2022. The OASIS certification assessment was to be submitted for transmission on 11-3-22. The record failed to evidence that OASIS submission occurred within 30 days of completion. 10. A review of the active clinical record for Patient #15 was reviewed, with the start of care date of 09-19-2022 and the recertification assessment on 11-16-2022. The OASIS certification assessment was to be submitted for transmission on 10-19-2022, and the recertification assessment on 12-16-2022. The record failed to evidence that OASIS submission occurred within 30 days of completion. 11. A review of the active clinical record for Patient #18 was reviewed, with the start of care date of 11-08-2022. The OASIS certification assessment was to be submitted for transmission on 12-08-2202. The record failed to evidence that OASIS submission occurred within 30 days of completion. 12. A review of the active clinical record for Patient #20 was reviewed, with the start of care date of 10-12-2022. The OASIS certification assessment was to be submitted for transmission on 11-11-2022. The record failed to evidence that OASIS submission occurred within 30 days of completion. 13. A review of the active clinical record for Patient #21 was reviewed, with the start of care date of 10-14-2022, and a transfer to an acute hospital on 11-30-2022. The OASIS certification assessment was to be submitted for transmission on 11-13-2022, and the transfer assessment on 12-30-2022. The record failed to evidence that OASIS submission occurred within 30 days of completion. 14. A review of the active clinical record for Patient #22 was reviewed, with the start of care date of 10-29-2022. The OASIS certification assessment was to be submitted for transmission on 11-18-2022. The record failed to evidence that OASIS submission occurred within 30 days of completion. 15. A review of the active clinical record for Patient #23 was reviewed, with the start of care date of 11-30-2022. The OASIS certification assessment was to be submitted for transmission on 12-30-2022. The record failed to evidence that OASIS submission occurred within 30 days of completion. 16. A review of the active clinical record for Patient #24 was reviewed, with the start of care date of 9-16-2022. The OASIS certification assessment was to be submitted for transmission on 10-16-2022. The record failed to evidence that OASIS submission occurred within 30 days of completion. 17. A review of the inactive clinical record for Patient # 29 was reviewed, with the start of care date of 10-25-2022, and discharge date of 12-25-2022. The OASIS certification assessment was to be submitted for transmission on 11-24-22. The record failed to evidence that OASIS submission occurred within 30 days of completion. 18. A review of the clinical record for Patient #31 was reviewed, with the start of care date of 10-13-2022, and a discharge date of 12- 25-2022. The OASIS certification assessment was to be submitted for transmission on 11-12-2022; no evidence of a discharge OASIS being completed or submitted. The record failed to evidence that OASIS submission occurred within 30 days of completion. During an interview on 01-06-2023 at 11:34 AM, the CEO, Corp Staff 1, stated, “I do all the submissions on Medicare patients only.”

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 agency’s correct contact information was provided to its patients (G 414), failed to ensure patients were informed about the care and treatment as ordered (G 434), failed to ensure patients consented to treatment and/or participated in ongoing care decisions (G 434), failed to ensure all services were provided in the plan of care (G 436), failed to ensure the confidentiality of patient records was maintained (G 438), and failed to provide patients notice of any charges they may expect (G 440.) The cumulative effects of these systemic problems resulted in the home health agency's inability to ensure the provision of quality health care in a safe environment for the Condition of Participation of 42 CFR 484.50, Patient Rights. Findings include: *

HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator's name, business address, and business phone number in order to receive complaints. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to provide the Administrator’s name and contact information to the patients for 3 (Patients 1, 2, and 9) of 3 home visit observations made. Findings Include: 1. On 10-03-2023, received from Admin 1 an agency booklet titled “Home Health Admission Booklet.” A review of page 9, the section titled, “Problem Solving Procedure,” indicated but was not limited to “…2. Notify the Administrator, sic [Former Employee 56], RN, by phone at (317) 279-6092 or in writing to 6201 La Pas Trail Suite 120, Indianapolis IN 467268….” 2. During a home visit at Patient #2’s residence on 01-04-2023 at 10:16 AM, observed the Registered Nurse (RN) complete wound care. A review of Patient #2’s agency booklet titled, “Home Health Admission Booklet,” failed to provide the contact information and name of the Administrator, Admin 1. 3. During a home visit at Patient #1’s residence on 01-04-2023 at 9:30 PM, observed the Physical Therapist (PT). A review of Patient #1’s agency booklet titled, “Home Health Admission Booklet,” failed to provide the contact information and name of the Administrator, Admin 1. 4. During a home visit at Patient #9’s residence on 01-04-2023 at 10:16 AM, observed the Registered Nurse (RN) complete skilled care. A review of Patient #9’s agency booklet titled, “Home Health Admission Booklet,” failed to provide the contact information and name of the Administrator, Admin 1. A review of an agency document titled, “Governing Body Minutes and QAPI Meeting,” dated 12-22-2022, evidenced the governing body appointing Admin 1 as the Director of Nursing and the Administrator. During a daily conference interview on 01-06-2023 at 11:00 AM with Corporate Staff #1 and Admin 1, Corporate Staff 1, when queried who the Administrator of the agency was, confirmed that Admin 1, was the Administrator.

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure patients were informed of their right to consent for treatment and participate in their care, informed of the frequency of visits and ongoing care and treatment they may receive as evidenced over 7 of 7 survey days. (Patient: 9, 28) Findings include: On 01-03-2023 at 10:15 AM, Administrator #1 (Admin#1) provided a November 2021, Union Healthcare Services policy titled, "“Patient Bill of Rights, Policy N 2-002.1”. The policy indicated but was not limited to, “…Each patient will be an active, informed participant in his/her plan of care. 1. The patient will be informed verbally and in writing during the initial evaluation visit…” On 01-04-2023 at 10:00 AM during a home visit with Patient #9, the agency folder failed to evidence signed consents by the patient prior to treatment, a schedule of anticipated visits or the current plan of care (POC) with the correct medication list. On 01-01-05-2023 at 10:15 AM, the clinical record of Patient #28 was reviewed. Patient #28 had a start of care dated 02-17-2022. The record failed to evidence signed consents by the patient prior to treatment. During an interview on 01-10-2023 at 1:35 PM with Administrative Staff #2 (Admin#2), Admin #2 was queried about the presence of consents for Patient #28. Admin #2 indicated they could not be located. 410 IAC 17-12-3 (b)(2)(D)(i)(AA) and (BB)

Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure all patients receive all services as outlined in the plan of care in 16 of 25 active clinical records (Active Patients: #4, 5, 7, 10, 11, 12, 15, 16, 20, 21, 22, 23, 24, 25, 28, and 30) reviewed and 2 of 7 inactive clinical records reviewed. (Inactive Patients: 29, 31) Findings Include: 1. A review of the clinical record for Patient #4, the start of care date of 10-11-22, contained a signed plan of care for the initial certification period of 10-11-22 to 12-09-22. The plan of care indicated orders for skilled nursing (SN) 1 time a week for 4 weeks, 2 times a week for 4 weeks, and 1 time a month for 1 month for med setup. Physical therapy (PT) 3 times a week for 4 weeks, 1 time a week for 4 weeks for treatment and evaluation for muscle strength. Occupational therapy (OT) 3 times a week for 4 weeks, 1 time a week for 4 weeks, treatment, and evaluation for muscle strength. A review of an agency document dated 10-25-2022, titled “Physical therapy Plan of Care with Full Evaluation,” signed by the physician, indicated orders for PT 2 times a week for 4 weeks and 2 times a week for 4 weeks. A review of the SN visit notes evidenced the following: A. On 10-11-22, a Registered Nurse (RN) completed a start of care initial assessment. B. No SN visits were completed during the week of 10-16-22 through 10-22-22. C. No SN visits were completed during the week of 10-23-22 through 10-29-22. D. No SN visits were completed during the week of 10-30-22 through 11-5-22. E. No SN visits were completed during the week of 11-6-22 through 11-12-22. F. No SN visits were completed during the week of 11-13-22 through 11-19-22. G. No SN visits were completed during the week of 11-20-22 through 11-26-22. H. No SN visits were completed during the week of 11-27-22 through 12-3-22. E. On 12-8-22, a RN completed a recertification assessment. The agency failed to provide SN services per the plan of care. A review of the PT notes evidenced a PT evaluation dated 10-25-22. The clinical record failed to evidence any visits conducted after the evaluation. The agency failed to provide PT services per the plan of care. A review of the clinical record for Patient #4 failed to provide evidence of an OT evaluation or visits completed. The agency failed to provide an OT service per the plan of care. During an interview on 1-3-2023 at 2:31 PM, the Director of Nursing/Administrator, Admin 1, when queried regarding Patient #4’s visits, confirmed the visits were not completed. 2. A review of the clinical record for Patient #10, the start of care date of 11-25-22, contained a plan of care for the initial certification of 11-25-22 to 01-23-23. The plan of care indicated orders for SN 1 time a month for 2 months for recertification, supervisory visits, and resumption of care, and a Home Health Aide (HHA) 5 times a week for 9 weeks to assist with Activities of Daily Living (ADLs), and Instrumental Activities of Daily Living (IADLs), and PT to assess function and status. The clinical record failed to provide evidence that a PT evaluation visit was completed. The agency failed to provide PT services per the plan of care. During an interview on 1-4-22 at 12:01 PM, the Director of Nursing/Administrator, Admin 1, when queried regarding Patient #10’s PT evaluation order, confirmed the evaluation was not completed. 3. A review of the clinical record for Patient #15, with a start of care date of 9-19-22, contained a signed plan of care for the recertification period of 11-18-22 to 1-16-23. The plan of care indicated that Patient #15 had orders for SN 1 time a week for 9 weeks, 3 PRN to perform a comprehensive physical assessment, medication review and reconciliation, and aide supervision. HHA 3 times a week for 9 weeks on Monday, Wednesday, and Friday from 10:00 AM to 1:00 PM. A review of the SN visit notes evidenced the following: A. The RN completed a recertification assessment visit on 11-16-22; no further visits were completed the week of 11-13-22 through 11-19-22. B. No SN visits were completed during the week of 11-20-22 to 11-26-22. C. No SN visits were completed during the week of 11-27-22 to 12-3-22. D. No SN visits were completed during the week of 12-4-22 to 12-10-22. E. No SN visits were completed during the week of 12-25-22 to 12-31-22. The agency failed to provide SN services per the plan of care. A review of the HHA notes evidenced the following: no evidence of documentation of HHA visits made for 5 weeks, dates 11-6-22 thru 12-10-22. The agency failed to provide HHA services per the plan of care. During an interview on 1-4-23 at 1:30 PM, Patient #15 confirmed that the agency was not providing HHA services until 4 weeks ago when they found their own HHA. The patient further indicated that they had a family member get certified to provide them with care. 4. A review of the clinical record for Patient #20, with a start of care date of 10-12-22, contained a signed plan of care for the initial certification of 10-12-22 to 12-10-22. The plan of care indicated that Patient #20 had orders for SN 1 time a week for 4 weeks, 2 times a month for 1 month for med management, PT evaluation, and treatment. A review of the SN visit notes evidenced the following: A. On 10-12-22, the RN completed an initial start of care assessment. B. No SN visits were completed during the week of 10-16-22 through 10-22-22. C. No SN visits were completed during the week of 10-23-22 through 10-29-22. D. No SN visits were completed during the week of 10-30-22 through 11-5-22. E. No SN visits were completed during the week of 11-6-22 through 11-12-22. F. No SN visits were completed during the week of 11-13-22 through 11-19-22. G. No SN visits were completed during the week of 11-20-22 through 11-26-22. H. On 12-3-22, SN documented a missed visit during the week of 11-27-22 through 12-3-22. I. On 12-9-22, the RN completed a recertification assessment. The agency failed to provide SN services per the plan of care. A review of the PT notes evidenced a PT evaluation dated 10-14-22, with a PT plan of care to see the patient 2 times weekly for 4 weeks. A review of the PT visit notes evidenced the following: A. No PT visits were completed during the week of 10-16-22 through 10-22-22. B. No PT visits were completed during the week of 10-23-22 through 10-29-22. C. No PT visits were completed during the week of 10-30-22 through 11-5-22. D. No PT visits were completed during the week of 11-6-22 through 11-12-22. During an interview on 1-10-23 at 1:00 PM, Patient #20, when queried regarding therapy and skilled nurse visits, confirmed that the PT or SN did not come back to visit them. 5. A review of the clinical record for Patient #21, with a start of care date of 10-14-22, contained a signed plan of care for the initial certification of 10-14-22 to 12-12-22. The plan of care indicated that Patient #21 had orders for SN 1time a week for 9 weeks for med set up, HHA supervision, and 1-2 prn (as needed), PT 3 times a week for 9 weeks to evaluate and treatment, Home Health Aide (HHA) 2 home visits 5 days a week for 9 weeks to assist with ADLs and IADLS. A review of a signed agency document dated 10-20-22, titled “PT Plan of Care,” indicated orders for PT eval for services and to see the patient 2 times a week for 4 weeks. The agency failed to provide PT visits 2 times a week for 6 weeks before Patient #21 was admitted to an acute care facility, Entity 16. A review of a signed agency document dated 10-20-22 and electrically signed by the Administrator, titled “OT Evaluation,” indicated OT frequency and plan for one time a week for 1 week for eval, then 2 times a week for 3 weeks. The agency failed to provide OT visits 2 times a week for 3 weeks, before Patient #21 was admitted to an acute care facility, Entity 16. A review of the SN notes evidenced a start of care on 10-14-22; no further documentation of SN visits was completed. The agency failed to provide SN weekly visits for 7 weeks, before Patient #21 was admitted to an acute care facility, Entity 16. A review of the HHA notes evidenced that no HHA notes were completed during the 7 weeks before Patient #21 was admitted to an acute care facility, Entity 16. During an interview on 1-10-23 at 9:15 AM, the Administrator, Admin 1, no visits were made by the HHA before the patient was admitted to the acute care facility, Entity 16, on 11-30-22. 6. A review of the clinical record for Patient #22, with a start of care date of 10-29-22, contained a signed plan of care for the initial certification of 10-29-22 to 12-27-22. The plan of care indicated that Patient #22 had orders for SN 1 time a week for 9 weeks for med set up, recert of services prn (as needed) for change in condition, PT 3 times a week for 9 weeks, evaluate and treat, Home Health Aide (HHA) 2 home visits 5 days a week for 8 weeks to assist with ADLs and IADLS. A review of a signed agency document dated 12-11-22, titled “Physician Order,” indicated orders to change the HHA frequency to 8 hours a day, 5 days a week (Monday -Friday). A review of the SN visit notes evidenced the following: A. On 10-29-22, the RN completed a start of care initial assessment. B. No SN visits were completed during the week of 11-30-22 through 11-5-22. C. No SN visits were completed during the week of 11-6-22 through 11-12-22. D. No SN visits were completed during the week of 11-13-22 through 11-19-22. E. No SN visits were completed during the week of 11-20-22 through 11-26-22. The agency failed to provide SN services per the plan of care. A review of the PT visit notes evidenced the following: A. On 10-31-22, the PT completed an evaluation and one visit on 11-5-22. B. During the week of 11-6-22 through 11-12-22, the PT made 2 visits, missing 1 visit. C. During the week of 11-13-22 through 11-19-22, the PT made 2 visits, missing 1 visit. D. During the week of 11-20-22 through 11-26-22, the PT made 2 visits, missing 1 visit. E. During the week of 11-27-22 through 12-3-22, the PT completed 1 visit and 1 evaluation, missing 1 visit. A review of the HHA visit notes evidenced the following: A. On 11-3-22, an HHA visit was made. No further HHA visits were completed. The agency failed to provide HHA 5 times a week for 8 weeks per the plan of care. A review of an agency document dated 12-13-22, titled “Home Health Certification and Plan of Care Resumption of Care Following Hospital Stay,” indicated Patient #22 had orders for an SN 1 time a week for 9 weeks for med set up, recert of services prn (as needed) for change in condition, PT 3 times a week for 9 weeks, evaluate and treat, Home Health Aide (HHA) 2 home visits 5 days a week for 8 weeks to assist with ADLs and IADLS. A review of the RN visit notes evidenced the following: A. On 11-29-22, the RN completed a resumption of care assessment. B. No SN visits were completed during the week of 12-4-22 through 12-10-22. C. On 12-21-22, the RN completed a recertification assessment. The agency failed to provide SN services per the plan of care. A review of the PT visit notes evidenced that no visits were completed for the 3 weeks of 12-4-22 to 12-24-22. The agency failed to provide Pt services 3 times a week per the plan of care. A review of the HHA visit notes evidenced that no visits were completed for the 3 weeks of 12-4-22 through 12-24-22. The agency failed to provide HHA services 2 visits a day 5 times a week per the plan of care. During an interview on 1-10-23 at 3:50 PM, Patient #22, and their caregiver, Person 26, indicated that the staff from Union Healthcare Services do not come consistently. They further indicated that the PT would call and then not show up. The PT called the last time and stated that Patient #22 was not on his schedule. OT never came, and there is no HHA. Patient #22 indicated they fell trying to transfer to the wheelchair, and their family member had to come to help get them up. 7. A review of the clinical record for Patient #23, with a start of care date of 11-30-22, contained a signed plan of care for the initial certification of 11-30-22 to 1-28-23. The plan of care indicated that Patient #23 had orders for SN 1 time a week for 9 weeks for medication management, recertification, resumption of care, and PT evaluation and treatment. A review of an agency document dated 12-9-22, titled “PT Evaluation and Order,” indicated PT 3 times a week for 4 weeks. A review of the PT visit notes evidenced a PT evaluation dated 12-9-22; no further visits were completed. The agency failed to provide PT services 3 times a week as ordered. A review of the SN visit notes evidenced the following: A. On 11-3-22, the RN completed a start of care initial assessment. B. No visits were made during the week of 12-4-22 through 12-10-22, missing 1 SN visit. The agency failed to provide SN services per the plan of care. During an interview on 1-10-23 at 11:34 AM, Person 53, Patient #23’s caregiver, confirmed the PT came out to their home 1 time and never returned. Person 53 further indicated they were never told why the PT never returned by the agency or the PT. 8. A review of the clinical record of Patient #24, the start of care date of 9-16-22, contained a signed plan of care for the initial certification of 9-16-22 to 11-14-22, indicated that Patient #24 had orders for SN 1 time a week for 9 weeks for med set up, education and compliance, disease management, and recertification, PT 3times a week for 9 weeks, OT 2 times a week for 9 weeks. A review of the SN notes evidenced the following: The RN completed a start of care initial assessment on 9-16-22. Further review indicated an SN visit note on 9-28-22 with no further evidence of SN visits. The clinical record failed to evidence that the physician or allowed practitioner responsible for the plan of care had been notified of the agency’s inability to provide services as ordered. A review of the PT visit notes evidenced a PT evaluation dated 9-22-22; a missed visit on 11-2-22 with no other visits completed. The clinical record failed to evidence that the physician or allowed practitioner responsible for the plan of care had been notified of the agency’s inability to provide services as ordered. A review of an agency document dated 11-2-22, titled “Physician Order,” indicated that Patient #24 was to receive SN 1time a week for 9 weeks, HHA 7 times a week for 9 weeks up to 6 hours a day, PT 3 times a week for 9 weeks, and OT 3 times a week for 9 weeks. A review of the Sn visit notes evidenced the following: A. On 9-16-2022, the RN completed a start of care initial assessment dated 9-16-22. B. During the week of 9-18-22 through 9-24-22, no SN visits were completed. C. During the week of 10-2-22 through 10-8-22, no SN visits were completed. D. During the week of 10-9-22 through 10-15-22, no SN visits were completed. E. During the week of 10-16-22 through 10-22-22, no SN visits were completed. F. During the week of 10-23-22 through 10-29-22, no SN visits were completed. G. During the week of 10-30-22 through 11-5-22, no SN visits were completed. H. During the week of 11-6-22 through 11-12-22, no SN visits were completed. The agency failed to provide SN services 1 time a week for 9 weeks as ordered per the plan of care. A review of the PT visit notes evidence that no Pt visits were completed. The agency failed to provide PT services 3 times a week for 9 weeks as ordered per the plan of care. A review of the OT visit notes evidenced an OT evaluation dated 9-22-22; a visit on 9-27-22 with no other visits completed. The agency failed to provide OT services 3 times a week for 9 weeks as ordered per the plan of care. A clinical record review failed to provide evidence that any HHA visits were completed. The agency failed to provide HHA services 7 times a week for 9 weeks, up to 6 hours a day, as ordered per the plan of care. During an interview on 1-10-23 at 11:21 AM, Patient #24 confirmed the therapist came 1 time and has yet to return. 9. A review of the clinical record for Patient #25, with a start of care date of 12-19-22, contained a signed plan of care for the initial certification of 12-19-22 to 2-16-23. The plan of care indicated that Patient #25 had orders for SN 1 time a week for 1 week for the start of care assessment (SOC), PT to evaluate and treat, and OT to evaluate and treat. A review of the SN visit notes evidenced a start of care comprehensive assessment on 12-19-22, with no further visits. A review of the PT notes evidenced a PT evaluation completed on 1-2-2023, with no further visits. A review of the OT visits notes evidenced that no visits were made. The agency failed to provide OT services per the plan of care. During an interview on 1-10-23 at 10:53 AM, Patient #25 confirmed that the physical therapist came 1 time and has yet to return, no further SN visits since the start, and OT has not been to their home. 10. During the Entrance Conference on 1-3-23 at 9:35 AM, the Administrator/Director of Nursing, Admin 1, stated, " We do not take cases unless we can staff them." 11. A review of the clinical record for Patient #12, with the start of care date of 4-19-2022, contained a plan of care for the recertification period of 10-16-2022 to 12-14-2022. The plan of care indicated orders for Skilled Nursing (SN) 1 time a month for 2 months for recertification evaluation and supervisory visits. Home Health Aide (HHA) 2 hours a visit, 5 days a week, 5 days a week for 8 weeks for assistance with personal care Instrumental Activities of daily living (IADL) and Activities of daily living (ADL). A review of the HHA visit notes evidenced no HHA visit notes were completed during the week of 11-20-2022 to 11-26-2022. During an interview on 1-10-2023 at 9:15 AM, when queried regarding Patient #12 not being seen for a week according to the clinical record, Admin #1 stated the missed visits are because of staffing. During the entrance conference on 1-3-2023 at 9:11 AM, Admin #1 stated the agency would not take the patient if the agency was unable to staff the patient’s needs. 12. A review of the closed clinical record for Patient #29, with the start of care date of 10-25-2022, contained a plan of care for the initial certification period of 10-25-2022 to 12-23-2022. The plan of care indicated orders for SN 1 time a week for 9 weeks and 1-2 times as needed for Registered Nurse (RN) HHA supervision for a comprehensive assessment, Physical Therapy (PT) 3 times a week for 9 weeks to evaluate and treat, and HHA 2 hours a visit, 5 days a week for 8 weeks. A review of the clinical record on 1-10-2023 at 12:30 PM failed to evidence PT visits past the initial PT Evaluation. The agency failed to provide PT services as listed on the plan of care. A review of the clinical record failed to evidence any visit notes from the HHA. No HHA visit notes were noted for the weeks 10-25-2022 to 10-29-2022, 10-30-2022 to 11-5-2022, 11-6-2022 to 11-12-2022, 11-13-2022 to 11-19-2022, 11-20-2022 to 11-26-2022, and 11-27-2022 to 12-3-2022. The agency failed to provide HHA services according to the order listed on the plan of care. During an interview on 1-10-2023 at 9:15 AM, when queried regarding Patient #29 not being seen according to the plan of care, Admin #1 stated the missed visits are because of staffing. 13. A review of the clinical record for Patient #11, who is on hold, with the start of care date of 4-19-2022, contained a plan of care for the recertification period of 10-16-2022 to 12-14-2022. The plan of care indicated orders for Skilled Nursing (SN) 1 time a month for 2 months for recertification evaluation and supervisory visits. Home Health Aide (HHA) was listed as a service the patient would receive; the plan of care did not state the ordered frequency of HHA services. A Physician Order signed by Admin #1 and dated 10-14-2022 at 2:00 PM, stated for Patient #11 to receive HHA services 4 hours a day, 7 days a week for the patient’s decline in health. The Physician Order stated the order was read back and verified. The order stated the patient would receive assistance with Instrumental Activities of daily living (IADL) and Activities of daily living (ADL), incontinence care, medication reminders, meal prep, cleaning, and laundry. A review of the HHA visit notes evidenced no HHA visit notes were completed during the week of 11-20-2022 to 11-26-2022. During an interview on 1-10-2023 at 9:15 AM, when queried regarding Patient #11 not being seen for a week according to the clinical record, Admin #1 stated the missed visits are because of staffing. 14. A review of the clinical record for Patient #16 with the start of care date of 12-28-2022, the clinical record had no plan of care and no hold orders from the physician. The document titled “OASIS-D1 Start of Care” stated the patient was to receive SN 1 time a week for 9 weeks for recertification and medication management and disease process teaching, PT 3 times a week for 9 weeks for evaluation and treatment, and OT 3 times a week for 9 weeks for evaluation and treatment. A review of the electronic medical record and the paper chart failed to evidence SN, PT, and OT visits for the weeks of 12-19-2022 to 12-24-2022 and 12-25-2022 to 12-31-2022. During an interview on 1-11-2023 at 10:35, Patient #16’s family member, Person #39, was queried regarding whether the agency had been to see the patient or had care provided by the agency. The family member stated the facility had not come to see the patient; the facility had called Patient #16 regarding a time to start care. The family member stated the agency had not set a time to come see the patient. During an interview on 1-5-2023 at 10:25 AM, Admin #1 stated PT had not been able to go over to the patient’s house over the holidays and there were no orders to hold care or change the visit. 15. A review of the closed clinical record for Patient #31 with a start of care date of 10-13-2022 for the initial certification period of 10-13-2022 to 12-11-2022. The care plan was ordered for SN 2 times a week for 9 weeks, starting on 10-22-2022 for wound care, medication set up, and disease management. HHA 4 hours a day, 5 days a week for 8 weeks. PT 3 times a week for 9 weeks for therapeutic exercise, range of motion (ROM), gait and balance training, and fall risk education. OT 3 times a week for 9 weeks for safety with Instrumental Activities of daily living (IADL) and Activities of daily living (ADL), and strengthening. A record review of the closed record of Patient #31 evidenced the patient received only 1 visit from SN during the week of 10-30-2022 to 11-5-2022. The agency failed to follow the orders on the plan of care. A record review of the close record of Patient #31 failed to evidence the patient was seen by SN during the week of 11-6-2022 to 11-12-2022. The agency failed to follow the orders on the plan of care. A record review of the closed record of Patient #31 evidenced the patient received only 1 visit from SN during the week of 11-13-2022 to 11-19-2022. The agency failed to follow the orders on the plan of care. A record review of the closed record of Patient #31 evidenced the patient received only 1 visit from SN during the week of 11-20-2022 to 11-26-2022. The agency failed to follow the orders on the plan of care. A record review of the closed record of Patient #31 evidenced the patient received only 1 visit from SN during the week of 11-27-2022 to 12-3-2022. The agency failed to follow the orders on the plan of care. A record review of the closed record of Patient #31 evidenced the patient received only 1 visit from SN during the week of 12-4-2022 to 12-10-2022. The agency failed to follow the orders on the plan of care. A record review of the closed record of Patient #31 evidenced the patient received only 1 visit from PT during the week of 10-23-2022 to 10-29-2022. The PT visit note dated 11-1-2022 for the visit on 11-1-2022 was signed by Admin #1, who is an RN. The agency failed to follow the orders on the plan of care. A record review of the closed record of Patient #31 evidenced the patient had not received PT services from the week of 11-6-2022 to 11-12-2022. The agency failed to follow the orders on the plan of care. A record review of the closed record of Patient #31 evidenced the patient received only 1 visit from PT during the week of 11-13-2022 to 11-19-2022. The agency failed to follow the orders on the plan of care. A record review of the closed record of Patient #31 evidenced the patient received only 2 visits from PT during the week of 11-20-2022 to 11-26-2022. The agency failed to follow the orders on the plan of care. A record review of the closed record of Patient #31 evidenced the patient received only 1 visit from PT during the week of 11-27-2022 to 12-3-2022. The agency failed to follow the orders on the plan of care. A record review of the closed record of Patient #31 evidenced the patient had not received PT services from the week of 12-4-2022 to 12-10-2022. The agency failed to follow the orders on the plan of care. A record review of the closed record of Patient #31 evidenced the patient had not received OT services from the week of 10-16-2022 to 10-22-2022. The agency failed to follow the orders on the plan of care. A record review of the closed record of Patient #31 evidenced the patient received only 1 visit from OT for the week of 10-23-2022 to 10-29-2022. The agency failed to follow the orders on the plan of care. A record review of the closed record of Patient #31 evidenced the patient had not received OT services from the week of 10-16-2022 to 10-22-2022. The agency failed to follow the orders on the plan of care. A record review of the closed record of Patient #31 evidenced the patient had not received OT services from the week of 10-30-2022 to 11-5-2022. The agency failed to follow the orders on the plan of care. A record review of the closed record of Patient #31 evidenced the patient had not received OT services from the week of 11-6-2022 to 11-12-2022. The agency failed to follow the orders on the plan of care. A record review of the closed record of Patient #31 evidenced the patient had not received OT services from the week of 11-13-2022 to 11-19-2022. The agency failed to follow the orders on the plan of care. A record review of the closed record of Patient #31 evidenced the patient had not received OT services from the week of 11-20-2022 to 11-26-2022. The agency failed to follow the orders on the plan of care. A record review of the closed record of Patient #31 evidenced the patient had not received OT services from the week of 11-27-2022 to 12-3-2022. The agency failed to follow the orders on the plan of care. A record review of the closed record of Patient #31 evidenced the patient had not received OT services from the week of 12-4-2022 to 12-10-2022. The agency failed to follow the orders on the plan of care. A record review of the closed record of Patient #31 evidenced no HHA visit notes for the certification period of 10-13-2022 to 12-11-2022. Patient #31 had an active chart, Patient #12, where HHA visits were noted following the plan of care under another payor source, Medicaid. During an interview on 1-10-2023 at 9:15 AM, when queried regarding Patient #31 not being seen for a week according to the clinical record, Admin #1 stated the missed visits are because of staffing. On 01-03-2023 at 10:15 AM, Administrator #1 (Admin #1) provided a November 2021, Union Healthcare Services policy titled, "Ongoing Assessments, Policy No. 4-019.1". The policy indicated but was not limited to, "...The scope and intensity of ongoing assessments will be determined by the patient's diagnoses, condition, desire for care, response to previous care and the care setting...". On 01-09-2023 at 12:20 PM a clinical record review for Patient #7 for the certification period 10-07-2022 through 12-05-2022, was completed. Patient #7’s diagnosis included a Pressure Ulcer to the right lower extremity and Diabetes Mellitus(high blood sugar that interferes with healing.) A referral was sent on 09-12-2022, for home care services to be initiated immediately following a discharge from Entity #16, an acute care hospital on 09-12-2022. The record indicated the OASIS start of care (SOC) was dated 10-07-2022. The orders included skilled nursing (SN), Physical Therapy, and home health aide. A home health aide plan of care was submitted. A verbal order documented by Administrative staff #1, the Director of Nursing, on 10-10-2022, included wound care orders: "Cleanse RLE(sic right lower extremity) pressure ulcer with gauze 4X4 and wound cleanser. Apply Xeroform gauze cut to size and cover with ABD (sic Army Battle Dressing) pad. Wrap in Kerlix (stretchy gauze) and Coban (flexible sticky rolls.) SN to change dressing 3x/week and train PT (sic patient) to change dressing in event dressing gets wet or soiled.” The clinical record failed to evidence SN visit notes after 10-07-2022, failed to evidence documentation of missed visits to the physician, failed to evidence PT completed an admission or follow up visits and failed to evidence HHA services were provided. On 01-03-2023 at 10:15 AM, a review of the clinical record for Patient #5, with SOC of 01-03-2023 contained a plan of care (POC) for the certification period 12-17-2022 through 02-14-2023. The POC included SN visits 1 time per month and home health aide (HHA) visits 5 times per week for 9 weeks. The records indicated HHA visits were completed 3 times per week for the certification period. On 01-05-2023 at 10:00 AM, a review of the clinical record for Patient #28 with a SOC of 02-17-2022 contained a POC for the certification period 12-14-2022 through 02-11-2023. The POC included HHA visits to be completed 4 hours per day 5 times per week. Patient #28 was hospitalized at Entity #15 on 01-02-2023. Completed HHA visit notes were submitted for 01-02, 01-03 and 01-04-2023. On 01-05-2023 at 10:30 AM, Admin #1 was queried about the HHA documentation for the dates Patient #28 was hospitalized. Admin #1 indicated Patient #28 required visits due to their paraplegia. Admin #1 was directed to review the hospitalization dates and the HHA records. Admin #1 indicated there should be no documentation on those dates. On 01-11-2023 at 11:15 AM, a review of the clinical record for Patient #30, with a SOC date of 11-03-2022, contained a signed plan of care for the initial certification period of 11-03-22 to 12-027-22. The plan of care indicated orders for skilled nursing (SN) 1 time a week for 1 week for an admit and evaluation. Physical therapy (PT) 3 times a week for 9 weeks, 1 time a week for 1 week for treatment and evaluation. Occupational therapy (OT) 2 times a week for 9 weeks, 1 time a week for 1 week, treatment, and evaluation. A review of the PT notes evidenced a PT evaluation dated 11-04-2022. The clinical record failed to evidence any visits conducted after the evaluation. The agency failed to provide PT services per the plan of care (POC). The POC notes were blank for any follow up visits.

Have a confidential clinical record CFR(s): 484.50(c)(6) Have a confidential clinical record. Access to or release of patient information and clinical records is permitted in accordance with 45 CFR parts 160 and 164. This ELEMENT is not met as evidenced by: Based on observation and interview, the agency failed to ensure the patients' rights were maintained as it related to the confidentiality of clinical records located in the office as observed over 7 of 7 survey days. Findings include: 1. On 01-03-2023 at 10:15 AM, during the Entrance Conference, Administrator # 1 indicated the confidentiality of a patient’s paper chart is maintained as they were kept in a locked filing cabinet by the Office Manager, Administrative Staff #2 (Admin #2). The Entrance Conference took place in a red office containing two tall, black filing cabinets labeled, “Previous Patient Records.” 2. On 01-03-2023 at 11:30 AM, the black, filing cabinet was determined to not be secured and previous patient records were held in the filing cabinet of the top drawer. 3. On 01-05-2023 at 12:13 PM, the black, filing cabinet in the red office contained two inactive Physical Therapy records for Patient #32 and Patient #33 had Physical Therapy visit notes on top of the cabinet. 4. On 01-06-2023 at 9:10 AM, the Physical Therapy visit records for Patient #32 and Patient #33 remained on top of the filing cabinet. 5. On 01-09-2023 at 9:15 AM, after entering the red office, the tall black filing cabinet was found unlocked. The agency doors open at 9:00 AM. The physical records for Patient #32 and Patient #33 remained on top of the filing cabinet. 6. During an interview on 01-06-2023 at 11:00 AM, the Chief Executive Officer (CEO), Corporate Staff #1 was queried about the safety of clinical records. Corporate Staff #1 indicated the agency office doors are locked when the building’s contracted services clean the office daily. Corporate Staff #1 was asked to clarify whether the contracted services had access to all the agency’s office rooms to clean them daily. Corporate Staff #1 answered affirmatively. 410 IAC 17-12-3 (b) (2) (E)

Payment from federally funded programs CFR(s): 484.50(c)(7)(i, ii, iii, iv) Be advised, orally and in writing, of- (i) The extent to which payment for HHA services may be expected from Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (ii) The charges for services that may not be covered by Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (iii) The charges the individual may have to pay before care is initiated; and (iv) Any changes in the information provided in accordance with paragraph (c)(7) of this section when they occur. The HHA must advise the patient and representative (if any), of these changes as soon as possible, in advance of the next home health visit. The HHA must comply with the patient notice requirements at 42 CFR 411.408(d)(2) and 42 CFR 411.408(f). This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to provide the patients with the extent of payment from their insurance and possible charges for services that their insurance may not cover in 15 of 24 active clinical records (Patients: #2, 3, 4, 10, 11, 12, 15, 16, 18, 20, 21, 22, 23, 24, 25 ) and 3 of 6 inactive clinical records reviewed. (Patients: #14, 29, 31) Findings Include: 14. A review of a close record of the clinical record of Patient #29, with a start of care date of 10-25-2022, failed to evidence consent for treatment in the electronic medical record or clinical paper chart. During an interview on 1-10-2023 at 9:05 AM, the Administrative Assistant, Admin #2, confirmed they could not provide Patient #29’s admission consent from the electronic medical record or the clinical paper chart. 15. A review of the clinical record for Patient #16, with the start of care 12-19-2022, contained an agency document titled “Union Healthcare Services Admission Consent” with an area subtitled “Consent for treatment.” The subtitled area had a box containing the services, frequency, charges, insurance pays, and I pay. The column titled “Frequency” was filled out for “Skilled nursing: 1W9” (1 time a week for 9 weeks), “Physical Therapy: 3W9” (3 times a week for 9 weeks), and “Occupational Therapy: 3W9” (3 times a week for 9 weeks). The column titled “Charges,” the box was left blank. The column titled “Insurance Pays,” the box was left blank. The column titled “I Pay,” the box was left blank. The subtitle titled “Authorization For Payment” failed to inform the patients whom the agency was billing. The agency failed to provide the patients with the extent of payment from their insurance, failed to provide the cost of services to be provided, and failed to provide the possible charges for services the patient’s insurance may not cover. 16. A review of a held record of the clinical record of Patient #11, with a start of care date of 4-19-2022, failed to evidence consent for treatment in the electronic medical record or clinical paper chart. During an interview on 1-10-2023 at 9:05 AM, the Administrative Assistant, Admin #2, confirmed they could not provide Patient #11’s admission consent from the electronic medical record or the clinical paper chart. 17. A review of a close record of the clinical record of Patient #31, with a start of care date of 10-13-2022, failed to evidence consent for treatment in the electronic medical record or clinical paper chart. During an interview on 1-10-2023 at 9:05 AM, the Administrative Assistant, Admin #2, confirmed they could not provide Patient #31’s admission consent from the electronic medical record or the clinical paper chart. 18. A review of clinical record for Patient #12, with the start of care 4-19-2022, contained an agency document titled “Union Healthcare Services Admission Consent” with an area subtitled “Consent for treatment.” The subtitled area had a box containing the services, frequency, charges, insurance pays, and I pay. The column titled “Frequency” was filled out for “Home Health Aide: 7 days a week for 9 weeks, 2-4 H (hours a visit).” The column titled “Charges,” the box was left blank. The column titled “Insurance Pays,” the box was left blank. The column titled “I Pay,” the box was left blank. The subtitle titled “Authorization For Payment” failed to inform the patients whom the agency was billing. The agency failed to provide the patients with the extent of payment from their insurance, failed to provide the cost of services to be provided, and failed to provide the possible charges for services the patient’s insurance may not cover. 19. A review of the clinical record of Patient #3, with a resumption of care date of 3-4-2022, failed to evidence consent for treatment in the electronic medical record or clinical paper chart. During an interview on 1-10-2023 at 9:05 AM, the Administrative Assistant, Admin #2, confirmed they could not provide Patient #3’s admission consent from the electronic medical record or the clinical paper chart. 20. A review of the clinical record of Patient #1, with a start of care date of 12-12-2022, failed to evidence consent for treatment in the electronic medical record or clinical paper chart. During an interview on 1-10-2023 at 9:05 AM, the Administrative Assistant, Admin #2, confirmed they could not provide Patient #1’s admission consent from the electronic medical record or the clinical paper chart. 1. A review of a Union Healthcare Services Inc. policy revised date November 2021, titled “Patient Bill of Rights” Policy No. 2-002.1, was received from the Administrator on 1-9-23. The policy indicated, “…Policy: Each patient will be an active, informed participant in his/her plan of care… D. Care costs/charges, to the patient….” 2. A review of the clinical record for Patient #2, with the start of care 10-27-22, contained an agency document titled “Union Healthcare Services Admission Consent” with an area subtitled “Consent For Treatment. The subtitled area had a column titled” Charges,” the box was left blank. In the column titled “Insurance Pays,” the box was left blank. In the column titled “I Pay,” the box was left blank. The Section Titled “Authorization For Payment” failed to list who the agency was billing. The agency failed to provide the patients with the extent of payment from their insurance, failed to provide the cost of services, and failed to provide the possible charges for services that their insurance may not cover. 3. A review of the clinical record for Patient #4, with the start of care 10-11-22, failed to evidence consent for treatment in the electronic record or paper chart. During an interview on 1-10-23 at 9:05 AM, the Administrative Assistant., Admin 2, confirmed they could not provide Patient #4’s admission consent from the electronic medical record or the clinical paper file. 4. A review of the clinical record for Patient #10, with the start of care 11-25-22, contained an agency document titled “Union Healthcare Services Admission Consent” with an area subtitled “Consent For Treatment. The subtitled area had a column titled” Charges,” the box was left blank. In the column titled “Insurance Pays,” the box was left blank. In the column titled “I Pay,” the box was left blank. The Section Titled “Authorization For Payment” failed to list who the agency was billing. The agency failed to provide the patients with the extent of payment from their insurance, failed to provide the cost of services, and failed to provide the possible charges for services that their insurance may not cover. 5. A review of the inactive clinical record for Patient #14, with the start of care 10-04-22, contained an agency document titled “Union Healthcare Services Admission Consent” with an area subtitled “Consent For Treatment. The subtitled area had a column titled” Charges,” the box was left blank. In the column titled “Insurance Pays,” the box was left blank. In the column titled “I Pay,” the box was left blank. The Section Titled “Authorization For Payment” failed to list who the agency was billing. The agency failed to provide the patients with the extent of payment from their insurance, failed to provide the cost of services, and failed to provide the possible charges for services that their insurance may not cover. 6. A review of the clinical record for Patient #15, with the start of care 9-19-22, contained an agency document titled “Union Healthcare Services Admission Consent” with an area subtitled “Consent For Treatment. The Section Titled “Authorization For Payment” failed to list who the agency was billing. The agency failed to provide the patients with the extent of payment from their insurance and failed to provide the possible charges for services that their insurance may not cover. 7. A review of the clinical record for Patient #18, with the start of care 11-8-22, contained an agency document titled “Union Healthcare Services Admission Consent” with an area subtitled “Consent For Treatment. The subtitled area had a column titled” Charges,” the box was left blank. In the column titled “Insurance Pays,” the box was left blank. In the column titled “I Pay,” the box was left blank. The Section Titled “Authorization For Payment” failed to list who the agency was billing. The agency failed to provide the patients with the extent of payment from their insurance, failed to provide the cost of services, and failed to provide the possible charges for services that their insurance may not cover. 8. A review of the clinical record for Patient #20, with the start of care 10-12-22, contained an agency document titled “Union Healthcare Services Admission Consent” with an area subtitled “Consent For Treatment. The subtitled area had a column titled” Charges,” the box was left blank. In the column titled “Insurance Pays,” the box was left blank. In the column titled “I Pay,” the box was left blank. The Section Titled “Authorization For Payment” failed to list who the agency was billing. The agency failed to provide the patients with the extent of payment from their insurance, failed to provide the cost of services, and failed to provide the possible charges for services that their insurance may not cover. 9. A review of the clinical record for Patient #21, with the start of care 10-14-22, contained an agency document titled “Union Healthcare Services Admission Consent” with an area subtitled “Consent For Treatment. The subtitled area had a column titled” Charges,” the box was left blank. In the column titled “Insurance Pays,” the box was left blank. In the column titled “I Pay,” the box was left blank. The Section Titled “Authorization For Payment” failed to list who the agency was billing. The agency failed to provide the patients with the extent of payment from their insurance, failed to provide the cost of services, and failed to provide the possible charges for services that their insurance may not cover. 10. A review of the clinical record for Patient #22, with the start of care 10-29-22, failed to evidence consent for treatment in the electronic record or paper chart. During an interview on 1-10-23 at 9:05 AM, the Administrative Assistant., Admin 2, confirmed they could not provide Patient #22’s admission consent from the electronic medical record or the clinical paper file. 11. A review of the clinical record for Patient #23, with the start of care 11-30-22, contained an agency document titled “Union Healthcare Services Admission Consent” with an area subtitled “Consent For Treatment. The subtitled area had a column titled” Charges,” the box was left blank. In the column titled “Insurance Pays,” the box was left blank. In the column titled “I Pay,” the box was left blank. The Section Titled “Authorization For Payment” failed to list who the agency was billing. The agency failed to provide the patients with the extent of payment from their insurance, failed to provide the cost of services, and failed to provide the possible charges for services that their insurance may not cover. 12. A review of the clinical record for Patient #24, with the start of care 9-16-22, failed to evidence consent for treatment in the electronic record or paper chart. During an interview on 1-10-23 at 9:05 AM, the Administrative Assistant., Admin 2, confirmed they could not provide Patient #24’s admission consent from the electronic medical record or the clinical paper file. 13. A review of the clinical record for Patient #25, with the start of care 12-19-22, contained an agency document titled “Union Healthcare Services Admission Consent” with an area subtitled “Consent For Treatment. The consent was blank, undated, and unsigned by Patient #25, their healthcare representative, or the clinician. The subtitled area had a column titled” Charges,” the box was left blank. In the column titled “Insurance Pays,” the box was left blank. In the column titled “I Pay,” the box was left blank. The Section Titled “Authorization For Payment” failed to list who the agency was billing. The agency failed to provide the patients with the extent of payment from their insurance, failed to provide the cost of services, and failed to provide the possible charges for services that their insurance may not cover. During an interview on 1-10-2023 at 10:18 AM, the Administrator/Director of Nursing, Admin 1, indicated they were unaware of the missing consent and completeness of the document being filled out. Admin 1 further confirmed that it was their responsibility to ensure the clinicians turned them in. The Admin stated, " I cannot show you where on the consent where the payor is listed. I did not know we needed to tell the patients who is paying for their services."

Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient's eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This CONDITION is not met as evidenced by: Based on record review, and interview, the agency failed to ensure that the skilled nurse completed the initial assessment within 48 hours from the date of the physician referral, G 512) failed to ensure that all disciplines completed the comprehensive assessment within 5 days from the start of care date, (G 516) failed to ensure the completion of the comprehensive assessment, (G 518) failed to ensure that the comprehensive assessments were complete and accurately reflected the patients’ status, including current health, psychosocial, functional, and cognitive status, (G 528) ailed to ensure a complete and accurate assessment of the patient's medical, nursing, rehabilitative, social, and discharge planning needs, (G 534) to ensure a registered nurse reconciled all medications with the patient, health care representative, outside agencies, and ordering physicians, (G 536) failed to ensure that the patients’ comprehensive assessment was updated in the last 5 days of every 60 days (G 546.) The cumulative effects of these systemic problems resulted in the home health agency's inability to ensure the provision of quality health care in a safe environment for the Condition of Participation of 42 CFR 484.55, Comprehensive Assessment of Patients. Findings include: *

Standard: Initial assessment visit. CFR(s): 484.55(a) Standard: Initial assessment visit. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the skilled nurse and physical therapist completed the initial assessment within 48 hours from the date of the physician referral in 4 of 17 focused active patient records reviewed. (Patients #13, 15, 23, and 25) Findings Include: 1. A review of a Union Healthcare Services Inc. policy revised date November 2021, titled, “Initial and Comprehensive Assessment” Policy No. 4-018.1, was received from the Administrator on 01-06-2023. The policy indicated, “…An initial assessment will be performed and documented in the patient’s clinical record by the registered nurse, physical therapist…The initial assessment visit must be performed either within 48 hours of the referral, within 48 hours of patient’s return home, or on the start of care date ordered by the physician…” 2. A review of the clinical record for Patient #13, with a start of care date of 01-03-2023, evidenced by a document titled, “Ambulatory referral to Home Health (initial) Order,” from Entity 1, a group of healthcare providers. The initial referral and order dated 12-30-2022, contained orders PT. A review of the document “OASIS D-1 Start of Care,” dated 01-03-2023, and assigned visit noted by the Physical Therapist, by PT# 1. The clinical record failed to evidence that an initial assessment had been completed within 48 hours of the referral/order. During an interview on 01-09-2023 at 10:00 AM, the Administrative Assistant, Admin 2, when requested the plan of care and consent, indicated they were not turned in and completed by PT 1. 3. A review of the clinical record for Patient #15, the start of care date of 09-19-2022, the initial certification period 09-19-2022 to 11-17-2022, evidenced an agency document titled, “Initial Assessment Referral Process,” that listed the date of 09-14-2022 signed by Registered Nurse. RN#1. A review of the initial certification period, 09-19-2022 to 11-17-2022, evidenced in the section subtitled, "Start of Care Date,” that the start of care date was 09-14-2022. A review of the document “OASIS D-1 Start of Care,” dated 09-19-2022, and electronically signed by the Administrator/Director of Nursing, Admin 1. The clinical record failed to evidence that an initial assessment had been completed within 48 hours of the referral/order. During an interview on 01-05-2023 at 2:15 PM, the Administrator/Director of Nursing, Admin 1, when queried regarding the start of care and initial evaluations being completed by staff, confirmed the staff had 48 hours for completion. 4. A review of the clinical record for Patient #23, with a start of care date of 11-30-2022, the initial certification period of 11-30-2022 to 01-28-2023, evidenced a document titled, “Ambulatory referral to Home Health (initial) Order,” from Entity 1, a group of healthcare providers. The initial referral and order dated 11-23-2022, contained orders for RN and PT. A review of the initial certification period, 11-30-2022 to 01-28-2023, evidenced in the section subtitled” Start of care date” that the start of care date was 09-14-2022. A review of the document “OASIS D-1 Start of Care,” dated 11-30-2022, and electronically signed by RN# 1. The clinical record failed to evidence that an initial assessment had been completed within 48 hours of the referral/order. 5. A review of the clinical record for Patient #25, with a start of care date of 12-19-2022, the initial certification period of 12-19-2022 to 2-16-2023, evidenced a document titled, “Physician/Prescriber Order,” dated 12-05-2022, signed by Person 57, the practitioner, With Entity 1, a group of healthcare providers. The initial referral and order dated 11-23-2022, contained orders for RN and PT. A review of the initial certification period, 12-19-2022 to 02-16-2023, evidenced in the section subtitled,” Start of Care Date,” that the start of care date was 12-19-2022. A review of the document “OASIS D-1 Start of Care,” dated 12-19-2022, and electronically signed by RN# 1. The clinical record failed to evidence that an initial assessment had been completed within 48 hours of the referral/order. During an interview on 01-10-2023 at 10:53 AM, the caregiver of Patient #25 confirmed that Patient #25 was discharged home with orders for skilled nursing and physical therapy on 12-05-2022.

Skilled professional performs assessment CFR(s): 484.55(a)(2) When rehabilitation therapy service (speech language pathology, physical therapy, or occupational therapy) is the only service ordered by the physician or allowed practitioner, who is responsible for the home health plan of care, and if the need for that service establishes program eligibility, the initial assessment visit may be made by the appropriate rehabilitation skilled professional. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure that the Occupational Therapist (OT) and the Physical Therapist (PT) completed their comprehensive assessment within 5 days from the start of care date in 6 of 25 active patients (Patient #4, 10, 21, 23, 24, and 25) and 1 of 6 inactive records reviewed. (Patient #14) Findings Include: 1. A review of an undated agency policy, titled, “Acceptance/Admission of Patients,” Policy No. 10001, was received from the Administrator on 01-06-2023. The policy indicated, “Purpose: To facilitate delivery of quality care and services…If PT…is the only referred discipline at the start of care, they may make the Initial Assessment visit within 5 days following admission…” 2. A review of the clinical record for Patient #4, the start of care date of 10-11-2022, contained a plan of care for the initial certification period 10-11-2022 to 12-9-2022. The plan of care in the section titled, “Orders for Discipline and Treatment,” indicated Patient #4 had orders for Skilled Nursing (SN) 1 time a week for 4 weeks, 2 times a week for 4 weeks, and 1 time a month for 1 month for med set up, Physical Therapy (PT) 3 times a week for 4 weeks and 1 time a week for 4 weeks for treatment and evaluation for muscle weakness, and Occupational Therapy (OT) 3 times a week for 4 weeks and 1 time a week for 4 weeks for treatment and evaluation for muscle weakness. A review of an agency document “Physical Therapy Plan of Care with Full Evaluation,” dated 10-25-22, and electronically signed by the Physical Therapist, PT 1. PT 1 completed their evaluation 14 days after the start of care date. A review of the clinical record failed to evidence an OT evaluation. 3. A review of the clinical record for Patient #10, the start of care date of 11-25-22, contained a plan of care for the initial certification period 11-25-2022 to 01-23-2023. The plan of care in the section titled, “Orders for Discipline and Treatment,” indicated Patient #10 had orders for SN 1 time for 2 months for recertifications, supervisory visits, and resumptions of care, Home Health Adie (HHA) 5 times a week for 9 weeks to assist with Instrumental Activities of Daily Living (IADLs) and Activities of Daily Living (ADLs), and a PT evaluation. The clinical record failed to evidence that a PT evaluation had been completed. During an interview on 01-10-2023 at 1:45 PM, Patient #10 confirmed that the PT from Union Healthcare Services never came to their home for an evaluation. 4. A review of the inactive clinical record for Patient #14, the start of care date of 10-04-2022, contained an initial comprehensive assessment dated 10-04-2022 electronically signed by the Registered Nurse (RN), RN#1. The initial comprehensive assessment in the section titled, “Frequency and Duration,” indicated Patient #14 had orders for Skilled Nursing (SN) 1 time a week for 9 weeks, for med set up, Physical Therapy (PT) 3 times a week for 9 weeks for evaluation and treatment, and Occupational Therapy (OT) 3 times a week for 9 weeks for evaluation and treatment. A review of an agency document “PT Plan of Care” dated 11-11-2022 for certification period 10-04-2022 to 12-02-22, and electronically signed by PT 1. PT 1 completed their patient evaluation 38 days after the start of care date. During an interview on 01-09-2023 at 11:00 AM, the Administrative Assistant, Admin 2, indicated there is no plan of care in Patient #14’s clinical records. 5. A review of the clinical record for Patient #21, the start of care date of 10-14-2022, contained a signed plan of care for the initial certification period 10-14-2022 to 12-12-2022. The plan of care in the section titled “Orders for Discipline and Treatment” indicated Patient #21 had orders for SN 1 time a week for 9 weeks, 1-2 as needed (PRN), for med set up and HHA supervision, and PT 3 times a week for 9 weeks for evaluate and treat, and HHA 2 hour visits for 5 days a week for 9 weeks to assist with IADLs and ADLs. A review of an agency document “Physical Therapy Plan of Care with Full Evaluation,” dated 10-20-22, and electronically signed by the Physical Therapist, PT 1. PT 1 completed their evaluation 6 days after the start of care date. A review of an agency document “OT Plan of Care with Full Evaluation,” dated 10-20-22 and electronically signed by the Occupational Therapist, OT 1. OT 1 completed their evaluation 6 days after the start of care date. 6. A review of the clinical record for Patient #24, the start of care date of 09-16-2022, contained a signed plan of care for the initial certification period 09-16-2022 to 11-14-2022. The plan of care in the section title,d “Orders for Discipline and Treatment,” indicated Patient #24 had orders for SN 1 time a week for 9 weeks, evaluation, comprehensive assessment, and PT 3 times a week for 9 weeks for evaluation, and OT 2 times a week for 9 weeks for evaluation. A review of an agency document titled, “Physical Therapy Plan of Care with Full Evaluation,” dated 10-22-2022, and electronically signed by the Physical Therapist, PT 1. PT 1 completed their evaluation 6 days after the start of care date. A review of an agency document “OT Plan of Care with Full Evaluation,” dated 10-22-2022, and electronically signed by the Occupational Therapist, OT 1. OT 1 completed their evaluation 6 days after the start of the care date. 7. A review of the clinical record for Patient #25, the start of care date of 12-19-2022, contained a signed plan of care for the initial certification period 12-19-2022 to 02-16-2023. The plan of care in the section titled, “Orders for Discipline and Treatment,” indicated Patient #25 had orders for SN 1 time a week for 1 week, for the start of care assessment, PT evaluation and treatment, and OT evaluation and treatment. A review of an agency document “PT Evaluation,” dated 01-02-2023, was incomplete, and the visit was assigned to the Physical Therapist, PT 1. PT 1 completed their incomplete evaluation 14 days after the start of care date. A review of the clinical record failed to evidence an OT evaluation. During an interview on 01-10-2023 at 10:53 AM, the caregiver/family member of Patient #25, Person 27, indicated that Patient #25 had fallen while they attempted to transfer out of their bed to their wheelchair. Person 27 further indicated they went to an acute care facility, for x-rays to ensure Patient #25 had no further injuries. Person 27 confirmed that Patient #25 had 1 visit from the PT, 1 visit from the SN, and no visits from OT from Union Healthcare Services. 8. During an interview on 01-05-2023 at 2:15 PM, the Administrator/Director of Nursing, Admin 1, when queried regarding the initial evaluations being completed by the therapy staff, confirmed the therapist had 48 hours after the start of care for completion. IAC 410 17-14-1(b)(3)(C)

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure the medication lists for patients were up to date and present in the home of their patients as noted in 1 (Patient #9) of 3 home visits completed. During a home visit on 01-04-2021 at 10:00 AM, Patient #9 indicated they had a change in their Torsemide and they were also taking Vicoden (a pain medication) following a hospitalization for cardiac issues at Entity #16 on 12-16-2022 through 12-18-2022. Patient #9 had a start of care (SOC) dated 02-09-2022. Patient #9 had a diagnosis of Diabetes ( a disease resulting in the inability of the body to manage blood sugar levels) and Chronic Obstructive Pulmonary Disease (COPD) (a disease of the lungs due to constriction of the airways). Upon discharge from Entity #16, Patient #9 had a change to their Torsemide (a diuretic) from 100 Milligrams (mg) to 50 mg to be taken by mouth every day and they were taking Vicoden as needed for pain. There was no medication list present in the home. On 01-04-2023 at 10:05 AM, Registered Nurse #2 (RN #2) indicated they were aware of the medication changes. When queried if the changes were addressed on the medication list, RN #2 indicated they should have been. When queried if the medication list should be present in the home, RN #2 indicated it should be present. On 01-06-2023 at 10:25 AM, the clinical record of Patient #9 was reviewed. The skilled RN visit note for 01-04-2023 was reviewed. The record indicated RN#2 completed a medication review and verified there were no changes. The Torsemide and Vicoden orders did not reflect the changes post-hospitalization. The diuretic, Torsemide remained listed as 100 mg and Vicoden was not present on the medication list. There were no physician orders received nor communication to the physician regarding the med changes. On 01-10-2023 at 11:30 AM, the clinical record of Patient #9 was reviewed. The skilled RN visit note for 01-09-2023 reflected medications were reviewed and verified. The diuretic, Torsemide remained listed as 100 mg and Vicoden was not present on the medication list. 410 IAC 17-14-1(a)(1)(B)

Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive recertification assessment was conducted during the last 5 days of every 60 days, 4 of 6 records reviewed (Patient #2, 5, 7 and 26) of patients who had continued care. Findings Include: 1. A review of a Union Healthcare Services Inc. policy revised date November 2021, titled “Initial and Comprehensive Assessment” Policy No. 4-018.1, was received from the Administrator on 1-6-23. The policy indicated, “…This assessment will measure patient outcomes at the start of care and at the following defined intervals thereafter: 1. The last five (5) days of every 60-day episode beginning with the start of care date (recertification)…” 2. A review of the clinical record for Patient #2, with the start of care date 10-27-2022, for the recertification period of 12-26-22 to 02-23-23, contained an agency document dated 12-23-22, titled “OASIS-D1 Recertification.” The recertification had no time in, time out, or signature. The recertification assessment contained on page 1, a subtitled section titled “Demographics,” which was completed with Patient #2’s name, address, phone number, date of birth, insurance, insurance number, agency name, the agency’s certification number, the patient’s start of care, certification period, physician’s name, race, and ethnicity. The section titled “Clinical Records” with the subtitled section titled “Discipline of Person Completing Assessment” marked Registered Nurse (RN). The subtitled section titled “Date of Assessment” was left blank. The subtitled section titled “This Assessment is Currently Being Completed for the Following Reason” was marked Recertification. The subtitled section titled “Episode Timing” was marked N/A. the Subtitled section titled “Diagnosis Symptom Control indicated the following diagnoses: a primary diagnosis of non-pressure chronic pressure ulcer in another part of the left foot with a severity of 2; other diagnoses were essential hypertension with a severity of 2; type 2 diabetes with other diabetic neurological complication with a severity of 2; and peripheral vascular disease with a severity of 2. The recertification assessment pages 2-10 were incomplete and left blank. The agency failed to ensure the recertification comprehensive assessment was completed within the 5-day window of days 56-60. During an interview on 1-4-23 at 9:15 AM, the Administrator/Director of Nursing, confirmed that the recertification reassessment for Patient #2 was not completed. 410 IAC 17-14-1(a)(1)(B) On 01-03-2023 at 11:45 AM, a clinical record review was completed on Patient #5. Patient #5 had a start of care (SOC) date of 08-19-2022. The period reviewed was 10-18-2022 through 12-16-2022. A document titled, "OASIS-D1 Recertification" was completed by Administrator #1 (Admin#1) on 10-14-2022. The section titled, "Risk Assessment, Shingles Vaccination" was blank. The section titled, "Hospitalization Risk Assessment Tools and Emergency Preparedness" was blank. The section titled, "Risk for Hospitalization", was blank. The section titled, "Integumentary status", was blank. The section titled, Plan of Care: Durable Medical Equipment", was blank. The section titled, "Labs and Infection Control", was blank. The section titled, "Patient Rights", was blank. The section titled, "Visit Interventions", was blank. The section titled, "Medications", was blank. The section titled, "Plan of Care: Rehabilitation Potential and Discharge Plans", was blank. The agency failed to ensure the comprehensive recertification assessment was conducted during the last 5 days of every 60 days. On 01-05-2023 at 10:15 AM, a clinical record review was completed on Patient #26. Patient #26 had a SOC date of 09-30-2021. The certification reviewed was for period11-24-2022 through 01-22-2023. A document titled, "OASIS-D1 Recertification" was found to be incomplete by Registered Nurse (RN#1). The section titled, "Risk Assessment", was blank. The section titled, "Hospitalization Risk Assessment Tools", was blank. The section titled, "Sensory Status", was blank. The section titled, "Integumentary Status", was blank. The section titled, "Cardiac Status", was blank. The section titled, "Functional Status", was blank. The section titled, "Nutrition", was blank. The agency failed to ensure the comprehensive recertification assessment was conducted during the last 5 days of every 60 days. On 01-06-2023 at 11:30 AM, a clinical record review was completed on Patient #7. Patient #7 had a SOC date of 10-07-2022. The SOC OASIS-D1 was found to be incomplete by RN #1. The section titled, "Cultural Preferences", was blank. The section titled, "Genitourinary", was blank. The agency failed to ensure the comprehensive recertification assessment was conducted during the last 5 days of every 60 days.

At discharge CFR(s): 484.55(d)(3) At discharge. This ELEMENT is not met as evidenced by: Based on record review, and interview, the agency failed to ensure an updated comprehensive assessment was completed at discharge, including a summary of the patient’s progress in meeting their goals in 5 of 7 discharged patients’ records reviewed. (Patients #6, 7, 29, 30, and 31) Findings Include: A review of the closed clinical record for Patient #31 on 1-9-2023 at 9:00 AM with a start of care date of 10-13-2022, the electronic clinical record and paper charts failed to evidence a discharge summary to the physician and failed to complete an OASIS discharge. A review of Patient #31's electronic medical record and paper chart had failed to evidence a discharge summary to the physician regarding the patient not receiving services from Skilled Nursing (SN), Physical Therapy (PT), and Occupational Therapy (OT). Attempted to call Patient #31 on 1-5-2023 at 12:02 PM, the patient had answered the phone and was informed the call was regarding some questions about the patient being seen by the agency and the patient had ended the call. Attempted to call Entity #16, a hospital, on 1-6-2023 at 12:14 PM, a voicemail was left for the social worker to return the call. Attempted to call Person #11, physician, on 1-9-2023 at 11:35 AM, a voicemail was left for the physician to return the call. Attempted to call Entity #16 again on 1-9-2023 at 11:40 AM, a voicemail was left for public affairs and communication to return the call. During an interview on 1-9-2023 at 3:34 PM with Admin #1, he/she was queried regarding where the patients were discharged. Admin #1 stated all the discharged patients were discharged home. A review of the closed clinical record for Patient #29 with a start of care date of 10-25-2022 had a document titled "Home Health Discharge Summary" and the document had stated the patient's "Condition at Discharge: Improved". The agency had provided a document titled "OASIS-D1 Discharge" in the patient's clinical record and the document had stated the reason for discharge was, "Other: Patient is being referred to a wound care agency to provide further treatment for (the patient's) pressure ulcer." During an interview with Patient #29 on 1-10-2023 at 1:48 PM, the patient stated they are still a client with the agency and had an HHA. The patient stated the nurse informed the patient they did not feel confident taking care of the patient’s wound. The patient stated they saw a wound care nurse from another agency until about a week ago because the wound care nurse informed the patient the wound was healing. The patient stated they were never seen by physical therapy. The patient provided the wound care nurse’s telephone number. A voicemail was left for a return call. Attempted to call Entity #42 to request to speak with Person #43 on 1-10-2023 at 2:15 PM, a voicemail was left for a return call. On 01-06-2023 at 10:15 AM, the clinical record of Patient #6 was reviewed. Patient #6 had orders for Skilled Nursing (SN), 1 time per week for 9 weeks and Physical Therapy (PT) 2 times per week for 8 weeks for the certification period 11-29-2022 through 01-27-2023. The last PT visit was documented on 10-30-2022 and a document titled, "PT Discharge", was dated 11-28-2022 at 1:00 PM. The document was blank and unsigned. The record failed to evidence goals were met and that the physician was notified by the agency. On 01-06-2023 at 10:40 AM, the clinical record of Patient #7 was reviewed. Patient #7 had a start of care (SOC) date of 10-07-2022. The orders included in the OASIS D-1 Start of Care were for SN visits 3 times per week for 9 weeks for wound care to the right lower extremity (RLE). Home Health Aide (HHA) visits 5 times per week for 9 weeks and PT visits 3 times per week for 9 weeks. Patient #7 did not have SN visit following the SOC on 10-07-22. There were no HHA visits completed and there were no PT visits completed. Patient #7 was admitted with a diagnoses of Diabetes (a disease affecting blood sugar levels) and a RLE wound. During an interview on 01-06-2023 at 12:20 PM, Patient #7 indicated there were no visits after 10-07-2022 when "someone" from the office notified them they would not be seen any further as they did not accept Patient #7's insurance. There was no transfer communicated to another agency or to the physician. Patient #7 indicated they were admitted to Entity #16 for Sepsis (a bloodstream infection) on 10-24-2022. Patient #7 underwent a RLE below the knee amputation on 10-26-2022. Patient #7 was discharged from Entity #16 on 11-03-2022 for rehabilitation services. On 01-11-2023 at 11:00 AM, the clinical record of Patient #30 was reviewed. Patient #30 had orders for SN 1 time per week for 1 time, PT visits 3 times per week for 9 weeks, Occupational Therapy (OT) visits 2 times per week for 9 weeks for the certification period 11-03-2022 through 12-27-2022. On 11-03-2022 the SN, visit was completed on 11-03-2022 with the admission. The first PT visit was completed on 11-04-2022 by PT #1. The treatment plan indicated PT would continue 3 times per week for 4 weeks. The PT Discharge note dated 12-02-2022 at 2:00 PM was not signed. The OT visit was completed on 11-07-2022 by OT #1 at 9:00 PM with no further visits scheduled following the evaluation and physician notification. There was no communication to the physician regarding the discontinuation of PT visits and no record of goals being met. 1. A review of a Union Healthcare Services Inc. policy revised date November 2021, titled “Initial and Comprehensive Assessment” Policy No. 4-018.1, was received from the Administrator on 1-6-23. The policy indicated, “…This assessment will measure patient outcomes at the start of care and at the following defined intervals thereafter: 5. At discharge…”

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 observation, record review, and interview the agency failed to ensure they met the needs of 26 of 27 skilled patients (active 20, inactive 6) by having failed to furnish the ordered care visits to include skilled nursing, therapies, and home health aide services. The agency failed to provide visits as ordered on the plan of care and failed to coordinate care with physicians and insurance providers for their patients. (Active Patients: #2, 4, 5, 9, 10, 11, 12, 13, 15, 16, 19, 20, 21, 22, 23, 24, 25, 26, 27, and 28, and Inactive Patients: #6, 7, 14, 29, 30, and 31.) The cumulative effects of these systemic problems resulted in the home health agency's inability to ensure the provision of quality health care in a safe environment for the Condition of Participation of 42 CFR 484.60, Care Planning, Coordination of Care, and Quality of Care. Findings Include: 1. During a home visit on 1-4-2023, at 10:15 AM, at Patient #2’s residence, the Registered Nurse (RN), RN #3, was observed providing wound care. RN #3 performed hand hygiene, donned gloves and removed the Coban dressing and gauze wrap from the patient’s left plantar and heel wounds. After removing the soiled dressings, the RN cleansed the wounds with a wound cleanser and 4x4 gauze without changing gloves or hand hygiene and discarded the 4x4s in the plastic trash bag. RN #3 then applied from a container labeled “Medi honey” to the two telfa dressings and then applied the telfa dressings to the left plantar and left heel wounds without performing hand hygiene and donning new gloves. After applying the telfa dressings, gauze cling wrap and Coban wrap were used to secure the dressing to the left foot dressings. The RN obtained the patient’s scissors from the end table next to the patient’s chair and cut the Coban without cleaning the scissors. The RN then picked up thrash trash, discarded their gloves, and performed hand hygiene. RN #3 and Patient #2 indicated that the RN had changed the treatment from Betadine to Medi honey for the last couple of treatments. A review of the clinical record for Patient #3, with a start of care on 10-27-2022, contained an agency document titled “Home Health Certification and Plan of Care” for the initial certification period of 10-27-2022 to 12-25-2022, signed by the physician. The initial plan of care evidenced the patient’s diagnoses as non-pressure chronic ulcer in other part of left foot with fat layer exposed, type 2 diabetes with other diabetic neurological complications, essential (primary) hypertension, peripheral vascular disease, non-pressure chronic ulcer of left heel with midfoot with fat layer exposed. The orders for discipline and treatment indicated a Skilled Nurse (SN) 3 times a week for 9 weeks for wound dressing changes. The wound care orders were for the SN to cleanse both wounds to the left foot with wound cleanser, apply betadine dressing wet to dry, wrap in Kerlix and Coban, and secure with tape. The plan of care was electronically signed by RN #3 on 10-27-2022 and by the physician on 11-15-2022. A review of an agency document titled “SN Wound Care Visit” dated 12-09-2022, electronically signed by RN #1, indicated in the section titled “Visit Narrative,” indicated but was not limited to, “…Applied Betadine over calcium alginate to wound bed….” RN #1 failed to follow orders per the signed plan of care. A review of the recertification assessment dated 12-23-2022, listed the primary diagnosis as a non-pressure chronic ulcer in the other part left foot with a fat layer exposed and other diagnoses as essential (primary) hypertension. The subsection, “Discipline of Person Completing Assessment,” was marked RN. The other sections of the OASIS recertification comprehensive assessment were left blank. A review of a plan of care for the recertification period of 12-26-200 to 2-23-2023, was electronically signed by RN #3 on 12-23-2022. The plan of care indicated orders for SN for wound care. Wound care orders to cleanse both wounds to the left foot with wound cleanser, apply Betadine dressing wet to dry, wrap in Kerlix and Coban, and secure with tape. A review of an agency document titled “60-day Summary” for the episode period of 10-27-2022 to 12-12-25-22 was blank. A review of the referral documents from Entity 1, dated 10-26-2022, indicated a document titled, “Ambulatory referral to Home Health’s Initial Order,” signed by Person 2, the ordering podiatrist, for Patient #3. The physician’s order indicated but was not limited to “…Wound care for chronic diabetic foot wound left heel. Home health wound care for dressing changes 2-3 times a week weekly. Cleanse rule wound with normal saline or Vashe solution. Dress wound with Betadine gauze, moist to dry dressings. Recommend offloading in DFU shoe or similar….” A review of the communication notes from 10-27-22 to 1-3-23 failed to evidence any documentation of notification to the physician regarding Patient #3’s wound care, measurements, and outcomes. During an interview on 1-4-2023 at 2:45 PM, Person 2, the physician for Patient #2, indicated they had not changed Patient #2’s wound care orders from Betadine to Medi honey or been notified by the agency of the patient’s wound measurements or changes. The physician requested a phone call from the nurse treating the patient with updated wound progress and pictures. During an interview on 1-4-2023 at 2:50 PM, the Director of Nursing/Administrator, Admin 1, was made aware of the phone interview with Patient #2’s physician. Admin 1 stated, “We changed the order. I know we cannot change wound care without a physician’s order.” The Administrator further confirmed that RN #3 had not completed her documentation in the comprehensive recertification assessment. 2. A review of the clinical record for Patient #4, the start of care date of 10-11-22, contained a start of care assessment dated 10-11-22, indicated a primary diagnosis of atherosclerosis heart disease of the native coronary artery without angina pectoris heart, and other diagnoses of hyperlipidemia and localized edema. The Functional status indicated poor balance and a fall risk score of 7 (A score of 4 or more is considered at risk for falling). The Ambulation and Locomotion status indicated that the patient requires a two-handed device, and the patient transferred using a walker. A review of the signed plan of care for the initial certification period of 10-11-22 to 12-09-22, indicated orders for skilled nursing 1 time a week for 4 weeks, 2 times a week for 4 weeks, and 1 time a month for 1 month for med setup. Physical therapy (PT) 3 times a week for 4 weeks, 1 time a week for 4 weeks for treatment and evaluation for muscle strength. Occupational therapy (OT) 3 times a week for 4 weeks, 1 time a week for 4 weeks, for treatment and evaluation for muscle strength. A review of an agency document dated 10-14-22, titled “Physician Order,” signed by the physician, indicated the Administrator received a verbal order to evaluate for home care services for PT, OT, and SN. A review of an agency document dated 10-25-2022, titled “Physical therapy Plan of Care with Full Evaluation,” signed by the physician, indicated orders for PT 2 times a week for 4 weeks and 2 times a week for 4 weeks. A review of the SN notes evidenced an RN start of care initial assessment on 10-11-22 and a recertification assessment on 12-8-22. The clinical record failed to evidence that the physician or allowed practitioner responsible for the plan of care had been notified of the agency’s inability to provide services as ordered. A review of the PT notes evidenced a PT evaluation dated 10-25-22. The clinical record failed to evidence any visits conducted after the evaluation. The clinical record failed to evidence that the physician or allowed practitioner responsible for the plan of care had been notified of the agency’s inability to provide services as ordered. A clinical record review failed to provide evidence that an OT evaluation or further visits were completed. The clinical record failed to evidence that the physician or allowed practitioner responsible for the plan of care had been notified of the agency’s inability to provide services as ordered. During an interview on 1-3-2023 at 2:31 PM, the Director of Nursing/Administrator, Admin 1, when queried regarding Patient #4’s orders, indicated they did not see the patient due to prior insurance authorization. Admin 1 confirmed that the agency failed to notify the patient, failed to notify the physician, or allowed practitioner, and failed to provide evidence of the coordinating documentation. 3. A review of the clinical record of Patient #10, the start of care date of 11-25-22, contained a start of care assessment dated 11-25-22, indicated a primary diagnosis of type 2 diabetes mellitus, without complications, and other diagnoses of essential (primary) hypertension, and systemic lupus erythematosus. The Functional status indicated muscle weakness and a fall risk score of 4 (A score of 4 or more is considered at risk for falling). A review of the plan of care for the initial certification of 11-25-22 to 01-23-23, indicated orders for SN 1 time a month for 2 months, for recertifications, supervisory visits, and resumption of care, Home Health Aide (HHA) 5 times a week for 9 weeks for assist with Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs), and PT to assess function and status. The clinical record failed to provide evidence that a PT evaluation visit was completed. The clinical record failed to evidence that the physician or allowed practitioner responsible for the plan of care had been notified of the agency’s inability to provide services as ordered. During an interview on 1-4-2022 at 12:01 PM, the Director of Nursing/Administrator, Admin 1, when queried regarding Patient #10’s PT evaluation order, confirmed the evaluation was not completed. Admin 1 confirmed that the agency failed to notify the patient, failed to notify the physician, or allowed practitioner, and failed to provide evidence of the coordinating documentation. 4. A review of the clinical record of Patient #13, the start of care date of 1-3-23, contained an incomplete start of care assessment and no plan of care available upon request on 1-9-2023. The clinical record failed to evidence that the physician or allowed practitioner responsible for the start of care order had been notified of the agency’s inability to provide services as ordered. A review of the referral document dated 12-30-22, titled “Ambulatory Referral to Home Health Initial Order,” indicated that Patient #13 had admission orders for PT. 5. A review of an inactive clinical record for Patient #14, the start of care date of 10-4-22, and the record contained a discharge non-visit assessment dated 12-28-22. The start of care assessment, dated 10-24-22, indicated a primary diagnosis of chronic systolic (congestive) heart failure and other diagnoses of permanent atrial fibrillation, type 2 diabetes mellitus without complications, depression, anxiety disorder, and atherosclerosis heart disease of the native coronary artery without angina pectoris heart. The Function status indicated poor balance, muscle weakness, unsteady gait, and a fall risk score of 7 (A score of 4 or more is considered at risk for falling). The admission summary evidenced that the patient had been in the hospital from 9-28-22 to 9-30-22 for volume overload and diuresis. The assessment further indicated frequency and duration SN 1 time a week for 9 weeks for med set up, PT 3 times a week for 9 weeks for evaluation and treatment, and OT 3 times a week for 9 weeks for evaluation and treatment. The admission summary further evidence that the plan of care was developed and agreed upon by the physician, patient, nurse, and family for HHA, PT, and OT for weakness to treat and evaluate. A review of a physician-signed document dated 10-27-22, titled “Ambulatory referral to Home Health,” indicated orders for RN and needs for PT and Speech Therapy. A review of a signed agency document dated 12-11-22, titled “Physician Order,” indicated orders to change the HHA frequency to 8 hours a day, 5 days a week (Monday -Friday). A review of the SN notes evidenced the following: The RN start of care initial assessment on 10-4-22, and a non-visit discharge assessment on 12-28-22. The clinical record failed to evidence that the physician or allowed practitioner responsible for the plan of care had been notified of the agency’s inability to provide services as ordered. A clinical record review failed to provide evidence of any documentation of the HHA visit notes. The clinical record failed to evidence that the physician or allowed practitioner responsible for the plan of care had been notified of the agency’s inability to provide services as ordered. A review of the PT notes evidenced a PT evaluation dated 11-11-22, with a PT plan of care to see the patient 3 times weekly for 4 weeks. The clinical record failed to evidence any further PT visits. The clinical record failed to evidence that the physician or allowed practitioner responsible for the plan of care had been notified of the agency’s inability to provide services as ordered. During an interview on 1-9-23 at 11:00 AM, the Administrative Assistant, Admin 2, when queried about copies and plan of care, indicated no plan of care was completed in Patient #14’s records. 6. A review of the clinical record of Patient #15, the start of care date of 9-19-22, contained a comprehensive recertification assessment dated 11-16-22, indicated a primary diagnosis of other complications of a kidney transplant, and other diagnoses of end stage renal disease, and unspecified juvenile rheumatoid arthritis, multiple sites. The Functional status indicated joint pain, poor balance, joint stiffness, muscle weakness, unsteady gait, bladder incontinence, autoimmune diseases affecting function, rheumatoid arthritis, and a fall risk score of 5 (A score of 4 or more is considered at risk for falling). The initial assessment indicated that Patient #15 required the use of a cane for their assistive device. In the section Bathing/Toileting, the patient requires intermittent assistance getting in and out and washing difficult areas. Patient #13 requires someone to help with dressing the lower body safely. A review of a signed plan of care for the recertification period of 11-18-22 to 1-16-23, indicated that Patient #15 had orders for SN 1time a week for 9 weeks, 3 PRN to perform a comprehensive physical assessment, medication review and reconciliation, and aide supervision. HHA 3 times a week for 9 weeks on Monday, Wednesday, and Friday from 10:00 AM to 1:00 PM. A review of the SN notes evidenced the following: The RN completed a visit during the week of 11-6-22 to 11-12-22, the week of 11-13-22 to 11-19-22, a recertification assessment on 11-16-22, no SN visits were evidenced the week of 11-20-22 to 11-26-22, no SN visits were evidenced the week of 11-27-22 to 12-3-22, no SN visits were evidenced the week of 12-4-22 to 12-10-22, no SN visits the week of 12-25-22 to 12-31-22. The clinical record failed to evidence that the physician or allowed practitioner responsible for the plan of care had been notified of the agency’s inability to provide services as ordered. A review of the HHA notes evidenced the following: no evidence of documentation of HHA visits made for 5 weeks, dates 11-6-22 thru 12-10-22. The clinical record failed to evidence that the physician or allowed practitioner responsible for the plan of care had been notified of the agency’s inability to provide services as ordered. During an interview on 1-4-23 at 1:30 PM, Patient #15 confirmed that the agency was not providing HHA services until 4 weeks ago when they found their own HHA. The patient further indicated that they had a family member get certified to provide them with care. 7. A review of the clinical record of Patient #20, the start of care date of 10-12-22, contained a start of care assessment dated 10-12-22, indicated a primary diagnosis of type 2 diabetes mellitus, without complications, and other diagnoses of essential (primary) hypertension, and pain right hip. The Functional status indicated no problems identified and a fall risk score of 4 (A score of 4 or more is considered at risk for falling). A review of a signed plan of care for the initial certification of 10-12-22 to 12-10-22, indicated that Patient #20 had orders for SN 1 time a week for 4 weeks, 2 times a month for 1 month for med management, PT evaluation, and treatment. A review of the SN notes evidenced the following: the RN completed an initial start of care assessment on 10-12-22, and a recertification assessment on 12-9-22. There is a missed visit notification for 12-3-22. The clinical record failed to evidence any clinical documentation of SN visits for 6 weeks, for the dates of 10-16-22 thru 12-3-22. The clinical record failed to evidence that the physician or allowed practitioner responsible for the plan of care had been notified of the agency’s inability to provide services as ordered. A review of the PT notes evidenced a PT evaluation dated 10-14-22, with a PT plan of care to see the patient 2 times weekly for 4 weeks. The clinical record failed to evidence any PT visits for 4 weeks, for the dates of 10-16-22 thru 11-12-22. The PT completed a re-evaluation on 11-13-22. The clinical record failed to evidence that the physician or allowed practitioner responsible for the plan of care had been notified of the agency’s inability to provide services as ordered. During an interview on 1-10-23 at 1:00 PM, Patient #20 confirmed that the agency, PT, or SN did not make them aware that they were not going to continue seeing them. 8. A review of the clinical record of Patient #21, the start of care date of 10-14-22, contained a start of care initial PT assessment, dated 10-14-22, electronically signed by RN #1. The start of care assessment indicated a primary diagnosis of malignant neoplasm of the prostate and other diagnoses of essential (primary) hypertension, depression, insomnia, and other abnormalities of gait and mobility. The Functional status indicated poor balance, muscle weakness, unsteady gait, and a fall risk score of 5 (A score of 4 or more is considered at risk for falling). Functional limitations included ambulation, and ambulation indicated that the patient used a walker. A review of a signed plan of care for the initial certification of 10-14-22 to 12-12-22, indicated that Patient #21 had orders for SN 1time a week for 9 weeks for med set up, HHA supervision, and 1-2 prn (as needed), PT 3 times a week for 9 weeks evaluate and treat, Home Health Aide (HHA) 2 home visits 5 days a week for 9 weeks to assist with ADLs and IADLS. A review of a signed agency document dated 10-20-22, titled “PT Plan of Care,” indicated orders for PT eval for services and to see the patient 2 times a week for 4 weeks. A review of a signed agency document dated 10-20-22 and electrically signed by the Administrator, titled “OT Evaluation,” indicated OT frequency and plan for 1 time a week for 1 week for eval, then 2 times a week for 3 weeks. A review of the SN notes evidenced a start of care on 10-14-22; no further documentation of SN visits were completed. The clinical record failed to evidence that the physician or allowed practitioner responsible for the plan of care had been notified of the agency’s inability to provide services as ordered. A review of the PT visit notes evidenced a PT evaluation dated 10-20-22; no further visits were completed. The clinical record failed to evidence that the physician or allowed practitioner responsible for the plan of care had been notified of the agency’s inability to provide services as ordered. A review of the OT visit notes evidenced an OT evaluation dated 10-20-22; no further visits were completed. The clinical record failed to evidence that the physician or allowed practitioner responsible for the plan of care had been notified of the agency’s inability to provide services as ordered. A clinical record review failed to provide evidence that any HHA visits were completed. The clinical record failed to evidence that the physician or allowed practitioner responsible for the plan of care had been notified of the agency’s inability to provide services as ordered. During an interview on 1-10-22 at 9:18 AM, the Administrator confirmed that Patient #21 had no HHA visits. 9. A review of the clinical record of Patient #22, the start of care date of 10-29-22, contained a start of care assessment dated 10-29-22, indicated a primary diagnosis of type 2 diabetes mellitus, without complications, and other diagnoses of essential (primary) hypertension, unspecified sequelae of unspecified cerebrovascular disease, continuous leakage, and cocaine abuse, and systemic lupus erythematosus. The Functional status indicated poor balance, muscle weakness, unsteady gait, and a fall risk score of 5 (A score of 4 or more is considered at risk for falling). Functional limitations included ambulation, endurance, and ambulation indicated the patient was chairfast and unable to wheel themselves. A review of a signed plan of care for the initial certification of 10-29-22 to 12-27-22, indicated that Patient #22 had orders for SN 1time a week for 9 weeks for med set up, recert of services prn (as needed) for change in condition, PT 3 times a week for 9 weeks evaluate and treat, Home Health Aide (HHA) 2 home visits 5 days a week for 8 weeks to assist with ADLs and IADLS. A review of a document dated 9-21-22, titled “Ambulatory referral to Home Health,” was electronically signed by Person 51, a practitioner for Entity 38. The document contained orders for physical therapy, registered nurse, occupational therapy, and home health aide. The referral indicated that Patient #22 needed skilled and non-skilled services related to a 3rd stroke patient had on 7-20-22 and has right-side weakness, unable to bear weight, urinary and fecal incontinence, wheelchair-bound, unable to use their right arm, and impaired speech. A review of a signed agency document dated 12-11-22, titled “Physician Order,” indicated orders to change the HHA frequency to 8 hours a day, 5 days a week (Monday -Friday). A review of the SN notes evidenced the following: The RN start of care initial assessment on 10-29-22, a resumption of care certification assessment on 12-29-22, and a recertification assessment on 12-21-22. The clinical record failed to evidence that the physician or allowed practitioner responsible for the plan of care had been notified of the agency’s inability to provide services as ordered. A review of the PT notes evidenced a PT evaluation dated 10-31-22. During the 4 weeks dates of 11-31-22 to 11-26-22, the PT made visits 2 times a week. PT made an evaluation visit on 12-3-22. The clinical record failed to evidence that the physician or allowed practitioner responsible for the plan of care had been notified of the agency’s inability to provide services as ordered. A clinical record review failed to provide evidence that an OT evaluation or further visits were completed. The clinical record failed to evidence that the physician or allowed practitioner responsible for the plan of care had been notified of the agency’s inability to provide services as ordered. A review of the HHA notes evidenced that the HHA made a visit on 11-3-22. The clinical record failed to evidence that the physician or allowed practitioner responsible for the plan of care had been notified of the agency’s inability to provide services as ordered. During an interview on 1-10-23 at 3:50 PM, Patient #22, and their caregiver, Person 26, indicated that the staff from Union Healthcare Services do not come consistently. They further indicated that the PT would call and then not show up. The PT called the last time and stated that Patient #22 was not on his schedule. OT never came, and there is no HHA. Patient #22 stated they fell trying to transfer to the wheelchair, and their family member had to come to help get them up. 10. A review of the clinical record of Patient #23, the start of care date of 11-30-22, contained a start of care assessment dated 11-30-22, indicated a primary diagnosis of acute respiratory failure with hypoxia and other diagnoses of morbid obesity, type 2 diabetes mellitus with unspecified complications, essential (primary) hypertension, personal history of other venous thrombosis and embolism, and pneumonia. The Functional status indicated poor balance, muscle weakness, unsteady gait, and a fall risk score of 5 (A score of 4 or more is considered at risk for falling). Functional limitations included ambulation, bladder incontinence, endurance, and ambulation, indicated that the patient used a walker as an assistive device. A review of a signed plan of care for the initial certification of 11-30-22 to 1-28-23, indicated that Patient #23 had orders for SN 1 time a week for 9 weeks for medication management, recertification, resumption of care, and PT evaluation and treatment. A review of an agency document dated 12-9-22, titled “PT Evaluation and Order,” indicated PT 3 times a week for 4 weeks. A review of the PT visit notes evidenced a PT evaluation dated 12-9-22; no further visits were completed. The clinical record failed to evidence that the physician or allowed practitioner responsible for the plan of care had been notified of the agency’s inability to provide services as ordered. During an interview on 1-10-23 at 11:34 AM, Person 53, Patient #23’s caregiver, confirmed the PT came out to their home 1 time and never returned. Person 53 further indicated they were never told why the PT never returned by the agency or the PT. 11. A review of the clinical record of Patient #24, the start of care date of 9-16-22, contained a start of care assessment dated 9-16-22, indicated a primary diagnosis of essential (primary) hypertension, and other diagnoses of heart failure unspecified, type 2 diabetes mellitus with diabetic neuropathy, chronic obstructive pulmonary disease, and unspecified asthma. The Functional status indicated poor balance, amputation (left below the knee), high risk for falls, muscle weakness, unsteady gait, and a fall risk score of 6 (A score of 4 or more is considered at risk for falling). Functional limitations included ambulation, bowel incontinence, bladder incontinence, endurance, and ambulation, indicated that the patient used a walker as an assistive device and a wheelchair. A review of a signed plan of care for the initial certification of 12-19-22 to 2-16-23, indicated that Patient #25 had orders for SN 1 time a week for 1 week for the start of care assessment (SOC) PT evaluate and treat, OT evaluate and treat. A review of a signed agency document dated 10-13-22, titled “Physician Order,” indicated a frequency change for PT effective 11-15-22, for 2 times a week for 4 weeks. A review of a signed agency document dated 11-2-22, titled “Physician Order,” indicated HHA 7 times a week for 9 weeks, 6 hours a day. A review of the SN notes evidenced the following: The RN completed a start of care initial assessment on 9-16-22. Further review indicated an SN visit note on 9-28-22 with no further evidence of SN visits. The clinical record failed to evidence that the physician or allowed practitioner responsible for the plan of care had been notified of the agency’s inability to provide services as ordered. A review of the PT visit notes evidenced a PT evaluation dated 9-22-22; a missed visit on 11-2-22 with no other visits completed. The clinical record failed to evidence that the physician or allowed practitioner responsible for the plan of care had been notified of the agency’s inability to provide services as ordered. A review of the OT visit notes evidenced an OT evaluation dated 9-22-22; a visit on 9-27-22 with no other visits completed. The clinical record failed to evidence that the physician or allowed practitioner responsible for the plan of care had been notified of the agency’s inability to provide services as ordered. A clinical record review failed to provide evidence that any HHA visits were completed. The clinical record failed to evidence that the physician or allowed practitioner responsible for the plan of care had been notified of the agency’s inability to provide services as ordered. During an interview on 1-10-23 at 11:21 AM, Patient #24 confirmed the therapist came 1 time and has yet to return. 12. A review of the clinical record of Patient #25, the start of care date of 12-19-22, contained a start of care assessment dated 12-19-22, indicated a primary diagnosis of bilateral osteoarthritis resulting from hip dysplasia, other diagnoses of depression, unspecified atrial fibrillation, and anemia. The Functional status indicated poor balance, high risk for falls, muscle weakness, unsteady gait, and a fall risk score of 5 (A score of 4 or more is considered at risk for falling). Functional limitations included ambulation, bowel incontinence, bladder incontinence, and endurance, and ambulation indicated that the patient used a walker as an assistive device and a wheelchair. A review of the PT visit notes evidenced an incomplete PT evaluation dated 1-2-23, with no other visits completed. The clinical record failed to evidence that the physician or allowed practitioner responsible for the plan of care had been notified of the agency’s inability to provide services as ordered. A clinical record review failed to provide evidence that an OT evaluation or further visits were completed. The clinical record failed to evidence that the physician or allowed practitioner responsible for the plan of care had been notified of the agency’s inability to provide services as ordered. During an interview on 1-10-23 at 10:23 AM, Person 27, the family member of Patient #25, indicated that Patient #25 came home from a stay in a rehab center, Entity 5, on 12-5-22. The social worker at the rehab center set everything up with this agency for therapy. Person 27 further indicated that a PT was outside the house now in January, wanting to come to assess the patient. The patient and family member agreed to the visit. Person 27 further indicated they were on their way home from an emergency room hospital visit. Patient #25 fell while trying to transfer out of bed to the wheelchair to use the bathroom. They had to call 911 to assist in getting Patient #25 off the floor. 13. During the Entrance Conference on 1-3-23 at 9:35 AM, the Director of Nursing/Administrator confirmed that the agency only accepts patients if they can staff them. 13. The closed record of the clinical record of former patient #29 was reviewed on 1-10-2023 at 12:30 PM. The clinical record contained a document titled “Home Health Certification and Plan of Care” signed by the physician on 11-23-2022. Plan of care ordered skilled nursing, physical therapy, and home health aide care to be provided to the patient with a start date of 10-25-2022 for the certification period of 10-25-2022 to 12-23-2022. Skilled nursing frequency was scheduled for 1 time a week for 9 weeks with PRN Registered nurse supervisory comprehensive assessment. Physical therapy frequency was scheduled for 3 times a week for 9 weeks for evaluation and treatment. Home health aide frequency was scheduled for 2 hours a visit, 5 days a week for 8 weeks. Review of the clinical record of former patient #29, a document titled “Physical Therapy Assessment/Evaluation,” Physical Therapists (PT) #1 performed assessment and evaluation on 10-28-2022 at 3:00 PM. The agency failed to provide physical therapy visit notes for the remainder of the certification period of 10-25-2022 to 12-23-2022. Review of documents given to surveyor by Administrative (Admin) staff #2 on 1-11-2023 at 9:00 AM for patient #29. The clinical record contained a document of a referral from Entity #49 to the agency. Document verified patient #29 was admitted to Entity #49 on 11-4-2022 and discharged on 11-8-2022. Document titled “OASIS-D1 Resumption of Care” visit was completed on 11-9-2022. Review of the clinical record for former patient #29, no orders were provided to the patient’s physician by the agency for services to be held by the agency during the patient’s hospitalization. Review of the clinical record, the agency failed to submit complete documents titled “Skilled Wound Care Visit” documentation for the dates 11-9-2022, 11-25-2022, 11-26-2022, 12-3-2022, and 12-4-2022. Review of the clinical record, the agency failed to provide documentation for skilled nurse visits on the dates 11-12-2022, 11-13-2022, and 11-17-2022. Review of the clinical record, the agency failed to provide documentation of Home Health Aide (HHA) visits for the certification period of 10-25-2022 to 12-23-2022 for patient #29. Document titled “Transfer Summary” signed by Admin #1 on 11-3-2022 stated, “HHA services pending Medicaid PA authorization.” Agency failed to evidence notification of the physician. Review of the clinical record, RN #2 submitted a document titled “OASIS-D1 Discharge” on 12-5-2022 at 12:12 PM, and the patient was discharged home for meeting goals. The document titled “Home Health Discharge Summary” on 12-7-2022 at 11:14 AM evidenced the physician and patient agreed with the discharge plan. During an interview on 1-10-2023 at 1:48 PM, when queried former patient #29 stated “I am still a client with the agency.” Patient #29 stated, “the nurse with Union told me she did not feel confident taking care of the wound.” When queried about if she is receiving home health aide services, the patient stated she has an aide with the agency, but the aide left the country, and the agency sent a replacement aide. Patient stated she has never been seen by physical therapy. Patient stated the wound care nurse saw Entity #52 until last week. Patient stated, “the nurse said she did not need to come back because my wound was healing.” Attempted to call Entity #52 on 1-10-2023 at 2:11 PM. A voicemail was left, requesting the entity to call the surveyor back. Attempted to call Entity #42 on 1-10-2023 at 2:15 PM. A voicemail was left, requesting the entity to call the surveyor back. During an interview on 1-10-2023 at 2:24 PM, Person #41 stated Patient #29 was not a patient. 14. The clinical record of Patient #16 was reviewed on 1-4-2023 at 2:30 PM. The clinical record contained a document titled “OASIS-D1 Start of Care,” the document was dated as a visit on 12-28-2022 and not signed. Review of the clinical record document titled “Eskenazi Health” stated the request from the physician for physical therapy, occupational therapy, and speech therapy. The clinical record review evidenced no plan of care, no hold care orders, and no visit notes. Attempted to call Patient #16, a voicemail was left, requesting for the patient to call the surveyor back. During an interview with Entity #38 on 1-11-2023 at 11:40 AM, Entity #38 was queried about the agency’s communication with the entity regarding the patient. The entity stated, “there is no communication from Union Healthcare regarding the patient.” During an interview with Patient #16’s relative Person #39 on 1-11-2023 at 10:35, she was queried regarding whether the patient has been seen or contacted by the agency. Person #39 stated the agency has not seen the patient but contacted the patient regarding starting care. Person #39 informed surveyor the agency did not set a time with the patient to start care. During an interview on 1-5-2023 at 9:40 AM with Admin #2, she stated Patient #16 had been admitted to the hospital and the agency did not take the patient back. Patient #16 is on the active roster. During an interview on 1-5-2023 at 10:45 AM with Admin #1, she stated the physical therapist was not able to go over to the patient’s house over the holidays. There were no hold orders for the patient and no communication note to the physician. 15. The clinical record review on 1-4-2023 at 10:00 AM of Patient #11, the patient’s chart was placed on hold for hospitalization. The clinical record contained a document titled “Home Health Certification and Plan of Care” with a start date of 4-19-2022 and a certification period of 10-16-2022 to 12-14-2022. The plan of care had no signature from the physician. The plan of care contained the frequency of skilled nursing was 1 time a month for 2 months for recertification and supervisory visit. The Home Health Aide frequency was not listed on the plan of care. Review of the clinical record for Patient #11, a document titled “Physician Order” dated 10-14-2022 stated a verbal order was received for the home health aide hours to be increased to 4 hours a day and for 7 days a week. Agency failed to revise change of HHA frequency. Review of agency documents titled “HHA Visit” for the certification period of 10-14-22 to 12-14-2022 did not reflect the verbal order for the home health aide hours to be increased to 4 hours a day and for 7 days a week. Patient #11 was seen Monday, Tuesday, Wednesday, Thursday, and Friday. HHA visit notes were not reflected for Saturday and Sunday during the certification period. HHA visit notes were not reflected in the clinical record for the dates 11-21-2022, 11-22-2022, 11-23-2022, 11-24-2022, and 11-25-2022. Review of agency document titled “30-Day Summary/Case Conference” signed by Admin #1 on 11-11-2022. The document did not contain coordination of care with any other practice. During an interview on 1-4-2023 at 3:55, Admin #1 was queried regarding if the frequency of HHA visits are included in the plan of care. Admin #11 stated the HHA should have the frequency on the plan of care. During an interview on 1-5-2023 at 12:11 PM with Patient #11, he stated he was in rehab. Patient #11 stated the aide was there daily and the agency notified him when the agency was unable to complete a visit. The patient stated he did not have any complaints or problems with the agency. Patient stated he had been admitted to the hospital 4 weeks ago. Attempted to call on 1-5-2023 at 3:25, Entity #16, and was unsuccessful in retrieving communication documentation. Attempted to call on 1-6-2023 at 12:14, Entity #16, left a voicemail requesting entity to call surveyor back. During an interview on 1-11-2023 at 12:30 with Entity #13, the patient’s nurse stated, “no one from Union has contacted us.” During an interview on 1-10-2023 at 9:15 with Admin #1, when queried regarding patients not being seen, Admin #1 stated the agency had staffing and insurance issues. Admin #1 stated in the entrance conference if the agency was unable to provide staff to care for the patient, the patient would not be accepted as a patient. 16. The clinical record of Patient #12 was reviewed on 1-4-2023 at 11:00 AM. The clinical record contained a document titled “Home Health Certification and Plan of Care” with a start date of 4-19-2022 and a certification period of 10-16-2022 to 12-14-2022. The frequency of skilled nurse visits was listed as 1 time a month for 2 months. The Home Health Aide frequency was listed as 2 hours a visit, 5 days a week for 8 weeks. Review of clinical documents titled “HHA visit,” the agency failed to provide documentation of the patient having aide care for the week of 11-20-2022 to 11-26-2022. Review of the clinical record, the agency failed to provide communication notes notifying the physician of the missed visits. Attempted to interview Patient #12 on 1-5-2023 at 12:02 PM, the surveyor had identified themself and the patient canceled the call. Attempted to interview Person #11 on 1-9-2023 at 11:35 AM, a voicemail was left for the individual to return the call. During an interview on 1-10-2023 at 9:15 with Admin #1, when queried regarding patients not being seen, Admin #1 stated the agency had staffing and insurance issues. Admin #1 stated in the entrance conference if the agency was unable to provide staff to care for the patient, the patient would not be accepted as a patient. 17. The closed record of the clinical record of Patient #31 was reviewed on 1-9-2023 at 9:00 AM. The clinical record contained a document titled “Home Health Certification and Plan of Care” with a start of care date of 10-13-2022 and a certification period of 10-13-2022 to 12-11-2022. The plan of care stated the patient was to receive skilled nursing 2 times a week for nine weeks, physical therapy 3 times a week for 9 weeks, and occupational therapy 3 times a week for 9 weeks. An additional plan of care was listed in the clinical record stating the patient was to receive skilled nursing 3 times a week for nine weeks, physical therapy 2 times a week for 9 weeks, occupational therapy 2 times a week for 9 weeks, and a home health aide 4 hours a day for 5 days a week for 8 weeks. The closed clinical record failed to evidence any home health aide visits for the certification period of 10-13-2022 to 12-11-2022. Patient #31 had an open record with the agency under Medicaid where home health aide visits were documented. The clinical document titled “Physician order” was signed by Admin #1 on 10-16-2022 at 1:30 PM and signed by Person #11 on 10-19-2022 at 5:00. The order verified verbal order for skilled nursing to be 3 times a week, to treat wounds. The clinical document titled “OASIS-D1 Transfer” was dated 10-19-2022 by Registered Nurse (RN) #1 at 8:00 AM. The clinical record failed to evidence a discharge summary or hold orders to the physician. A document titled “OASIS-D1 Resumption of Care” was completed on 10-22-2022 at 11:00 AM by Admin #1. The clinical document titled “PT Visit” dated 11-1-2022 at 11:15 AM was completed by Admin #1, who is not a physical therapist. The clinical document titled “PT Visit” dated 11-3-2022 at 1:00 PM was completed by Admin #1, who is not a physical therapist. The clinical document titled “PT Visit” dated for the visit 11-8-2022 at 10:00 AM was submitted blank and unsigned. The clinical document titled “Skilled Nurse Visit” dated for the visit 11-9-2022 at 12:00 PM was submitted blank and unsigned. The clinical document titled “PT Re-Evaluation” dated for the visit 11-11-2022 at 2:00 PM was submitted blank and unsigned. The agency failed to evidence compliance with the frequency stated in the plan of care. The clinical document titled “PT Visit” dated for the visit 12-5-2022 at 4:00 PM was submitted complete, with no signature. The clinical document titled “PT Visit” dated for the visit 12-7-2022 was submitted with no time, no signature, and was blank. The clinical document titled “PT Visit” dated for the visit 12-9-2022 was submitted with no time, no signature, and was blank. The clinical document titled “Communication Note,” dated 10-20-2022 by Physical Therapist #1, was the only communication note informing the physician of missed visits. The agency failed to evidence compliance with the frequency stated in the plan of care. Attempted to interview Patient #31 on 1-5-2023 at 12:02 PM, the surveyor had identified themselves and the patient canceled the call. Attempted to interview Person #11 on 1-9-2023 at 11:35 AM, a voicemail was left for the individual to return the call. During an interview on 1-10-2023 at 9:15 with Admin #1, when queried regarding patients not being seen, Admin #1 stated the agency had staffing and insurance issues. Admin #1 stated in the entrance conference if the agency was unable to provide staff to care for the patient, the patient would not be accepted as a patient. Findings include: 1. On 01-03-2023 at 12:01 PM, a November 2021 revised policy titled, " Care/Service Coordination, policy No. 4-067.1", was provided by the Director of Nursing (DON), Administrator #1 . The policy indicated but was not limited to, "Timely and ongoing communication is the responsibility of each team member of the interdisciplinary group and will be appropriate to the needs and abilities of the patient, and relevant to the care/service provided. The clinician will be responsible for facilitating communications and changes in the patient's status among the assigned personnel... 4. Care coordination will include but not be limited to: clearly outlining each clinician's responsibilities...planned face -to-face conferences...timely documentation of coordination of care activities, appropriate involvement of the patient and caregivers, integration of services...coordination of care deliver to meet the patient's needs, and involve the patient, representative, and caregivers as appropriate, in the coordination of care activities... Organization personnel will communicate changes timely...". 2. On 01-09-2023 at 12:20 PM a clinical record review of Patient #7 for the certification period 10-07-2022 through 12-05-2022 was completed. Patient #7’s diagnosis included a Pressure Ulcer to the right lower extremity and Diabetes Mellitus. A referral was sent on 09-12-2022 for home care services to be initiated immediately following a discharge from Entity # on 09-12-2022. The record indicated the OASIS start of care (SOC) was 10-07-2022. The orders included skilled nursing, therapies, and home health aide. A home health aide plan of care was submitted. A verbal order documented by Administrative staff #1, the Director of Nursing, on 10-10-2022 included wound care orders. The following orders included, “Cleanse RLE(sic) pressure ulcer with gauze 4X4 and wound cleanser. Apply Xeroform gauze cut to size and cover with ABD (sic) pad. Wrap in Kerlix and Coban. SN to change dressing 3x/week and train PT (sic) to change dressing in event dressing gets wet or soiled.”. No documentation of skilled nurse visits after 10-07-2022, documentation to the physician, another agency or insurance indicate care was provided. There was no documentation of a discharge. An interview was conducted on 01-09-2023 at 12:20 PM with Patient #7. Patient #7 indicated the agency notified him they would not be able to provide care to him because, “They could not take his insurance.” When asked if anyone else was treating the patient, the patient indicated they were in a rehab facility, Entity # 15, following the amputation of their right lower extremity. 3. On 01-10-2023 at 8:40 AM, the clinical records from Entity #15 and Entity #16 were reviewed. Patient #7 was admitted on 10-24-2022 to Entity #16 for signs of Sepsis (a blood stream infection) and a right lower extremity wound that was suspected to be gangrenous. On 10-26-2022 the records indicated Patient # 7 underwent a below the knee amputation of the right lower extremity. 4. On 01-04-2023 at 11:10 AM, a clinical record review of Patient #9 for the certification period 12-06-2022 through 02-03-2023 was completed. Patient #9’s diagnosis includes Diabetes Mellitus (DM) and Chronic Obstructive Pulmonary Disease (COPD). Patient #9 was admitted to Entity # on 12-16-2022 per the Registered Nurse’s (RN), #2 visit notes. The records do not include any transfer/discharge/hold orders or communications to the physician. The records fail to include case conference notes with anyone other than a RN. On 01-04-2023 at 9:50 AM, during a home visit with RN #2 , Patient #9 was interviewed. Patient #9 indicated their Torsemide (a diuretic) was decreased to 50 mg from 100mg, and they continue to take a Vicoden as needed for pain following their December 16, 2022 hospitalization. The clinical records fail to include communication to the physician regarding these changes. The case conference notes within the clinical record were completed by the RN only and not interdisciplinary. 5. On 01-05-2023 at 11:36 AM, the clinical record of Patient #28 was reviewed for the certification period 12-14-2022 through 02-11-2023. Patient #28 is a Paraplegic with Type 2 Diabetes Mellitus. Patient #28 was admitted to the hospital on 01-02-2023. There was no record of a transfer OASIS completed or communication to the physician. The case conference notes within the clinical record were completed by the RN only and not interdisciplinary. 6. On 01-05-2023 at 12:00 PM, the clinical record of Patient #26 was reviewed for the certification period 11-24-2022 through 01-22-2023. Patient #26 is a patient diagnosed with Type 2 Diabetes Mellitus and Hypertension (high blood pressure). The case conference notes within the clinical record were completed by the RN only and not interdisciplinary. 7. On 01-03-2023 at 12:56 PM, the clinical record of Patient #5 was reviewed for the certification period 12-17-2022 through 02-14-2023. Patient #5 is a patient diagnosed with Ataxic gait for medication management. The Home Health Aide (HHA) visit notes reflect HHA #2 did not follow the plan of care (POC) from the time of admission on 08-19-2022. The Supervisory visits completed by RN #1 indicate the HHA followed the (POC). The case conference notes within the clinical record were completed by RN #1 alone, were not interdisciplinary and did not reflect the patients request for a female caregiver. On 01-09-2023 at 11:40 AM, an interview was conducted with Patient #5. Patient #5 was queried about the services provided by the Home Health Aide. Patient #5 indicated they notified the agency they would not allow a male HHA complete the activities ordered on the HHA Care Plan and preferred a female caregiver. 8. On 01-11-2023 at 11:30 AM, the clinical record of Patient #30 was reviewed for the certification period 11-03-2022 through 12-27-2022. Patient #30 is a patient diagnosed with Type 2 Diabetes Mellitus. The orders included a skilled nurse eval, physical therapist (PT) three times per week and occupational therapist (OT) two times per week. PT #1 did not complete visit documentation on 11-07, 11-09, 11-11, 11-14, 11-16, 11-18, 11-21, 11-23, 11-25, 11-30 and 12-02-2022. There was no discharge documentation, physician communication notes or case conference notes indicating any interdisciplinary communication. On 01-11-2023 at 1:10 PM, Patient #30 was queried about the ordered PT visits. Patient #30 indicated PT #1, visited the patient on one occasion. The patient refused any further visits. 9. On 1-06-2023 at 9:30 AM, the clinical record of Patient #6 was reviewed for the certification period 11-29-2022 through 01-27-2023. Patient #6 is a patient diagnosed with a Cerebral Infarct (Stroke). The orders included skilled nursing for medication management and physical therapy (PT) two times a week. The last PT visit was on 10-30-2022. There were no discharge orders when goals were met. There was no communication, completed case conference or summary notes indicating any interdisciplinary communication. On 1-11-2023 at 12:13 PM, the sister-in-law, Other #32 was queried about the services provided. Other # 32 indicated PT #1 did complete therapy visits but there were no updates when the patient was discharged. “They just stopped coming.”

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to evidence updated individualized plans of care for 12 of 25 active patients (Patients #2, 5, 7, 11, 12, 16, 20, 22, 23, 24, 26, and 27) and 2 of 7 inactive patients. (Patients #29 and 31) Findings Include: 1. A review of the clinical record for Patient #2, with a start of care date of 10-27-2022, contained a start of care assessment completed on 10-27-2022. The initial comprehensive assessment indicated Patient #2 evidenced the patient’s diagnoses as a non-pressure chronic ulcer in other part of the left foot with a fat layer exposed, type 2 diabetes with other diabetic neurological complications ( nerve damage affecting legs and feet), essential (primary) hypertension ( high blood pressure), peripheral vascular disease (narrow blood vessels reducing blood flow to the limbs), non-pressure chronic ulcer of left heel with midfoot with fat layer exposed. Patient #2 lived alone, was homebound, had no caregiver, with a history of falls, and was chairfast and wheelchair-type motorized; blood sugars are performed by the patient, with their blood sugar ranging from 110-180. Patient #2 administers their insulin and has pain, muscle weakness, poor balance, unsteady gait, laxative/enema use, and urinary incontinence. Discharge planning and Care Coordination were checked N/A (Not Applicable). A review of a physician-signed plan of care for the initial certification period of 10-27-2022 to 12-25-2022, indicated the following diagnoses: the principal diagnosis was; a non-pressure chronic ulcer in other part of the left foot with a fat layer exposed; the other diagnoses listed; type 2 diabetes with other diabetic neurological complications, essential (primary) hypertension, peripheral vascular disease, and non-pressure chronic ulcer of left heel with midfoot with fat layer exposed, orders for skilled nursing 3 times a week for wound care dressing, skilled assessment, instruct patient on strategies to mitigate pain, assess integumentary status, and instruct on the disease process. The section titled “Goals” indicated, “The Patient’s personal health goal able to understand regarding instruction and teaching. Nursing indicated, “Patient will be able to verbalize signs and symptoms of cardiac complications when to call physician, nurse or 911 by the end of this episode. The patient will adapt optimally and develop effective coping skills related to changes in body image or limitations by the end of the cert period. Patient/Caregiver will achieve a pain level of less than 8 by the end of the cert period. The patient’s Activity level will improve due to effective pain control by the end of the cert period. The patient will demonstrate compliance with the medication regimen as evidenced by correct administration and reporting side effects or adverse reactions by the end of the cert period.” The “Rehabilitation Potential and Discharge Plan” section indicated “Rehabilitation potential fair for treatment plan implementation. Discharge to Care of Physician. Discharge When: Caregiver demonstrates the ability to manage wounds at home and follow-up with physician visits and unauthorized services when the wound healed.” The plan of care failed to include individualized and measurable outcomes and goals specific to the patient’s diagnosis and care needs, and the patient does not have a caregiver. A review of the clinical record for Patient #2, with the start of care date 10-27-2022, for the recertification period of 12-26-2022 to 02-23-2023, contained an agency document dated 12-23-2022, titled “OASIS-D1 Recertification.” The recertification had no time in, time out, or signature. The recertification assessment contained on page 1, a subtitled section titled “Demographics,” which was completed with Patient #2’s name, address, phone number, date of birth, insurance, insurance number, agency name, the agency’s certification number, the patient’s start of care, certification period, physician’s name, race, and ethnicity. The section titled “Clinical Records” with the subtitled section titled “Discipline of Person Completing Assessment” marked Registered Nurse (RN). The subtitled section titled “Date of Assessment” was left blank. The subtitled section titled “This Assessment is Currently Being Completed for the Following Reason” was marked Recertification. The subtitled section titled “Episode Timing” was marked N/A. the Subtitled section titled “Diagnosis Symptom Control indicated the following diagnoses: a primary diagnosis of non-pressure chronic pressure ulcer in another part of the left foot with a severity of 2; other diagnoses were essential hypertension with a severity of 2; type 2 diabetes with other diabetic neurological complication with a severity of 2; and peripheral vascular disease with a severity of 2. The recertification assessment pages 2-10 were incomplete and left blank. A review of the incomplete Plan of Care for the recertification period of 12-26-2022 to 02-23-2023, indicated the following diagnoses: the principal diagnosis was; a non-pressure chronic ulcer in the other part of the left foot with a fat layer exposed; the other diagnoses listed; type 2 diabetes with other diabetic neurological complications, essential (primary) hypertension, peripheral vascular disease, and non-pressure chronic ulcer of left heel with midfoot with fat layer exposed, order for Nursing, no frequency, SN to assess the integumentary status, SN to instruct patient of the disease process, and wound care. The section titled “Goals” indicated, No patient goals were listed, “ Nursing indicated, “Patient will be able to verbalize signs and symptoms of cardiac complications when to call physician, nurse, or 911 by the end of this episode. The patient will adapt optimally and develop effective coping skills related to changes in body image or limitations by the end of the cert period. The patient will demonstrate compliance with the medication regimen as evidenced by correct administration and reporting side effects or adverse reactions by the end of the cert period.” The section titled “Rehabilitation Potential and Discharge Plan” indicated “Rehabilitation potential,” but the section was left blank. Discharge When: When services are no longer needed or authorized. The plan of care repeated the identical goals found in the initial plan of care, was incomplete, and failed to provide evidence of any new or modified individualized and patient-specific objective and measurable goals that failed to accurately reflect changes and updates from the last assessment and plan of care. During an interview on 01-04-2023 at 9:15 AM, the Administrator/Director of Nursing, Admin 1, confirmed the recertification and that the care plan was incomplete and not updated to reflect Patient #2’s changes. 2. A review of the clinical record for Patient #4, the start of care date of 10-11-2022, contained a recertification assessment dated 12-08-2022, indicated a primary diagnosis of atherosclerosis heart disease of the native coronary artery (a build-up of fats in the walls of the arteries) without angina pectoris heart (chest pain), and other diagnoses of hyperlipidemia (high cholesterol), long term use of insulin, iron deficiency anemia, and localized edema. Patient #4 had a history of falls, lives alone with no caregiver available, left eye blindness uses glasses, and had severe neck and shoulder pain daily. Patient #4 had several bruises all over her body due to falls or loss of balance and used a walker for an assistive device. Patient #4 had bilateral lower extremity non-pitting +2 edema; the patient’s blood sugars were unknown because their glucometer had broken, and they had just received a new one; the patient will check blood sugars and gives their sliding scale insulin with meals. A review of the plan of care for the recertification period from 12-10-2022 to 02-07-2023, indicated a primary diagnosis of atherosclerosis heart disease of the native coronary artery (a build-up of fats in the walls of the arteries) without angina pectoris heart (chest pain), and other diagnoses of hyperlipidemia (high cholesterol), long term use of insulin, iron deficiency anemia, and localized edema. The “Goals” section indicated that Nursing goals were blank. The plan of care failed to evidence all required elements and failed to be individualized and updated patient specific with outcomes and measurable goals. 3. A review of the clinical record for Patient #20, the start of care date of 10-12-2022, contained an initial certification plan of care dated 10-12-2022 to 12-10-2022. The plan of care indicated the following diagnoses: type 2 diabetes mellitus, essential hypertension, and pain in the right hip. The plan of care contained a section titled, “Goals,” which indicated but was not limited to the following: Patient #20 would demonstrate compliance with self-management of diabetes mellitus; would demonstrate a return to stable endocrine status, activity level will improve, would demonstrate knowledge of pain medication and proper administration, would be able to demonstrate pain relief measures, will demonstrate a return to stable cardiovascular status, therapy evaluation will be performed, will demonstrate compliance with medication regimen, and the patient will demonstrate effectively manage medication regimen. The recertification plan of care failed to be updated with individualized and updated patient-specific outcomes and measurable goals. A review of the recertification plan of care dated 12-11-2022 to 02-08-2023, indicated the following diagnoses: type 2 diabetes mellitus, essential hypertension, and pain in the right hip. The plan of care contained a section titled, “Goals,” which indicated but was not limited to the following: Patient #20 would demonstrate compliance with self-management of diabetes mellitus; would demonstrate a return to stable endocrine status, activity level will improve, would demonstrate knowledge of pain medication and proper administration, would be able to demonstrate pain relief measures, will demonstrate a return to stable cardiovascular status, therapy evaluation will be performed, will demonstrate compliance with medication regimen, and the patient will demonstrate effectively manage medication regimen. 4. A review of the clinical record for Patient #22, the start of care date of 10-29-2022, contained an initial certification plan of care dated 10-29-2022 to 12-10-2022. The plan of care indicated the following diagnoses: essential hypertension (high blood pressure), unspecified sequelae of unspecified cerebrovascular disease (effects from lack of blood flow to parts of the brain), continuous leakage, and cocaine abuse. The plan of care contained a section titled, “Goals,” which indicated but was not limited to the following: Patient #22’s personal health goal was that the client would be able to follow and understand instructions. Nursing goals: the patient will be free of skin breakdown, the patient will be free of injury, the patient will receive safe and effective personal care, the patient/caregiver will be able to demonstrate pain relief measures, the patient /caregiver will achieve pain level less than 3, the patient’s activity level improves, the patient will demonstrate compliance with medication regimen, the patient will be free of falls, and the patient will demonstrate proper use of their assistive device. A review recertification plan of care dated 12-11-2022 to 02-08-2023, indicated the following diagnoses: essential hypertension, unspecified sequelae of unspecified cerebrovascular disease, continuous leakage, and cocaine abuse. The plan of care contained a section titled, “Goals,” which indicated but was not limited to the following: Patient #22’s personal health goal was blank; Nursing goals: the patient will be free of skin breakdown, the patient will be free of injury, the patient will receive safe and effective personal care, the patient/caregiver will be able to demonstrate pain relief measures, the patient /caregiver will achieve pain level less than 3, the patient’s activity level improves, the patient will demonstrate compliance with medication regimen, the patient will be free of falls, and the patient will demonstrate proper use of their assistive device. The recertification plan of care failed to be updated with individualized and updated patient-specific outcomes and measurable goals. 5. A review of the clinical record for Patient #23, the start of care date of 11-30-2022, contained a signed initial certification plan of care dated 11-30-2022 to 01-28-2023. The plan of care indicated the following diagnoses: acute respiratory failure with hypoxia (lack of oxygen exchange from the lungs to the body), morbid obesity, essential hypertension (high blood pressure), type 2 diabetes mellitus (the body is unable to process sugar), personal history of other venous thrombosis and embolism (blood clots in the legs or lungs), and pneumonia. The plan of care contained a section titled, “Goals,” which indicated but was not limited to the following: Patient #23’s healthcare goal was to comprehend the teaching and apply it; a physical therapy evaluation; Nursing; the patient will demonstrate a return to stable muscular skeletal status related to falls with improvement; patient/caregiver will adapt optimally and develop effective coping skills; patient/caregiver will demonstrate the ability to manage medication regimen effectively; the patient will be free of falls; and the patient/caregiver will demonstrate competence with self-management of diabetes mellitus. The section titled, “F2F Addendum (Admission Narrative),” indicated that the patient was obese and weighed 600 pounds, had no dyspnea at this time, had oxygen saturation (O2 SAT) of 94%, was incontinent of the bladder, and the patient required an INR (International Normalized Ratio) taken 2 times a week (a blood test that measures the clotting factor of the blood) due the patient is taking Warfarin ( a medication that thins the blood). The plan of care failed to be individualized with patient-specific outcomes and measurable goals, failed to address the patient’s respiratory status and underlying risks factors, failed to address their blood clotting underlying risk factors, 6. A review of the clinical record for Patient #24, the start of care date of 09-16-2022, contained a signed initial certification plan of care dated 09-16-2022 to 11-14-2022. The plan of care indicated the following diagnoses: essential hypertension, type 2 diabetes mellitus, heart failure (the heart cannot pump in or out the blood effectively), chronic obstructive pulmonary disease (an inflammatory disease that obstructs airflow from the lungs), and asthma. The plan of care contained a section titled, “Goals,” which indicated but was not limited to the following: Patient #24’s personal healthcare goal was to receive assistance safely and effectively from paraprofessional, family, and community, and the Nursing goals were blank. The plan of care failed to evidence all required elements and failed to be individualized and updated patient specific with outcomes and measurable goals. During an interview on 01-10-2023 at 10:27 AM, the Administrator/Director of Nursing, Admin 1, indicated the clinicians were to review interventions each visit and review progress towards those goals, document the patient’s response, and update the plan of care every 60 days. 410 IAC 17-13-1(a) 1. On 1-6-2023 at 9:30 AM a policy titled “Notice of Rights” was provided by Admin #1. The policy indicated but was not limited to, “… Policy,” on Page 2, “… “Right to participate in, be informed about, and consent and refuse care in advance of and during treatment… Completion of all assessments. The care to be furnished, based on the Comprehensive Assessment. Establishing and revising the Plan of Care. The discipline that will furnish the care. The frequency of visits…” 2. On 1-6-2023 at 9:30 AM a policy titled “Home Health Aide Plan of Care” was provided by the Administrator, Admin #1. The policy indicated but was not limited to, “Policy: Each patient receiving home health aide services will have an individualized plan developed by an appropriate professional and utilized to direct the care performed by the assigned aide… Procedure: 2. The home health aide plan of care will be individualized to the specific patient and will include at least: A. Type of services/procedures to be provided…B. Frequency of visits….” 3. A review of the clinical record for Patient #12, with the start of care date of 4-19-2022, contained a plan of care for the recertification period of 10-16-2022 to 12-14-2022. The plan of care indicated orders for Skilled Nursing (SN) 1 time a month for 2 months for recertification evaluation and supervisory visits. Home Health Aide (HHA) 2 hours a visit, 5 days a week, 5 days a week for 8 weeks for assistance with personal care Instrumental Activities of daily living (IADL) and Activities of daily living (ADL). A review of the HHA visit notes evidenced no HHA visit notes were completed during the week of 11-20-2022 to 11-26-2022. During an interview on 1-10-2023 at 9:15 AM, when queried regarding Patient #12 not being seen for a week according to the clinical record, Admin #1 stated the missed visits are because of staffing. During the entrance conference on 1-3-2023 at 9:11 AM, Admin #1 indicated the agency would not take the patient if the agency was unable to staff the patient’s needs. 4. A review of the closed clinical record for Patient #29, with the start of care date of 10-25-2022, contained a plan of care for the initial certification period of 10-25-2022 to 12-23-2022. The plan of care indicated orders for SN 1 time a week for 9 weeks and 1-2 times as needed for Registered Nurse (RN) HHA supervision for a comprehensive assessment, Physical Therapy (PT) 3 times a week for 9 weeks to evaluate and treat, and HHA 2 hours a visit, 5 days a week for 8 weeks. A review of the clinical record on 1-10-2023 at 12:30 PM failed to evidence PT visits past the initial PT Evaluation. The agency failed to provide PT services as listed on the plan of care. A review of the clinical record failed to evidence any visit notes from the HHA. No HHA visit notes were noted for the weeks 10-25-2022 to 10-29-2022, 10-30-2022 to 11-5-2022, 11-6-2022 to 11-12-2022, 11-13-2022 to 11-19-2022, 11-20-2022 to 11-26-2022, and 11-27-2022 to 12-3-2022. The agency failed to provide HHA services according to the order listed on the plan of care. During an interview on 1-10-2023 at 9:15 AM, when queried regarding Patient #29 not being seen according to the plan of care, Admin #1 indicated the missed visits are because of staffing. 5. A review of the clinical record for Patient #11, who is on hold, with the start of care date of 4-19-2022, contained a plan of care for the recertification period of 10-16-2022 to 12-14-2022. The plan of care indicated orders for Skilled Nursing (SN) 1 time a month for 2 months for recertification evaluation and supervisory visits. Home Health Aide (HHA) was listed as a service the patient would receive; the plan of care did not state the ordered frequency of HHA services. A Physician Order signed by Admin #1 and dated 10-14-2022 at 2:00 PM, stated for Patient #11 to receive HHA services 4 hours a day, 7 days a week for the patient’s decline in health. The Physician Order stated the order was read back and verified. The order stated the patient would receive assistance with Instrumental Activities of daily living (IADL) and Activities of daily living (ADL), incontinence care, medication reminders, meal prep, cleaning, and laundry. A review of the HHA visit notes evidenced no HHA visit notes were completed during the week of 11-20-2022 to 11-26-2022. During an interview on 1-10-2023 at 9:15 AM, when queried regarding Patient #11 not being seen for a week according to the clinical record, Admin #1 indicated the missed visits are because of staffing. 6. A review of the clinical record for Patient #16 with the start of care date of 12-28-2022, the clinical record had no plan of care and no hold orders from the physician. The document titled “OASIS-D1 Start of Care” stated the patient was to receive SN 1 time a week for 9 weeks for recertification and medication management and disease process teaching, PT 3 times a week for 9 weeks for evaluation and treatment, and OT 3 times a week for 9 weeks for evaluation and treatment. A review of the electronic medical record and the paper chart failed to evidence SN visits for the weeks of 12-19-2022 to 12-24-2022 and 12-25-2022 to 12-31-2022. A review of the electronic medical record and the paper chart failed to evidence PT visits for the weeks of 12-19-2022 to 12-24-2022 and 12-25-2022 to 12-31-2022. A review of the electronic medical record and the paper chart failed to evidence OT visits for the weeks of 12-19-2022 to 12-24-2022 and 12-25-2022 to 12-31-2022. During an interview on 1-11-2023 at 10:35, Patient #16’s family member, Person #39, was queried regarding whether the agency had been to see the patient or had care provided by the agency. The family member confirmed the facility had not come to see the patient; the facility had called Patient #16 regarding a time to start care. The family member confirmed the agency had not set a time to come see the patient. During an interview on 1-5-2023 at 10:25 AM, Admin #1 indicated PT had not been able to go over to the patient’s house over the holidays and there were no orders to hold care or change the visit. 7. A review of the closed clinical record for Patient #31 with a start of care date of 10-13-2022 for the initial certification period of 10-13-2022 to 12-11-2022. The care plan was ordered for SN 2 times a week for 9 weeks, starting on 10-22-2022 for wound care, medication set up, and disease management. HHA 4 hours a day, 5 days a week for 8 weeks. PT 3 times a week for 9 weeks for therapeutic exercise, range of motion (ROM), gait and balance training, and fall risk education. OT 3 times a week for 9 weeks for safety with Instrumental Activities of daily living (IADL) and Activities of daily living (ADL), and strengthening. A record review of the closed record of Patient #31 evidenced the patient received only 1 visit from SN during the weeks of 10-30-2022 to 11-5-2022, 11-13-2022 to 11-19-2022, 11-20-2022 to 11-26-2022, 11-27-2022 to 12-3-2022, 12-4-2022 to 12-10-2022. The agency failed to follow the orders on the plan of care. A record review of the close record of Patient #31 failed to evidence the patient was seen by SN during the week of 11-6-2022 to 11-12-2022. The agency failed to follow the orders on the plan of care. A record review of the closed record of Patient #31 evidenced the patient received only 1 visit from PT during the week of 10-23-2022 to 10-29-2022. The PT visit note dated 11-1-2022 for the visit on 11-1-2022 was signed by Admin #1, who is an RN. The agency failed to follow the orders on the plan of care. A record review of the closed record of Patient #31 evidenced the patient had not received PT services from the week of 11-6-2022 to 11-12-2022 and 12-4-2022 to 12-10-2022. The agency failed to follow the orders on the plan of care. A record review of the closed record of Patient #31 evidenced the patient received only 1 visit from PT during the week of 11-13-2022 to 11-19-2022 and 11-27-2022 to 12-3-2022. The agency failed to follow the orders on the plan of care. A record review of the closed record of Patient #31 evidenced the patient received only 2 visits from PT during the week of 11-20-2022 to 11-26-2022. The agency failed to follow the orders on the plan of care. A record review of the closed record of Patient #31 evidenced the patient had not received OT services from the week of 10-16-2022 to 10-22-2022, 10-16-2022 to 10-22-2022, 10-30-2022 to 11-5-2022, 11-6-2022 to 11-12-2022, 11-13-2022 to 11-19-2022, 11-20-2022 to 11-26-2022, 11-27-2022 to 12-3-2022, and 12-4-2022 to 12-10-2022. The agency failed to follow the orders on the plan of care. A record review of the closed record of Patient #31 evidenced the patient received only 1 visit from OT for the week of 10-23-2022 to 10-29-2022. The agency failed to follow the orders on the plan of care. A record review of the closed record of Patient #31 evidenced no HHA visit notes for the certification period of 10-13-2022 to 12-11-2022. Patient #31 had an active chart, Patient #12, where HHA visits were noted following the plan of care under another payor source, Medicaid. During an interview on 1-10-2023 at 9:15 AM, when queried regarding Patient #31 not being seen for a week according to the clinical record, Admin #1 indicated the missed visits are because of staffing. Findings include: On 01-03-2023 at 10:15 AM, Administrator #1 (Admin #1) provided a November 2021, Union Healthcare Service policy titled, "Care Planning Process, Policy No. 4-001.1". The policy indicated but was not limited to, "...A written plan of care will be initiated within five days of start of care and updated at least every 60 days or as patient's condition warrants...". On 01-03-2023 at 11:30 AM, a clinical record review of Patient #5 was completed for the certification period 12-17-2022 through 02-14-2023. Patient #5 had a start of care (SOC) dated of 08-19-2022. The patient's goals within the POC were not updated for the current certification period and were dated from the SOC on 08-19-2022. On 01-05-2023 at 11:00 AM, a clinical record review of Patient #26 was completed for the certification period 11-24-2022 through 01-22-2023. The patient's goals within the POC were not updated for the current certification period and were dated for a previous certification period of 07-26-2022. On 01-05-2023 at 11:40 AM, a clinical record review of Patient #27 was completed for the certification period 11-30-2022 through 01-28-2023. The patient's goals within the POC were not updated for the current certification period and were dated for a previous certification period of 08-01-2022.

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 implement its policy that required the plan of care to be individualized to include all pertinent diagnoses, all supplies, and equipment necessary to meet the patient's needs in their home, failed to ensure documentation of patients' specific needs, nutritional requirements, accurate medications and treatments, all safety measures, services being provided by outside agencies/facilities, all necessary interventions, specific education and training provided, measurable outcomes and goals identified by the home health agency, discharge plans, and the patient for 15 of 25 active patient records reviewed (Active Patients #1, 2, 4, 7, 9, 10, 11, 18, 21, 22, 23, 24, 25, 26, and 30) and 2 of 7 inactive patients. (Inactive Patient: 29 and 31) Findings Include: During a closed record review of Patient #31 on 1-9-2023 at 9:00 AM, the plan of care (POC), titled, “Home Health Certification and Plan of Care (Resumption of Care Following Hospital Stay)”, for the initial certification period of 10-13-2022 to 12-11-2022 was reviewed. Patient #31 had a diagnosis of an open wound on the left thigh and the right thigh. For the Skilled Nursing (SN) responsibilities, the POC had stated the SN was to provide wound treatment for the patient. The POC failed to evidence, under Durable Medical Supplies (DME), supplies necessary for a patient with wound care. The subtitle titled “Goals” stated, “Patient’s personal healthcare goal(s): Client will able to follow instructions given above. Nursing. Occupational Therapy will be performed and a plan of care to increase functional independence with ADLS (SIC- Activities of Daily Living) and IADLS (SIC- Instrumental Activities of Daily Living)… Physical Therapy evaluation will be performed and a plan of care to increase functional independence will be established and countersigned by physician…” The subtitle, “Orders for Discipline and Treatment”, indicated patient-centered goal for Physical Therapy only. The goal stated, “Patient will demonstrate ability to follow home exercise program and will progress independently in home exercise, balance/ coordination, transfer training, kegel exercise for incontinence management, and to establish a home exercise program…” The agency failed to evidence individualized goals for Patient #31. On 01-04-2023 at 9:00 AM, a review of the clinical record of Patient #1 was reviewed for the plan of care initial certification of 12-12-2022 to 02-09-2023. Patient #1 had a principal diagnosis of Type 2 Diabetes (a disease impacting blood sugar levels). The plan of care did not indicate DME necessary for a patient with Diabetes. On 01-10-2023 at 12:30 PM, a review of Patient #29’s record, a discharged patient, was completed. The plan of care for the initial certification period of 10-25-2022 to 12-23-2022 indicated the patient had a diagnosis for Type 2 Diabetes. The plan of care did not indicate the necessary DME a patient with Diabetes requires. On 01-04-2023 at 10:00 AM, a review of Patient #11’s record, a patient on hold, was completed. The plan of care for the initial certification period of 10-16-2022 to 11-14-2022 indicated the patient had a diagnosis for Type 2 Diabetes. The plan of care did not indicate the necessary DME a patient with Diabetes requires. 1. A review of the clinical record for Patient #2, the start of care date of 10-27-2022, contained a plan of care for the initial certification period of 10-27-2022 to 12-25-2022. The plan of care indicated the following diagnoses: Non-pressure chronic ulcer other part of left foot with fat layer exposed, type 2 diabetes (a disease that affects the body’s way to process sugar) with other diabetic neurological complications, essential hypertension (high blood pressure), Non-pressure ulcer of the left heel and midfoot with fat layer exposed, and peripheral vascular disease (lack of blood flow causing pain to the lower extremities). The orders for discipline and treatment indicated a Skilled Nurse (SN) 3 times a week for 9 weeks for wound dressing changes. The wound care orders were for the SN to cleanse both wounds to the left foot with wound cleanser, apply betadine dressing wet to dry, wrap in Kerlix, and Coban, and secure with tape. The section titled, “Durable Medical Equipment (DME)/Supplies,” indicated the patient had a wheelchair and grab bars, but failed to list a glucometer, lancets, glucometer strips, insulin pen needles, wound cleanser, betadine, 4 x4 gauzes, kerlix gauze wrap, Coban and tape. The section titled, “Goals,” indicated the patient’s personal goal, “To understand regarding instructions and teaching,” which failed to be an individualized patient-specific goal. The section titled, “Rehabilitation Potential and Discharge Plan,” indicated the patient, “Discharge When: Caregiver demonstrates the ability to manage wounds at home…” Patient #2 lives alone with no willing or available caregiver. The plan of care failed to list patient-specific call parameters for blood sugars, blood pressure, oxygen saturation, respirations, pulse, and temperature. 2. A review of the clinical record for Patient #4, the start of care date of 10-11-2022, contained a plan of care for the initial certification period of 10-11-2022 to 12-09-2022. The plan of care indicated the following diagnoses: atherosclerosis heart disease of the native coronary artery without angina pectoris (narrowing of the arteries without chest pain), and essential hypertension, but failed to list peripheral vascular disease, diabetes mellitus edema of the lower extremities. The section titled, “DME/Supplies,” listed cane, toilet seat, tub/shower bench, and walker, but failed to list glucometer, lancets, glucometer strips, and insulin pen needles. The section titled, “F2F Addendum (Admission Narrative),” indicated Patient #4 lives alone with no available caregiver, had a diagnosis listed as type 2 diabetes mellitus, the patient took blood sugar ranging from 100-140, and is waiting on a new blood sugar glucometer machine, administered their own insulin via sliding scale insulin pens, and the patient had treated their own lower extremity open area due to a fall with triple antibiotic cream three times a day, and had bilateral lower extremity edema. The plan of care failed to list patient-specific call parameters for blood sugars, blood pressure, pulse, and temperature. The section titled, “Rehabilitation Potential and Discharge Plan,” indicated the patient, “Discharge When: Caregiver demonstrates the ability to manage wounds at home…” Patient #4 lives alone with no willing or available caregiver. A review of a physician-signed agency document titled, “Union Home Health Services Home Health Order Set and Documentation of Face to Face Encounter,” indicated Patient #4 had the medical conditions peripheral vascular disease (PVD), diabetes mellitus, lower extremity ulceration, and lower extremity swelling. A review of the plan of care for the recertification period of 12-10-2022 to 02-07-2023, indicated the following diagnoses: atherosclerosis heart disease of the native coronary artery without angina pectoris, and essential hypertension, hyperlipidemia iron deficiency anemia, and localized edema, but failed to list peripheral vascular disease, type 2 diabetes mellitus. The section titled, “DME/Supplies,” listed cane, elevated toilet seat, grab bars, nebulizer, tub/shower bench, and rollator walker, but failed to list glucometer, lancets, glucometer strips, and insulin pen needles. The medication list failed to list any medication used with a nebulizer. The plan of care failed to list patient-specific call parameters for blood sugars, blood pressure, pulse, oxygen saturation, respirations, and temperature. 3. A review of the clinical record for Patient #10, the start of care date of 11-25-2022, contained a plan of care for the initial certification period of 11-25-2022 to 01-23-2023. The plan of care indicated the following diagnoses: type 2 diabetes mellitus without complications, systemic lupus erythematosus (the immune system attacks its own tissues causing joint pain and fatigue), and essential hypertension. The “Medications,” section, indicated, “There is no data for this section.” The section titled, “Function Limitations,” indicated that Patient #10 had bladder incontinence and endurance. The section titled, “DME/Supplies,” listed, a walker, tub/shower bench, but failed to list incontinent supplies, failed to list glucometer, glucometer strips, and lancets. The plan of care section titled, “Goals,” indicated, “Patients foley catheter will remain patent during this episode and be free of signs or symptoms of Urinary Tract Infection (UTI).” The patient is incontinent. The section titled, “Rehab Potential,” was left blank. The plan of care failed to list patient-specific call parameters for blood sugars, blood pressure, pulse, oxygen saturation, respirations, and temperature. 4. A review of the clinical record for Patient #18, the start of care date of 11-08-2022, contained a plan of care for the initial certification period of 11-08-2022 to 01-06-2023. The plan of care indicated the following diagnoses: personal history of transient ischemic attack (TIA) (mini-strokes caused by a temporary disruption of blood supply to the brain), and cerebral infarct without residual deficits (lack of blood flow to the brain depriving the brain of oxygen with no long-term effects), and weakness, but failed to list seizure disorder A review of a physician-signed agency document titled, “Union Home Health Services Home Health Order Set and Documentation of Face to Face Encounter,” indicated that Patient #18, had medical conditions of a history of stroke and seizure disorder. The “Functional limitations,” section, indicated that the patient had bladder incontinence. The section titled, “DME/Supplies,” indicated that the patient used a walker and grab bars but failed to list incontinence supplies. The plan of care failed to address seizure interventions. The plan of care failed to list patient-specific call parameters for blood pressure, oxygen saturation, respirations, pulse, and temperature. 5. A review of the clinical record for Patient #21, the start of care date of 10-14-2022, contained a plan of care for the initial certification period of 10-14-2022 to 12-12-2022. The plan of care indicated the following diagnoses: malignant neoplasm of the prostate (cancer of the prostate), essential hypertension, depression, insomnia, and other abnormalities of the gait, but failed to list diagnoses for the medication Enoxaparin (a medication injection used to prevent blood clots the lower extremities) 40 milligrams(mg)/0.4 milliliters(ml) daily subcutaneous, Bisacodyl ( a medication used to treat constipation) 10 mg rectal suppository 1 suppository day as needed (PRN) listed by mouth, failed to list correct route, which should be listed per rectum, and Fleets Enema ( a medication used to treat constipation) 19-1 gram 133 ml daily prn per rectum. The section titled, “Psychosocial Status,” was left blank, and failed to list insomnia and depression. The sections titled, “Homebound Narrative,” and “medical Necessity,” indicated, “There is no data for this section.” The plan of care failed to list patient-specific call parameters for blood pressure, oxygen saturation, respirations, pulse, and temperature. 6. A review of the clinical record for Patient #22, the start of care date of 10-29-2022, contained a plan of care for the initial certification period of 10-29-2022 to 12-12-2023. The plan of care indicated the following diagnoses: essential hypertension, unspecified sequelae of unspecified cerebrovascular disease, continuous leakage, and cocaine abuse, but failed to list the diagnosis for the medication Levothyroxine (a medication used to treat hypothyroidism) 125 mcg oral daily, and Docusate 100mg capsule 3 times a day PRN for constipation. The plan of care in the section titled, “DME/Supplies,” indicated a wheelchair, tub/shower bench, and grab bars, but failed to list incontinent supplies The plan of care failed to list patient-specific call parameters for blood pressure, pulse, oxygen saturation, respirations, and temperature. 7. A review of the clinical record for Patient #23, the start of care date of 11-30-2022, contained a plan of care for the initial certification period of 11-30-2022 to 01-28-2023. The plan of care indicated the following diagnoses: acute respiratory failure with hypoxia (not enough oxygen in the blood from the lungs), morbid obesity, essential hypertension, type 2 diabetes mellitus, personal history of other venous thrombosis and embolisms (blood clots), and pneumonia. The plan of care in the section titled, “DME/Supplies,” was blank, and failed to list incontinent supplies, walker, wheelchair, glucometer, glucometer strips, lancets, INR (International Normalized Ratio) machine (a machine that checks how long it takes for the blood to clot), and INR strips. The “Medications” section indicated, “There is no data for this section.” The plan of care contained a section titled, “F2F Addendum (Admission Narrative),” which indicated that Patient #23 used a walker, is on Warfarin ( a medication that thins the blood), no dose, route, or frequency was listed, INR is taken 2 times a week, no information on whom is handling adjustments to medication and INR results, lives with their spouse, and is incontinent of the bladder. The plan of care failed to list patient-specific call parameters for blood sugars, blood pressure, pulse, oxygen saturation, respirations, and temperature. 8. A review of the clinical record for Patient #24, the start of care date of 09-16-2022, contained a signed plan of care for the initial certification period of 09-16-2022 to 11-14-2022. The plan of care indicated the following diagnoses: essential hypertension, type 2 diabetes mellitus with diabetic neuropathy (nerve damage affecting legs and feet), heart failure (the heart cannot pump or fill adequately), chronic obstructive pulmonary disease (airflow blockage, and breathing difficulties), and unspecified asthma, but failed to list weakness and new onset of atrial fibrillation. The section titled, “DME/Supplies,” indicated grab bars, walker, wheelchair, and other prostheses, but failed to list a glucometer, glucometer strips, lancets, and insulin pen needles. The section titled, “Medical Necessity,” indicated’ “There is no data for this section.” The plan of care failed to list patient-specific call parameters for blood sugars, blood pressure, pulse, oxygen saturation, respirations, and temperature. A review of a referral document dated 09-09-2022, titled, “Ambulatory referral to Home Health (initial) (Order),” from Entity 1, a healthcare provider, indicated, the needed findings and support for services for orders were due to weakness and new-onset atrial fibrillation (an irregular often rapid heart rate causing poor blood flow). 9. A review of the clinical record for Patient #25, the start of care date of 12-19-2022, contained a signed plan of care for the initial certification period of 12-19-2022 to 02-16-2023. The plan of care indicated the following diagnoses: bilateral osteoporosis resulting in hip dysplasia (bones of the hip joint are not aligned), depression, unspecified atrial fibrillation, and anemia. The plan of care contained a section titled, “DME/Supplies,” that indicated a walker, and a wheelchair, but failed to list a nebulizer, as needed for Ipratropium-Albuterol 0,5mg/3ml inhalation solution 1 vial every 4 hours as needed for shortness of breath (SOB)inhaled was listed in the section titled, Medications.” The plan of care failed to list patient-specific call parameters for blood pressure, pulse, oxygen saturation, respirations, and temperature. IAC 410 15-13-1(a)(1)(D)(ii, iii, v, vi, ix, xii) 1. A review of a Union Healthcare Services Inc. policy revised date November 2021, titled “Care Planning Process” Policy No. 4-001.1, was received from the Administrator on 1-6-23. The policy indicated, “…The plan of care will be developed or revised within five (5) working days of initiation of each service or of the assessment of the patient…The patient-specific clinical plan of care includes: …F. Homebound Status. G. Measurable outcomes and goals…H. Patient’s mental, psychosocial, and cognitive status. I. Functional limitations…K. Safety measures…L. Nutritional requirements. M. Mediations including dose/frequency/route. N. Orders for specific home health service needs…. treatments and procedures, including amount/frequency/duration. O. Patient-specific interventions and education. P. Supplies and equipment…Q. Discharge or referral plans. R. Patient and caregiver education and training…S. Frequency and duration of visits. T Prognosis. U. Rehabilitation potential…”. On 01-03-2023 at 10:30 AM, the clinical record of Patient #7 was reviewed for the certification period 10-07-2022 through 12-05-2022. Patient #7 had a diagnoses of Diabetes (a disease impacting blood sugar levels) and a pressure ulcer of the right lower extremity. There was no durable medical equipment (DME) listed on the plan of care (POC) for a patient with Diabetes or needing wound care. On 01-04-2023 at 10:15 AM, the clinical record of Patient #9 was reviewed for the certification period 12-06-2022 through 02-03-2023. Patient #9 had a diagnoses of Diabetes and Chronic Obstructive Pulmonary Disease (COPD) (a disease constricting the airways). The POC did not include diabetic supplies or the oxygen used by the patient. On 01-05-2023 at 10:30 AM, the clinical record of Patient #26 was reviewed for the certification period 11-24-2022 through 01-22-2023. Patient #26 had a diagnoses of Diabetes and Hypertension (high blood pressure). The POC did not include diabetic supplies. On 01-11-2023 at 10:15 AM, the clinical record of Patient #30 was reviewed for the certification period 11-03-2022 through 12-27-2022. Patient #30 had a diagnoses of Diabetes. The POC did not include diabetic supplies.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure the Registered Nurses (RN) had orders in place before performing wound care treatment in 1 (Patient #2) of 1 active patients receiving wound care. Findings Include: 1. A review of an undated agency policy, titled, “Telephone/Verbal Orders,” Policy No. 8013, was received from the Administrator on 1-6-23. The policy indicated, “Purpose: To provide care, treatment and/or services according to a state licensed physician or licensed practitioner’s orders or prescriptions...Union Health Care Services LLC HHA provides care, treatment and/or services to patients in accordance with current physician orders…” 2. During a home visit on 01-04-2023, at 10:15 AM, at Patient #2’s residence, the Registered Nurse (RN), RN #3, was observed providing wound care. RN #3 performed hand hygiene, donned gloves and removed the Coban dressing and gauze wrap from the patient’s left plantar and heel wounds. After removing the soiled dressings, the RN cleansed the wounds with a wound cleanser and 4x4 gauze without changing gloves or hand hygiene and discarded the 4x4s in the plastic trash bag. RN #3 then applied from a container labeled “Medi honey” to the two telfa dressings and then applied the telfa dressings to the left plantar and left heel wounds without performing hand hygiene and donning new gloves. After applying the telfa dressings, gauze cling wrap and Coban wrap were used to secure the dressing to the left foot dressings. The RN obtained the patient’s scissors from the end table next to the patient’s chair and cut the Coban without cleaning the scissors. The RN then picked up thrash trash, discarded their gloves, and performed hand hygiene. RN #3 and Patient #2 indicated that the RN had changed the treatment from Betadine to Medi honey for the last couple of treatments. RN #3 failed to perform the wound care as ordered per the signed plan of care. A review of the clinical record for Patient #2, with a start of care on 10-27-2022, contained an agency document titled, “Home Health Certification and Plan of Care,” for the initial certification period of 10-27-2022 to 12-25-2022, signed by the physician. The initial plan of care evidenced the patient’s diagnoses as non-pressure chronic ulcer other part left foot with fat layer exposed, type 2 diabetes with other diabetic neurological complications, essential (primary) hypertension, peripheral vascular disease, non-pressure chronic ulcer of left heel with midfoot with fat layer exposed. The orders for discipline and treatment indicated a Skilled Nurse (SN) 3 times a week for 9 weeks for wound dressing changes. The wound care orders were for the SN to cleanse both wounds to the left foot with wound cleanser, apply betadine dressing wet to dry, wrap in Kerlix, and Coban, and secure with tape. The plan of care was electronically signed by RN #3 on 10-27-2022 and by the physician on 11-15-2022. A review of an agency document “SN Wound Care Visit,” dated 12-09-2022, electronically signed by RN #1, indicated in the section titled, “Visit Narrative,” indicated but was not limited to, “…Applied Betadine over calcium alginate to wound bed….” RN #1 failed to follow orders per the signed plan of care. During an interview on 01-04-2023 at 2:45 PM, Person 2, the physician for Patient #2, indicated they had not changed Patient #2’s wound care orders from Betadine to Medi honey or been notified by the agency of the patient’s wound measurements or changes. The physician requested a phone call from the nurse treating the patient with updated wound progress and pictures. 3. During an interview on 01-04-2023 at 2:50 PM, the Administrator/Director of Nursing, Admin 1, confirmed the RNs are to follow the plan of care, and wound care cannot be changed without a physician’s order. IAC 410 17-13-1(a)

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patient’s clinical record included information about the services the patient received from other agencies and failed to ensure they coordinated care delivery to meet the patient’s needs for 5 of 5 active patient records reviewed receiving outside services. (Patients #1, 2, 15, 22, 23) Findings Include: During a home visit on 1-4-2023 at 1:09 PM, at Patient #1's residence, observed Person #58, a caregiver, open the door for Physical Therapist (PT) #1. Person #58 was at the patient's residence for the entire PT visit. Person #58, he/she had stated they were a paid caregiver from Entity #12. During a phone interview on 1-5-2023 at 11:13 AM, with Entity #12, when queried regarding the agency's communication with the entity, Entity #12 had stated, "no one has ever contacted us from the agency about what care we are providing for the patient or told us of the care they are providing the patient." State Code IAC 410-17-14-1(a)(1)(F) . 1. A review of a Union Healthcare Services Inc. policy revised date November 2021, titled “Care/Service Coordination” Policy No. 4-067.2, was received from the Administrator on 1-3-23. The policy indicated but was not limited to “…4. Care Coordination will include, but not be limited to…F. Timely documentation of coordination of care activities…I. Integration of services, whether services are provided directly or under the arrangement, to assure identification of patient needs and factors that could affect patient safety and treatment effectiveness…J. Care of care delivery to meet the patient’s needs and involve the patient…8. Written evidence of care coordination may be found in the plan of care/service, case conference summary forms, and clinical notes in the patient’s clinical record….” 2. During the Entrance Conference on 1-3-23 at 9:15 AM, when queried regarding shared patients and coordination of care, the Administrator/Director of Nursing, Admin 1, the agency did not have any shared patients. Admin 1 further indicated they only had shared referrals with another agency that could not provide skilled services. 3. During a home visit on During a home visit at Patient #2’s residence on 01-04-23 at 10:16 AM, observed the Registered Nurse (RN), RN #3, complete wound care. Patient #2 indicated that the Personal Care Agency (PSA), Entity 3, was sending out a different attendant to help them this afternoon. During a daily conference on 1-4-23 at 3:52 PM, the Administrator/Director of Nursing, Admin 1, confirmed there should be coordination of care in the communication notes or on the Conference Notes when reviewing Patient #4’s home visit. 4. During a phone interview on 1-4-23 at 1:39 PM, Patient #15 confirmed they went to outpatient therapy at Entity 4. Patient #15 further indicated that they received 40 hours of waiver service for housekeeping, errands, meals, shopping, and care assistance from Entity 6, a PSA agency. The agency failed to evidence documentation of care coordination in Patient #15’s plan of care, clinical notes, or case conferences. During an interview on 1-5-23 at 1:45 PM, the owner of Entity 6, Peron 7, confirmed that Patient #15 was receiving services from their agency and that Union Healthcare Services did not reach out to them to coordinate care. 5. During a phone interview on 1-10-23 at 3:50 PM, Patient #22 confirmed they had waiver services through Entity 22, a PSA agency. Patient #22 stated, “My niece works for them and takes care of me.” The agency failed to evidence documentation of care coordination in Patient #22’s plan of care, clinical notes, or case conferences. During an interview on 1-11-23 at 9:40 AM, the personal care attendant for Entity 22, Person 26, indicated they worked 35 hours a week for Entity 22 with Patient #22. Person 26 stated, “No, I did not know about Union Healthcare Services. This is the first time I have heard of this.” 5. During a phone interview on 1-10-23 at 11:34 AM, Patient 23’s caregiver, Person 27, indicated they provided full-time care to Patient #23. Person 27 stated, “I am a paid family caregiver for Entity 54.” The agency failed to evidence documentation of care coordination in Patient #22’s plan of care, clinical notes, or case conferences.

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the agency failed to provide the patients with a visit schedule in 3 of 3 patient home visits. (Patients #1, 2, and 9) Findings Include: 1. A review of a Union Healthcare Services Inc. policy revised date November 2021, titled “Care Planning Process” Policy No. 4-001.1, was received from the Administrator on 1-6-23. The policy indicated, “… 17. The organization shall provide the patient and caregiver with a copy of written instructions outlining: … A. Visit schedule, including the day of the week, frequency of visits by personnel and personnel acting on behalf of the organization ...” 2. During a home visit at Patient #2’s residence on 01-04-23 at 10:16 AM, observed the Registered Nurse (RN) complete wound care. A review of Patient #2’s agency booklet titled “Home Health Admission Booklet” failed to provide a visit schedule for Patient #2’s plan of care, making them aware of the staff providing care, including the day of the week with the frequency. 3. During a home visit at Patient #1’s residence on 01-04-23 at 9:30 PM, observed the Physical Therapist (PT). A review of Patient #1’s agency booklet titled “Home Health Admission Booklet” failed to provide a visit schedule for Patient #1’s plan of care, making them aware of the staff providing care, including the day of the week with the frequency. 4. During a home visit at Patient #9’s residence on 01-04-23 at 10:16 AM, observed the Registered Nurse (RN) complete skilled care. A review of Patient #9’s agency booklet titled “Home Health Admission Booklet” failed to provide a visit schedule for Patient #9’s plan of care, making them aware of the staff providing care, including the day of the week with the frequency. During an interview on 1-9-23 at 11:50 AM, the Administrator/Clinical Manager stated, “The patients should get a visit schedule and plan of care, but they do not get them.”

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the agency failed to provide the patients with medication schedules and instructions in 3 of the 3 home visits. (Patients #1, 2, and 9) Findings Include: 1. A review of a Union Healthcare Services Inc. policy revised date November 2021, titled, “Care Planning Process,” Policy No. 4-001.1, was received from the Administrator on 01-06-2023. The policy indicated, “…17. The organization shall provide the patient and caregiver with a copy of written instructions outlining: …B Patient medication schedules/instructions, including medication name, dosage, and frequency…1. Instructions will be written in plain language the patient can understand...” 2. During a home visit at Patient #1’s residence on 01-04-2023 at 9:30 PM, observed the Physical Therapist (PT). A review of Patient #1’s agency booklet titled, “Home Health Admission Booklet,” failed to provide a list of Patient #1’s current medication schedules and instructions in layman’s terms. 3. During a home visit at Patient #2’s residence on 01-04-2023 at 10:16 AM, observed the Registered Nurse (RN) complete wound care. A review of Patient #2’s agency booklet titled, “Home Health Admission Booklet,” failed to provide a list of Patient #2’s current medication schedules and instructions in layman’s terms. 4. During a home visit at Patient #9’s residence on 01-04-2023 at 10:16 AM, observed the Registered Nurse (RN) complete skilled care. A review of Patient #9’s agency booklet titled, “Home Health Admission Booklet,” failed to provide a list of Patient #9’s current medication schedules and instructions in layman’s terms. During an interview on 01-09-2023 at 11:50 AM, the Administrator/Clinical Manager stated, “The patients should get a medication profile and plan of care for their home folder, but they do not get them.”

Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This ELEMENT is not met as evidenced by: Based on record observation, record review, and interview, the agency failed to provide the name and contact information of the Clinical Manager to the patients and caregivers for 3 (Patients #1, 2, and 9)of 3 patients for whom home visit observations were made. Findings Include: 1. On 10-03-2023, received from Admin 1, an agency booklet titled, “Home Health Admission Booklet.” A review of page 9, titled, “Problem-Solving Procedure,” indicated but was not limited to “…1. Notify the Clinical Manager by phone at (317) 279-6092 from 9:00 a.m. to 5:00 p.m. ….” 2. A review of a Union Healthcare Services Inc. policy revised date November 2021, titled, “Care Planning Process,” Policy No. 4-001.1, was received from the Administrator on 01-06-2023. The policy indicated, “…17. The organization shall provide the patient and caregiver with a copy of written instructions outlining: …E. Name and contact information of the organization’s clinical manager.” 3. During a home visit at Patient #1’s residence on 01-04-2023 at 9:30 PM, observed the Physical Therapist (PT). A review of Patient #1’s agency booklet titled, “Home Health Admission Booklet,” failed to provide the contact information and name of the Director of Nursing, Admin 1. 4. During a home visit at Patient #2’s residence on 01-04-2023 at 10:16 AM, observed the Registered Nurse (RN) complete wound care. A review of Patient #2’s agency booklet titled, “Home Health Admission Booklet,” failed to provide the contact information and name of the Clinical Manager, Admin 1. 5. During a home visit at Patient #9’s residence on 01-04-2023 at 10:16 AM, observed the Registered Nurse (RN) complete skilled care. A review of Patient #9’s agency booklet titled, “Home Health Admission Booklet,” failed to provide the contact information and name of the Director of Nursing, Admin 1. 6. A review of an agency document “Governing Body Minutes and QAPI Meeting,” dated 12-22-2022, evidenced the governing body appointing Admin 1, as the Director of Nursing and the Administrator. During an interview during the Entrance Conference on 01-03-23 at 9:15 AM, The Administrator/Director of Nursing, Admin 1, when queried who was the Clinical Manager, confirmed that they were the Clinical Manager.

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 provide a Quality Assessment and Performance Improvement program as noted over 7 of 7 survey days. The cumulative effects of these systemic problems resulted in the home health agency's inability to ensure the provision of quality health care in a safe environment for the Condition of Participation of 42 CFR 484.65, Quality Assessment and Performance Improvement. Findings include: 1. On 01-03-2023 at 10:35 AM, Administrator #1 provided a November 2021, Union Healthcare Services policy titled, “Quality Outcomes/Performance Improvement (QAPI), Policy No. 5-001.4”. The policy indicated but was not limited to, “…Description of indicators/activities to be reported…responsible party, acceptable limits for findings…follow up plan…2. Provide organizational training in the approaches and methods of assessment… A. Be involved in performance improvement teams and activities. B. Promote communication and coordination of performance improvement activities…Trends noted…will be reported through the Governing Body…5. Results of performance improvement will be communicated with all staff via, intranet, newsletters, email…”. 2. On 01-03-2023 at 1: 45 PM, Administrator #1 (Admin #1), provided a Governing Body document dated 12-02-2022. The document indicated QAPI data was reviewed. There were no data elements or quality indicators attached to the minutes. 3. On 01-03-2023 at 2:50 PM, Admin #1 was queried about the QAPI process. Admin #1 indicated they tried to establish regular QAPI meetings with the owner, Chief Executive Officer, (CEO) and Corporate Staff #1. Corporate Staff #1 indicated they were not necessary. 4. On 01-06-2023 at 11:05 AM, the Chief Executive Officer, CEO, Corporate Staff #1 was interviewed. Corporate Staff #1 indicated the Administrator was responsible for the QAPI collection and reporting. Corporate Staff #1 was queried about the identification of the Administrator. They indicated it was the Director of Nursing, Administrator #1. They indicated in the past it was a consultant who previously reported this data to the Governing Body. 5. On 01-06-2023 at 11:30 AM, Corporate Staff #4 was queried about their role as a consultant and if they participated in any QAPI program. Corporate Staff #4 indicated they were only involved with training Admin #1 for approximately one month in August, 2022 and it did not include QAPI. Corporate Staff #4 indicated they had never participated in data collection or reporting of QAPI data. 6. On 01-11-2023 at 1:15 PM, Admin #1 provided a binder titled, “Quality Assessment and Improvement”. The binder was empty with no data and filled with blank pages. There was no tracking or trending of any quality indicators. There were no performance improvement plans initiated. 410 IAC 17-12-2 (a)

Infection prevention and control CFR(s): 484.70 Condition of Participation: Infection prevention and control. The HHA must maintain and document an infection control program which has as its goal the prevention and control of infections and communicable diseases. This CONDITION is not met as evidenced by: Based on observation, record review, and interview the agency failed to maintain an infection control program for the goal of prevention and control of infections and communicable diseases. The agency failed to ensure proper hand hygiene and infection control in 3 of 3 home visits (G 682). The agency failed to keep a current record of COVID-19 infections for staff, patients, and respective family members and failed to evidence data for tracking trends and provided direction for follow-up with the individuals infected with COVID-19 (G 684.)The agency failed to ensure staff had access to and knowledge of appropriate personal protective equipment (PPE). The agency failed to meet proper infection control standards for all 42 of 42 active patients and 29 of 29 employees. The cumulative effects of these systemic problems resulted in the home health agency's inability to ensure the provision of quality health care in a safe environment for the Condition of Participation of 42 CFR 484.70, Infection Control. Findings include: 1. On 1-11-2023 at 9:35 AM, a policy titled, “Exposure to Coronavirus (2019-NCOV): Disease Response and Management”, dated 2-17-2020 was provided by Admin #1. The policy indicated but was not limited to, “…the policy was used to supplement the agency’s existing policies and procedures for infection control and prevention to adhere to the recommendations of the CDC for responses to COVID-19 exposure… “5. Employees involved in the care of confirmed 2019-nCOV should use standard precautions, contact precautions, airborne precautions, and use eye protection (goggles or face shield). Hand hygiene- clinicians should perform hand hygiene before and after all patient contact, contact with potentially infectious material, and before putting on and upon removal of PPE (SIC- personal protective equipment), including gloves. Gloves- Perform hand hygiene, then put on clean, non-sterile gloves upon entry into the patient room or care area. Change gloves if they become torn or heavily contaminated. Remove and discard gloves if they become torn or heavily contaminated. Remove and discard gloves when leaving the patient room or care area, and immediately perform hand hygiene....” 2. On 1-11-2023 at 1:03 PM, a policy titled “COVID Immunization policy,” was provided by Admin #1. The policy was not dated and approved by the governing body. The policy indicated but was not limited to, “…required all employees to be vaccinated unless the employee requested an exemption for: …religious reasons, medical condition which their physician recommends that they not take the vaccination… a written explanation from their physician… will be placed into their personnel file….” 3. On 1-11-2023 at 9:35 AM, an agency document titled “Office COVID19 Guidelines” was provided by Admin #1. The document was dated for 6-17-2020. The policy indicated but was not limited to, “Screen each office employee… field staff member and visitor for elevated temperature and record on s/sheet. Fever of 100.4 or more reported to administrator or DON [Director of Nursing] immediately… Wear mask when interacting with outside people, even if they have a mask on… Mask to be worn to go beyond reception desk....” 4. A review of The Centers for Disease Control (CDC) website was found to be last updated on 9-23-2022. Infection control guidance for COVID-19. Retrieved from https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html. The guidelines indicated but were not limited to, “… Ensure everyone is aware of recommended IPC [Infection Prevention and Control] practices in the facility… Establish a process to make everyone entering the facility aware of recommended actions to prevent transmission to others if they have any of the following three criteria: 1) a positive viral test for SARS-CoV-2, 2) symptoms of COVID-19, or 3) close contact with someone with SARS-CoV-2 infection (for patients and visitors) or a higher-risk exposure (for healthcare personnel (HCP))… performance of pre-procedure or pre-admission testing is at the discretion of the facility… Performance of expanded screening testing of asymptomatic HCP without known exposures is at the discretion of the facility….” 5. The agency failed to provide a current infection control program which established the goal of preventing and controlling infection and communicable diseases. 6. The agency failed to provide a current policy regarding the changes in COVID-19 guidelines according to CMS. 7. The facility failed to ensure their current policy regarding COVID-19 guidelines was upheld by staff and visitors, as observed by no signage upon entry into the facility with visitation restrictions and screening procedures. During the entire survey, upon entry, surveyors were never screened for the 7 of 7 days at the facility. 8. A review of governing body minutes dated 12-02-2022, the document indicated, “review of infection control reports completed with no noted infection control issues. Will continue annual infection control education with staff on specific infection control plans…”. 9. The agency failed to provide the infection control reports mentioned in the governing body minutes dated 12-2-2022. 10. A review of the agency’s infection control binder on 01-09-2023 at 9:35 AM evidenced no screening of employees at the agency’s office from October 2022 to January 2023. 11. The agency failed to provide tracking and trending of infection control data and COVID-related infections through the agency’s Quality Assessment Performance Improvement (QAPI) plan and the agency’s infection control binder. QAPI was reviewed on 01-03-2023 at 12:05 PM. The infection control binder was reviewed on 01-11-2023 at 9:35 AM. 12. Requested in-service training for all employees on 01-09-2023 at 10:15 AM and dementia training for all employees. 13. During an interview on 1-9-2023 at 1:40 PM with Administrator (Admin) #3, when queried regarding the 12-hour in-service training they confirmed no education was provided to the staff in the last year besides the dementia training. 14. During an interview with Admin #1 on 1-11-2023 at 1:10, when queried regarding the date the COVID Immunization policy was made, Admin #1 stated, “the policy was just made.” 15. During an interview with Admin #1 on 1-11-2023 at 2:30 PM, Admin #1 was queried regarding COVID-19 Focused Infection Control. When queried regarding the agency’s screening process for visitors, Admin #1 indicated the agency takes temperatures and screens. When queried regarding whether the surveyors were screened, Admin #1 confirmed the surveyors were not screened upon entering the facility. When queried regarding a transmission-based precaution sign on the door, Admin #1 indicated they took the sign off the door when the door was being repainted, Admin #1 confirmed the sign is not currently on the door. When queried regarding how staff obtains PPE, Admin #1 indicated the staff was informed where to find supplies in orientation. Admin #1 was informed of staff purchasing their own equipment and PPE.

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 infection control practices were upheld according to the agency’s policy in 3 of 3 home visits for hand hygiene and gloving. (Patients: #1, 2, and 9) Findings Include: During a home visit on 1-4-2023, at 10:15 AM, at Patient #2’s residence, the Registered Nurse (RN), RN #3, was observed providing wound care. RN #3 performed hand hygiene, donned gloves and removed the Coban dressing and gauze wrap from the patient’s left plantar and heel wounds. After removing the soiled dressings, the RN cleansed the wounds with a wound cleanser and 4x4 gauze without changing gloves or hand hygiene and discarded the 4x4s in the plastic trash bag. RN #3 then applied from a container labeled “Medi honey” to the two telfa dressings and then applied the telfa dressings to the left plantar and left heel wounds without performing hand hygiene and donning new gloves. After applying the telfa dressings, gauze cling wrap and Coban wrap were used to secure the dressing to the left foot dressings. The RN obtained the patient’s scissors from the end table next to the patient’s chair and cut the Coban without cleaning the scissors. The RN then picked up thrash trash, discarded their gloves, and performed hand hygiene. The agency failed to ensure the RN practiced infection control for hand hygiene and gloving per the agency policies and CDC guidelines. During a daily conference on 1-11-2023 at 2:40 PM, the Administrator/Director of Nursing, Admin 1, confirmed that hand hygiene should be completed after removing gloves. Admin 1 further confirmed that gloves should be removed after removing a soiled dressing, and again, the clinician should perform hand hygiene, then don new gloves to apply the new dressing. 410 IAC 17-12-1(m) On 01-04-2023 at 9:20 AM, RN #2 was observed assessing Patient #9 during a home visit. RN #2 wore a face mask below their nose during the home visit. RN #2 was observed administering Insulin (medication for Diabetes) via a Kwik Pen (needle for injecting Insulin) for Patient #9. RN #2 completed an Accuchek (machine used for testing blood sugar) prior to administering the patient's Insulin. RN #2 failed to complete hand hygiene and don gloves prior to the administration of the medication. Findings include: 1. On 1-3-2023 at 2:36 PM, a policy titled “Bag technique” was provided by Administrator (Admin) #1. The policy indicated but was not limited to, “…Bag Technique 2. Hand washing will always be completed before opening the bag 3. After hand washing, the supplies and/or equipment needed for the visit will be removed from the bag. 4. The bag will contain a designated clean and dirty area. The clean area contains unused or cleaned supplies/equipment, and the dirty area is designated for contaminated materials. 5. When the visit is completed… equipment… cleaned using alcohol, soap and water, or other appropriate solution, hands… washed, and equipment and supplies… returned to the bag. 6. Hands will be decontaminated prior to returning clean equipment to bag….” 2. On 1-3-2023 at 2:36 PM, a policy titled “Infection Control/Expanded Precautions” was provided by Admin #1. The policy indicated but was not limited to, “… Policy: In addition to standard precautions, organization personnel will follow strict specifications when caring for patients with infectious diseases and those with bed bug infestation… Guidelines: 3. Specifications for Contact Precautions…E. Clean and disinfect contaminated patient care items, equipment, and surfaces on a daily basis. G. … gloves should be used with patient contact. H. Gloves must be removed prior to leaving the patient’s room, and hands should be washed immediately using an antimicrobial soap and water….” 3. On 1-6-2023 at 9:30 AM, a policy titled “Hand Hygiene” was provided by Admin #1. The policy indicated but was not limited to, “…Policy: When hands are visibly dirty… they should be washed with either a non-antimicrobial or antimicrobial soap and water. When hands are not visibly soiled, they should be washed using an alcohol-based hand rub… An alternate to use of an alcohol based hand rub is to wash hands with an antimicrobial soap and water… Procedure: Hand decontamination with an alcohol-based hand rub… 1. Apply alcohol-based hand rub product to palm of (1) hand and rub hands together, covering all surfaces of hands and fingers (including under nails) until hands are dry… 3. Hand decontamination using an alcohol-based hand rub should be performed: A. Before having direct contact with patients… C. After contact with a patient’s intact skin (when taking a pulse, blood pressure or lifting a patient). D. After contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings, if hands are not visibly contaminated. E. When moving from a contaminated body site to a clean body site during patient care. F. After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. G. After removing gloves… Hand washing with Soap and Water… 1. Wet hands and apply the soap, and rub hands together vigorously… 2. Wash hands for at least 20 seconds covering all surfaces of the hands and fingers… 5 Hand washing using soap and water should be performed…C. When hands are visibly dirty or contaminated…” 4. Centers for Disease Control last updated January, 2021. When to Perform Hand Hygiene. Retrieved from https://www.cdc.gov/handhygiene/providers/index.html indicated “Use an Alcohol-Based Hand Sanitizer: Immediately before touching a patient. Before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices. Before moving from work on a soiled body site to a clean body site on the same patient. After touching a patient or the patient’s immediate environment. After contact with blood, body fluids or contaminated surfaces. Immediately after glove removal… Wash with Soap and Water: When hands are visibly soiled. After caring for a person with known or suspected infectious diarrhea. After known or suspected exposure to spores…When using alcohol-based hand sanitizer: Put product on hands and rub hands together. Cover all surfaces until hands feel dry. This should take around 20 seconds… Techniques for Washing Hands with Soap and Water: The CDC recommends: When cleaning your hands with soap and water, wet your hands first with water, apply the amount of product recommended by the manufacturer to your hands, and rub your hands vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse your hands with water and use disposable towels to dry. Use towel to turn off the faucet. Avoid using hot water, to prevent drying of skin. Other entities have recommended that cleaning your hands with soap and water should take around 20 seconds. Either time is acceptable. The focus should be on cleaning your hands at the right times… When and How to Wear Gloves: Wear gloves, according to Standard Precautions, when it can be reasonable anticipated that contact with blood or other potentially infectious materials, mucous membranes, non-intact skin, potentially contaminated skin or contaminated equipment could occur. Gloves are not a substitute for hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, before touching the patient or the patient environment. Perform hand hygiene immediately after removing gloves. Change gloves and perform hand hygiene during patient care, if: gloves become damaged, gloves become visibly soiled with blood or body fluids following a task, moving from work on a soiled body site to a clean body site on the same patient or if another clinical indication for hand hygiene occurs. Never wear the same pair of gloves in the care of more than one patient, carefully remove gloves to prevent hand contamination….” 5. During a home visit at Patient #1’s residence on 1-4-2023 at 1:09 PM, observed Physical Therapist (PT) #1 not perform hand hygiene prior to entering the patient’s residence. PT #1 had not performed hand hygiene upon removing gloves, before reaching into the bag for more gloves, and before donning new gloves. 6. During an interview on 1-11-2023 at 2:30 with Admin #1, when queried regarding when hand hygiene was to be completed, Admin #1 stated hand hygiene was to be performed after removing personal protective equipment.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on observation, record review, and interview, the agency failed to implement a program to monitor, track, prevent, and control infectious and communicable diseases for 42 of 42 active patients. Findings Include: 1. On 1-3-2023 at 2:36 PM, a policy titled “Improving Organizational Performance” was provided by Admin #1. The policy indicated but was not limited to, “… Policy … Performance improvement results will be utilized to address problem issues, improve the quality of care and patient safety, and will be incorporated into program planning and process design and modifications. All personnel will be active participants in the organization’s performance improvement activities. The Governing Body is responsible for ensuring that the performance improvement program is defined, implemented and maintained, and is evaluated annually …. Procedure: C. Focus on high risk, high volume, and problem-prone areas. Consider incidence, prevalence, and severity of problems in those areas and lead to an immediate correction of any identified problem that directly or potentially threaten the health and safety of patients. D. Adopt a structured framework for performance improvement. The problem solving approach will stress the interrelationship of quality services provided, management activities, and sound business practices as applicable to the organization … E. Identify and set specific outcomes for measurable improvement and acceptable limits for findings …. G. Ensure that the organization adheres to the CMS Conditions of Participation for Quality Assessment and Performance Improvement (QAPI) standards….” 2. On 1-3-2023 at 3:30 PM, a document “Quality Improvement Project,” was provided by Administrator (Admin) #1. The document failed to evidence the agency’s tracking and trending of infection related to the patients, to include COVID-19. 3. On 1-4-2023 at 8:47 AM, a document “Quality Improvement Project,” was provided by Administrator (Admin) #1. The document failed to evidence the agency’s tracking and trending of infection related to the patients, to include COVID-19. 4. A review of governing body minutes dated 12-2-2022, the document indicated, “review of infection control reports completed with no noted infection control issues. Will continue annual infection control education with staff on specific infection control plans …" The minutes failed to address COVID-19 tracking and trending. 5. Upon request, the agency failed to provide the infection control reports referenced in the governing body minutes dated 12-2-2022. The agency did not provide COVID-19 infection reports for patients. 6. During a telephone interview on 1-6-2023 at 11:00 AM with Corporate Staff #1, when queried regarding QAPI, they stated, “it should be in the QAPI binder and quarterly.” The administrator indicated at that time agency patients had contracted COVID since the pandemic began. 7. The agency failed to evidence collection, monitoring, tracking, trending, prevention, and control of infectious and communicable diseases and therefore had no data to report for Quality Assessment and Performance Improvement activities.

Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician or allowed practitioner and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. This CONDITION is not met as evidenced by: Based on observation, record review, and interview, the agency failed to coordinate care within the agency’s interdisciplinary team for the 60-day summary notes (G 706), failed to include the patient and/or caregiver in the plan of care (G 708), and the home health agency failed to provide the services listed on the plan of care ordered by the physician (G 710.) The cumulative effect of these systemic problems resulted in the home health agency's inability to ensure the provision of quality health care in a safe environment for the Condition of Participation of 42 CFR 484.75, Skilled Professional Services. Findings Include: *

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the facility failed to include all health disciplines in the 60-day summary meetings for 3 of 25 active patients and 2 and 7 inactive patients. (active patients: 11, 12, 16 , inactive patients: 29, 31) Findings Include: 1. On 1-3-2023 at 2:36 PM a policy titled, “Case Conference/Progress Summary”, was provided by the Administrator (Admin), Admin #1. The policy indicated but was not limited to, “… Policy: Case conferences will be held at the start of care and at least every 60 days to review and discuss all multidisciplinary cases. Items of discussion will include… type and frequency of service by each discipline involved, changes in the patient’s overall status, problems, possible resolutions, progress toward goals, and any necessary revisions to the plan of care. Case conferences will include utilization review; therefore, all clinicians—both direct and contract personnel—working with patients will participate in case conferences. Procedure: 2…. The Case Manager will lead the conference and discuss: A. Physical status of the patient B. Clinical implications of diagnoses and treatment prescribed C. Patient treatment choices D. Changes in condition since last conference E. Interventions for all disciplines and patient response F. Teaching plan and its effectiveness G. Progress toward goals H. Indications for recertification I. Discharge plan 3. A record will be kept indicating who participated in the meeting and which patients were discussed…”. 2. A review of the clinical record of Patient #31 on 1-9-2023 at 9:00 AM, failed to evidence a 30-day conference involving all parts of the interdisciplinary team: Skilled Nursing (SN), Home Health Aide (HHA), Physical Therapy (PT), and Occupational Therapy (OT). The agency failed to follow the policy involving coordination of care. On 1-10-2023 at 9:00 AM, Office Assistant, Admin #2, confirmed the entire chart was printed off. The electronic medical record and the paper records failed to evidence a conference between the interdisciplinary team. During the entrance conference with the Administrator, Admin #1, on 1-3-2023 at 9:11 AM, Admin #1 indicated the case conferences would be in the communication notes. 3. A review of the clinical record of Patient #16 on 1-4-2023 at 2:30 PM, failed to evidence communication notes regarding the coordination of care and case conferences between the interdisciplinary team. The agency failed to follow their policy involving coordination of care. On 1-5-2023 at 9:40 AM, Office Assistant, Admin #2, confirmed the entire chart was printed off. The electronic medical record and the paper records failed to evidence a conference between the interdisciplinary team. 4. A review of the clinical record of Patient #11 on 1-4-2023 at 10:00 AM, failed to evidence the entire interdisciplinary team being involved in the document titled “30-day Summary/Case Conference” dated 11-11-2022 at 4:00 PM. The 30-day summary was signed by Admin #1, but no HHA had signed the document. The agency failed to follow the policy involving coordination. On 1-6-2023 at 1:00 PM, Admin #5 arrived with the entire paper chart for Patient #11. The electronic medical record and the paper records failed to evidence a conference between the interdisciplinary team. 5. A review of the clinical record of Patient #29 on 1-10-2023 at 12:30 PM, failed to evidence a conference or communication between all the interdisciplinary teams the patient is seen by, from the agency. The agency failed to follow their policy involving coordination of care. On 1-10-2023 at 9:00 AM, Office Assistant, Admin #2, confirmed the entire chart for Patient #29 was printed off. The electronic medical record and the paper records failed to evidence a conference between the interdisciplinary team. 6. A review of the clinical record of Patient #12 on 1-4-2022 at 11:00 AM, failed to evidence an interdisciplinary team conference for the clinicians the patient is seen by, from the agency. The document titled, “60-Day Summary/Case Conference” was signed by Registered Nurse (RN) #1 and dated 12-12-2022 at 1:00 PM and failed to evidence any other team members included in the conference note. The agency failed to follow their policy involving coordination of care. On 1-6-2023 at 1:00 PM, Admin #5 arrived with the entire paper chart for Patient #12. The electronic medical record and the paper records failed to evidence a conference between the interdisciplinary team.

Development and evaluation of plan of care CFR(s): 484.75(b)(2) Development and evaluation of the plan of care in partnership with the patient, representative (if any), and caregiver(s); This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the facility failed to include the patient and/or the patient’s representative in the patient’s plan of care at the time of admission or along the care continuum for 1 of 25 active patients (Active patient: #5) Findings Include: On 01-03-2023 at 11:00 AM, the clinical record of Patient #5 was reviewed. Patient #5 had a start of care date of 08-19-2022. The certification reviewed was 12-17-2022 through 02-14-2023. Patient #5 had a diagnoses of Ataxic Gait (unsteady with ambulation). The plan of care included Skilled Nurse (SN) visits 1 time per month and Home Health Aide (HHA) visits 5 times per week, 2 hours per day for 9 weeks. The records revealed a HHA plan of care dated 12-15-2022 was completed by Administrator #1 (Admin#1) with activities to include, "Turn and Position, Assist with Ambulation, Equipment Care, Make the Bed, Light Housekeeping, Meal Set-up and Assist with Feeding". The records included a HHA Supervisory Visit dated 12-15-2022 was completed by Registered Nurse #2 (RN#2). The visit reported HHA #2, "5. Informs supervisor of client's needs and changes in the patient's condition...". The HHA visit records evidenced the HHA completed visits 3 times per week from 12-19-2022 through 12-24-2022. The HHA completed visits 3 times per week from 12-26-2022 through 12-31-2022 and once on 01-02-2023. The records failed to evidence communication regarding a change in ordered HHA visits. The 60 day conference note completed by RN #2 failed to evidence communication with Patient #7 or the Patient's physician regarding the HHA visits not being met as ordered. During an interview on 01-06-2023 at 3:21 PM, HHA #2 indicated Patient #7 refused visits and care because the patient preferred a female caregiver. During an interview on 01-09-2023 at 11:40 AM, Patient #7 was queried about the HHA services provided by the agency. Patient #7 indicated they received services from the agency, " but won't let them do anything because he is a male". Patient #7 indicated they had not participated in a care conference. 1. On 01-06-2023 at 9:30 AM a policy titled, “Notice of Rights”, was provided by Admin #1. The policy indicated but was not limited to, “… Policy,” on Page 4, “… The HHA shall involve the patient’s family in care, treatment and/or services decisions to the extent permitted by the patient or surrogate decision-maker… Procedure:,” on Page 6, “… Inform the patient and/or legal representative of the right and responsibility to participate in the care planning process. Discuss the patient’s and/or legal representative’s expectations, desires/preferences and needs….” 2. A review of the clinical record of Patient #31 on 01-09-2023 at 9:00 AM, failed to evidence a 30-day conference involving the patient and/or legal representative. The agency failed to follow the agency’s policy regarding the patient’s rights to be a part of the interdisciplinary team and have the patient’s care choices and preferences discussed. 3. A review of the clinical record of Patient #16 on 01-04-2023 at 2:30 PM, failed to evidence communication notes regarding the coordination of care and case conferences involving the patient and/or legal representative. The agency failed to follow the agency’s policy regarding the patient’s rights to be a part of the interdisciplinary team and have the patient’s care choices and preferences discussed. 4. A review of the clinical record of Patient #11 on 01-04-2023 at 10:00 AM, failed to evidence the entire interdisciplinary team being involved in the document titled, “30-day Summary/Case Conference”, dated 11-11-2022 at 4:00 PM. The 30-day summary failed to involve the patient and/or legal representative. The agency failed to follow the agency’s policy regarding the patient’s rights to be a part of the interdisciplinary team and have the patient’s care choices and preferences discussed. 5. A review of the clinical record of Patient #29 on 01-10-2023 at 12:30 PM, failed to evidence a conference or communication involving the patient and/or legal representative. The agency failed to follow the agency’s policy regarding the patient’s rights to be a part of the interdisciplinary team and have the patient’s care choices and preferences discussed. 6. A review of the clinical record of Patient #12 on 01-04-2022 at 11:00 AM, failed to evidence, in the document titled, “60-Day Summary/Case Conference”, signed by Registered Nurse (RN) #1 and dated 12-12-2022 at 1:00 PM, the involvement of the patient and/or legal representative. The agency failed to follow the agency’s policy regarding the patient’s rights to be a part of the interdisciplinary team and have the patient’s care choices and preferences discussed. 7. During the Daily Conference on 01-05-2023 at 2:00 PM, when queried regarding the case conferences not including the entirety of the team, Admin #1 indicated there was no coordination between the different disciplines for the patients.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the facility failed to provide the services listed on the plan of care ordered by the physician for 14 of 25 active patients (Patients # 4, 5, 6, 7, 10, 11, 12, 15, 16, 20, 21, 22, 23, 24, 25) and 2 of 7 inactive patients. (Patients #29 and 31) Findings Include: 1. A review of the clinical record for Patient #4, the start of care date of 10-11-22, contained a signed plan of care for the initial certification period of 10-11-22 to 12-09-22. The plan of care indicated orders for skilled nursing (SN) 1 time a week for 4 weeks, 2 times a week for 4 weeks, and 1 time a month for 1 month for med setup. Physical therapy (PT) 3 times a week for 4 weeks, 1 time a week for 4 weeks for treatment and evaluation for muscle strength. Occupational therapy (OT) 3 times a week for 4 weeks, 1 time a week for 4 weeks, for treatment and evaluation for muscle strength. A review of an agency document dated 10-25-2022, titled “Physical therapy Plan of Care with Full Evaluation,” signed by the physician, indicated orders for PT 2 times a week for 4 weeks and 2 times a week for 4 weeks. A review of the SN visit notes evidenced the following: A. On 10-11-22, a Registered Nurse (RN) completed a start of care initial assessment. B. No SN visits were completed during the week of 10-16-22 through 10-22-22. C. No SN visits were completed during the week of 10-23-22 through 10-29-22. D. No SN visits were completed during the week of 10-30-22 through 11-5-22. E. No SN visits were completed during the week of 11-6-22 through 11-12-22. F. No SN visits were completed during the week of 11-13-22 through 11-19-22. G. No SN visits were completed during the week of 11-20-22 through 11-26-22. H. No SN visits were completed during the week of 11-27-22 through 12-3-22. E. On 12-8-22, an RN completed a recertification assessment. The agency failed to provide SN services per the plan of care. A review of the PT notes evidenced a PT evaluation dated 10-25-22. The clinical record failed to evidence any visits conducted after the evaluation. The agency failed to provide PT services per the plan of care. A review of the clinical record for Patient #4 failed to provide evidence of an OT evaluation or visits completed. The agency failed to provide an OT service per the plan of care. During an interview on 1-3-2023 at 2:31 PM, the Director of Nursing/Administrator, Admin 1, when queried regarding Patient #4’s visits, confirmed the visits were not completed. 2. A review of the clinical record for Patient #10, the start of care date of 11-25-22, contained a plan of care for the initial certification of 11-25-22 to 01-23-23. The plan of care indicated orders for SN 1 time a month for 2 months for recertifications, supervisory visits, and resumption of care. A Home Health Aide (HHA) 5 times a week for 9 weeks to assist with Activities of Daily Living (ADLs), and Instrumental Activities of Daily Living (IADLs), and PT to assess function and status. The clinical record failed to provide evidence that a PT evaluation visit was completed. The agency failed to provide PT services per the plan of care. During an interview on 1-4-22 at 12:01 PM, the Director of Nursing/Administrator, Admin 1, when queried regarding Patient #10’s PT evaluation order, confirmed the evaluation was not completed. 3. A review of the clinical record for Patient #15, with a start of care date of 9-19-22, contained a signed plan of care for the recertification period of 11-18-22 to 1-16-23. The plan of care indicated that Patient #15 had orders for SN 1 time a week for 9 weeks, 3 PRN to perform a comprehensive physical assessment, medication review and reconciliation, and aide supervision. HHA 3 times a week for 9 weeks on Monday, Wednesday, and Friday from 10:00 AM to 1:00 PM. A review of the SN visit notes evidenced the following: A. The RN completed a recertification assessment visit on 11-16-22; no further visits were completed the week of 11-13-22 through 11-19-22. B. No SN visits were completed during the week of 11-20-22 to 11-26-22. C. No SN visits were completed during the week of 11-27-22 to 12-3-22. D. No SN visits were completed during the week of 12-4-22 to 12-10-22. E. No SN visits were completed during the week of 12-25-22 to 12-31-22. The agency failed to provide SN services per the plan of care. A review of the HHA notes evidenced the following: no evidence of documentation of HHA visits made for 5 weeks, dates 11-6-22 thru 12-10-22. The agency failed to provide HHA services per the plan of care. During an interview on 1-4-23 at 1:30 PM, Patient #15 confirmed that the agency was not providing HHA services until 4 weeks ago when they found their own HHA. The patient further indicated that they had a family member get certified to provide them with care. 4. A review of the clinical record for Patient #20, with a start of care date of 10-12-22, contained a signed plan of care for the initial certification of 10-12-22 to 12-10-22. The plan of care indicated that Patient #20 had orders for SN 1 time a week for 4 weeks, 2 times a month for 1 month for med management, PT evaluation, and treatment. A review of the SN visit notes evidenced the following: A. On 10-12-22, the RN completed an initial start of care assessment. B. No SN visits were completed during the week of 10-16-22 through 10-22-22. C. No SN visits were completed during the week of 10-23-22 through 10-29-22. D. No SN visits were completed during the week of 10-30-22 through 11-5-22. E. No SN visits were completed during the week of 11-6-22 through 11-12-22. F. No SN visits were completed during the week of 11-13-22 through 11-19-22. G. No SN visits were completed during the week of 11-20-22 through 11-26-22. H. On 12-3-22, SN documented a missed visit during the week of 11-27-22 through 12-3-22. I. On 12-9-22, the RN completed a recertification assessment. The agency failed to provide SN services per the plan of care. A review of the PT notes evidenced a PT evaluation dated 10-14-22, with a PT plan of care to see the patient 2 times weekly for 4 weeks. A review of the PT visit notes evidenced the following: A. No PT visits were completed during the week of 10-16-22 through 10-22-22. B. No PT visits were completed during the week of 10-23-22 through 10-29-22. C. No PT visits were completed during the week of 10-30-22 through 11-5-22. D. No PT visits were completed during the week of 11-6-22 through 11-12-22. During an interview on 1-10-23 at 1:00 PM, Patient #20, when queried regarding therapy and skilled nurse visits, confirmed that the PT or SN did not come back to visit them. 5. A review of the clinical record for Patient #21, with a start of care date of 10-14-22, contained a signed plan of care for the initial certification of 10-14-22 to 12-12-22. The plan of care indicated that Patient #21 had orders for SN 1time a week for 9 weeks for med set up, HHA supervision, and 1-2 prn (as needed), PT 3 times a week for 9 weeks to evaluate and treatment, Home Health Aide (HHA) 2 home visits 5 days a week for 9 weeks to assist with ADLs and IADLS. A review of a signed agency document dated 10-20-22, titled “PT Plan of Care,” indicated orders for PT eval for services and to see the patient 2 times a week for 4 weeks. The agency failed to provide PT visits 2 times a week for 6 weeks prior to Patient #21 going to an acute care facility, Entity 16. A review of a signed agency document dated 10-20-22 and electrically signed by the Administrator, titled “OT Evaluation,” indicated OT frequency and plan for 1 time a week for 1 week for eval, then 2 times a week for 3 weeks. The agency failed to provide OT visits 2 times a week for 3 weeks prior to Patient #21 going to an acute care facility, Entity 16. A review of the SN notes evidenced a start of care on 10-14-22; no further documentation of SN visits was completed. The agency failed to provide SN weekly visits for 7 weeks prior to Patient #21 being admitted to an acute care facility, Entity 16. A review of the HHA notes evidenced that no HHA notes were completed during the 7 weeks prior to Patient #21 being admitted to an acute care facility, Entity 16. During an interview on 1-10-23 at 9:15 AM, the Administrator, Admin 1, no visits were made by the HHA prior to the patient being admitted to the acute care facility, Entity 16, on 11-30-22. 6. A review of the clinical record for Patient #22, with a start of care date of 10-29-22, contained a signed plan of care for the initial certification of 10-29-22 to 12-27-22. The plan of care indicated that Patient #22 had orders for SN 1 time a week for 9 weeks for med set up, recert of services prn (as needed) for change in condition, PT 3 times a week for 9 weeks, evaluate and treat, Home Health Aide (HHA) 2 home visits 5 days a week for 8 weeks to assist with ADLs and IADLS. A review of a signed agency document dated 12-11-22, titled “Physician Order,” indicated orders to change the HHA frequency to 8 hours a day, 5 days a week (Monday -Friday). A review of the SN visit notes evidenced the following: A. On 10-29-22, the RN completed a start of care initial assessment. B. No SN visits were completed during the week of 11-30-22 through 11-5-22. C. No SN visits were completed during the week of 11-6-22 through 11-12-22. D. No SN visits were completed during the week of 11-13-22 through 11-19-22. E. No SN visits were completed during the week of 11-20-22 through 11-26-22. The agency failed to provide SN services per the plan of care. A review of the PT visit notes evidenced the following: A. On 10-31-22, the PT completed an evaluation and one visit on 11-5-22. B. During the week of 11-6-22 through 11-12-22, the PT made 2 visits, missing 1 visit. C. During the week of 11-13-22 through 11-19-22, the PT made 2 visits, missing 1 visit. D. During the week of 11-20-22 through 11-26-22, the PT made 2 visits, missing 1 visit. E. During the week of 11-27-22 through 12-3-22, the PT completed 1 visit and 1 evaluation, missing 1 visit. A review of the HHA visit notes evidenced the following: A. On 11-3-22, an HHA visit was made. No further HHA visits were completed. The agency failed to provide HHA 5 times a week for 8 weeks per the plan of care. A review of an agency document dated 12-13-22, titled “Home Health Certification and Plan of Care Resumption of Care Following Hospital Stay,” indicated Patient #22 had orders for an SN 1 time a week for 9 weeks for med set up, recert of services prn (as needed) for change in condition, PT 3 times a week for 9 weeks, evaluate and treat, Home Health Aide (HHA) 2 home visits 5 days a week for 8 weeks to assist with ADLs and IADLS. A review of the RN visit notes evidenced the following: A. On 11-29-22, the RN completed a resumption of care assessment. B. No SN visits were completed during the week of 12-4-22 through 12-10-22. C. On 12-21-22, the RN completed a recertification assessment. The agency failed to provide SN services per the plan of care. A review of the PT visit notes evidenced that no visits were completed for the 3 weeks of 12-4-22 to 12-24-22. The agency failed to provide Pt services 3 times a week per the plan of care. A review of the HHA visit notes evidenced that no visits were completed for the 3 weeks of 12-4-22 through 12-24-22. The agency failed to provide HHA services 2 visits a day 5 times a week per the plan of care. During an interview on 1-10-23 at 3:50 PM, Patient #22, and their caregiver, Person 26, indicated that the staff from Union Healthcare Services do not come consistently. They further indicated that the PT would call and then not show up. The PT called the last time and stated that Patient #22 was not on his schedule. OT never came, and there is no HHA. Patient #22 stated they fell trying to transfer to the wheelchair, and their family member had to come to help get them up. 7. A review of the clinical record for Patient #23, with a start of care date of 11-30-22, contained a signed plan of care for the initial certification of 11-30-22 to 1-28-23. The plan of care indicated that Patient #23 had orders for SN 1 time a week for 9 weeks for medication management, recertification, resumption of care, and PT evaluation and treatment. A review of an agency document dated 12-9-22, titled “PT Evaluation and Order,” indicated PT 3 times a week for 4 weeks. A review of the PT visit notes evidenced a PT evaluation dated 12-9-22; no further visits were completed. The agency failed to provide PT services 3 times a week as ordered. A review of the SN visit notes evidenced the following: A. On 11-3-22, the RN completed a start of care initial assessment. B. No visits were made during the week of 12-4-22 through 12-10-22, missing 1 SN visit. The agency failed to provide SN services per the plan of care. During an interview on 1-10-23 at 11:34 AM, Person 53, Patient #23’s caregiver, confirmed the PT came out to their home 1 time and never returned. Person 53 further indicated they were never told why the PT never returned by the agency or the PT. 8. A review of the clinical record of Patient #24, the start of care date of 9-16-22, contained a signed plan of care for the initial certification of 9-16-22 to 11-14-22, indicated that Patient #24 had orders for SN 1 time a week for 9 weeks for med set up, education and compliance, disease management, and recertification, PT 3times a week for 9 weeks, OT 2 times a week for 9 weeks. A review of the SN notes evidenced the following: The RN completed a start of care initial assessment on 9-16-22. Further review indicated an SN visit note on 9-28-22 with no further evidence of SN visits. The agency failed to provide SN services per the plan of care. A review of the PT visit notes evidenced a PT evaluation dated 9-22-22; a missed visit on 11-2-22 with no other visits completed. The agency failed to provide PT visits per the plan of care. A review of an agency document dated 11-2-22, titled “Physician Order,” indicated that Patient #24 was to receive SN 1time a week for 9 weeks, HHA 7 times a week for 9 weeks up to 6 hours a day, PT 3 times a week for 9 weeks, and OT 3 times a week for 9 weeks. A review of the Sn visit notes evidenced the following: A. On 9-16-2022, the RN completed a start of care initial assessment dated 9-16-22. B. During the week of 9-18-22 through 9-24-22, no SN visits were completed. C. During the week of 10-2-22 through 10-8-22, no SN visits were completed. D. During the week of 10-9-22 through 10-15-22, no SN visits were completed. E. During the week of 10-16-22 through 10-22-22, no SN visits were completed. F. During the week of 10-23-22 through 10-29-22, no SN visits were completed. G. During the week of 10-30-22 through 11-5-22, no SN visits were completed. H. During the week of 11-6-22 through 11-12-22, no SN visits were completed. The agency failed to provide SN services 1 time a week for 9 weeks as ordered per the plan of care. A review of the PT visit notes evidence that no PT visits were completed. The agency failed to provide PT services 3 times a week for 9 weeks as ordered per the plan of care. A review of the OT visit notes evidenced an OT evaluation dated 9-22-22; a visit on 9-27-22 with no other visits completed. The agency failed to provide OT services 3 times a week for 9 weeks as ordered per the plan of care. A clinical record review failed to provide evidence that any HHA visits were completed. The agency failed to provide HHA services 7 times a week for 9 weeks, up to 6 hours a day, as ordered per the plan of care. During an interview on 1-10-23 at 11:21 AM, Patient #24 confirmed the therapist came 1 time and has yet to return. 9. A review of the clinical record for Patient #25, with a start of care date of 12-19-22, contained a signed plan of care for the initial certification of 12-19-22 to 2-16-23. The plan of care indicated that Patient #25 had orders for SN 1 time a week for 1 week for the start of care assessment (SOC), PT to evaluate and treat, and OT to evaluate and treat. A review of the SN visit notes evidenced a start of care comprehensive assessment on 12-19-22, with no further visits. A review of the PT notes evidenced a PT evaluation completed on 1-2-2023, with no further visits. A review of the OT visits notes evidenced that no visits were made. The agency failed to provide OT services per the plan of care. During an interview on 1-10-23 at 11:21 AM, Patient #25 confirmed that the physical therapist came 1 time and has yet to return, no further SN visits since the start, and OT has not been to evaluate Patient #25. On 01-03-2023 at 11:15 AM, the clinical record of Patient #5 was reviewed. Patient #5 had a start of care (SOC) date of 08-19-2022. The certification period reviewed was 12-17-2022 through 02-14-2023. The orders were for Skilled Nursing (SN) visits 1 time per month to supervise the home health aide (HHA). HHA visits were ordered 5 times per week for 9 weeks. The records indicated HHA visits were completed 3 times per week from 12-19-2022 through 12-24-2022, 3 times per week from 12-26-2022 through 12-31-2022 and 1 visit on 01-02-2023. The records failed to evidence communication to the physician regarding the change in services ordered. On 01-06-2023 at 11:30 AM, the inactive clinical record of Patient #6 was reviewed. Patient #6 had a SOC date of 09-30-2022. The certification period reviewed was 11-29-2022 through 01-27-2023. Patient #6 had orders for SN visits 1 time per week for 9 weeks and Physical Therapy (PT) visits 2 times per week for 8 weeks. There were no discharge orders evident in the clinical record. There were no visits completed within the certification period. The last PT visit note was on 10-30-2022. There was no evidence goals had been met or communication to the physician regarding discharge. On 01-06-2023 at 12:00 PM, the clinical record of Patient #7 was reviewed. Patient #7 had a SOC date of 10-07-2022. The certification period reviewed was 10-07-2022 through 12-05-2022. Patient #7 had orders for SN visits 3 times per week for 9 weeks to assess and provide wound care, Home Health Aide visits 5 times per week for 9 weeks and PT visits 3 times per week for 9 weeks. Patient #7 had a diagnoses of Diabetes (an inability to maintain blood sugar levels) and a Right Lower Extremity (RLE) wound. The record indicated there were no SN visits after 10-07-2022, there were no HHA visits completed, and there were no PT visits completed. There was no evidence of a discharge communication note to the patient or the physician. During an interview on 01-11-2023 at 11:00 AM, Patient #7 was queried about their home health admission and visits. Patient #7 indicated the agency came to their home and completed an admission. Patient #7 received a call from the agency indicating services could not be provided due to insurance issues. Patient #7 was not provided information regarding a referral for another agency to provide the necessary wound care. 1. On 1-6-2023 at 9:30 AM a policy titled “Notice of Rights” was provided by Admin #1. The policy indicated but was not limited to, “… Policy,” on Page 2, “… “Right to participate in, be informed about, and consent and refuse care in advance of and during treatment… Completion of all assessments. The care to be furnished, based on the Comprehensive Assessment. Establishing and revising the Plan of Care. The discipline that will furnish the care. The frequency of visits…” 2. On 1-6-2023 at 9:30 AM a policy titled “Home Health Aide Plan of Care” was provided by the Administrator, Admin #1. The policy indicated but was not limited to, “Policy: Each patient receiving home health aide services will have an individualized plan developed by an appropriate professional and utilized to direct the care performed by the assigned aide… Procedure: 2. The home health aide plan of care will be individualized to the specific patient and will include at least: A. Type of services/procedures to be provided…B. Frequency of visits….” 3. A review of the clinical record for Patient #12, with the start of care date of 4-19-2022, contained a plan of care for the recertification period of 10-16-2022 to 12-14-2022. The plan of care indicated orders for Skilled Nursing (SN) 1 time a month for 2 months for recertification evaluation and supervisory visits. Home Health Aide (HHA) 2 hours a visit, 5 days a week, 5 days a week for 8 weeks for assistance with personal care Instrumental Activities of daily living (IADL) and Activities of daily living (ADL). A review of the HHA visit notes evidenced no HHA visit notes were completed during the week of 11-20-2022 to 11-26-2022. During an interview on 1-10-2023 at 9:15 AM, when queried regarding Patient #12 not being seen for a week according to the clinical record, Admin #1 stated the missed visits are because of staffing. During the entrance conference on 1-3-2023 at 9:11 AM, Admin #1 stated the agency would not take the patient if the agency was unable to staff the patient’s needs. 4. A review of the closed clinical record for Patient #29, with the start of care date of 10-25-2022, contained a plan of care for the initial certification period of 10-25-2022 to 12-23-2022. The plan of care indicated orders for SN 1 time a week for 9 weeks and 1-2 times as needed for Registered Nurse (RN) HHA supervision for a comprehensive assessment, Physical Therapy (PT) 3 times a week for 9 weeks to evaluate and treat, and HHA 2 hours a visit, 5 days a week for 8 weeks. A review of the clinical record on 1-10-2023 at 12:30 PM failed to evidence PT visits past the initial PT Evaluation. The agency failed to provide PT services as listed on the plan of care. A review of the clinical record failed to evidence any visit notes from the HHA. No HHA visit notes were noted for the weeks 10-25-2022 to 10-29-2022, 10-30-2022 to 11-5-2022, 11-6-2022 to 11-12-2022, 11-13-2022 to 11-19-2022, 11-20-2022 to 11-26-2022, and 11-27-2022 to 12-3-2022. The agency failed to provide HHA services according to the order listed on the plan of care. During an interview on 1-10-2023 at 9:15 AM, when queried regarding Patient #29 not being seen according to the plan of care, Admin #1 stated the missed visits are because of staffing. 5. A review of the clinical record for Patient #11, who is on hold, with the start of care date of 4-19-2022, contained a plan of care for the recertification period of 10-16-2022 to 12-14-2022. The plan of care indicated orders for Skilled Nursing (SN) 1 time a month for 2 months for recertification evaluation and supervisory visits. Home Health Aide (HHA) was listed as a service the patient would receive; the plan of care did not state the ordered frequency of HHA services. A Physician Order signed by Admin #1 and dated 10-14-2022 at 2:00 PM, stated for Patient #11 to receive HHA services 4 hours a day, 7 days a week for the patient’s decline in health. The Physician Order stated the order was read back and verified. The order stated the patient would receive assistance with Instrumental Activities of daily living (IADL) and Activities of daily living (ADL), incontinence care, medication reminders, meal prep, cleaning, and laundry. A review of the HHA visit notes evidenced no HHA visit notes were completed during the week of 11-20-2022 to 11-26-2022. During an interview on 1-10-2023 at 9:15 AM, when queried regarding Patient #11 not being seen for a week according to the clinical record, Admin #1 stated the missed visits are because of staffing. 6. A review of the clinical record for Patient #16 with the start of care date of 12-28-2022, the clinical record had no plan of care and no hold orders from the physician. The document titled “OASIS-D1 Start of Care” stated the patient was to receive SN 1 time a week for 9 weeks for recertification and medication management and disease process teaching, PT 3 times a week for 9 weeks for evaluation and treatment, and OT 3 times a week for 9 weeks for evaluation and treatment. A review of the electronic medical record and the paper chart failed to evidence SN visits for the weeks of 12-19-2022 to 12-24-2022 and 12-25-2022 to 12-31-2022. A review of the electronic medical record and the paper chart failed to evidence PT visits for the weeks of 12-19-2022 to 12-24-2022 and 12-25-2022 to 12-31-2022. A review of the electronic medical record and the paper chart failed to evidence OT visits for the weeks of 12-19-2022 to 12-24-2022 and 12-25-2022 to 12-31-2022. During an interview on 1-11-2023 at 10:35, Patient #16’s family member, Person #39, was queried regarding whether the agency had been to see the patient or had care provided by the agency. The family member stated the facility had not come to see the patient; the facility had called Patient #16 regarding a time to start care. The family member stated the agency had not set a time to come see the patient. During an interview on 1-5-2023 at 10:25 AM, Admin #1 stated PT had not been able to go over to the patient’s house over the holidays and there were no orders to hold care or change the visit. 7. A review of the closed clinical record for Patient #31 with a start of care date of 10-13-2022 for the initial certification period of 10-13-2022 to 12-11-2022. The care plan was ordered for SN 2 times a week for 9 weeks, starting on 10-22-2022 for wound care, medication set up, and disease management. HHA 4 hours a day, 5 days a week for 8 weeks. PT 3 times a week for 9 weeks for therapeutic exercise, range of motion (ROM), gait and balance training, and fall risk education. OT 3 times a week for 9 weeks for safety with Instrumental Activities of daily living (IADL) and Activities of daily living (ADL), and strengthening. A record review of the closed record of Patient #31 evidenced the patient received only 1 visit from SN during the weeks of 10-30-2022 to 11-5-2022, 11-13-2022 to 11-19-2022, 11-20-2022 to 11-26-2022, 11-27-2022 to 12-3-2022, 12-4-2022 to 12-10-2022. The agency failed to follow the orders on the plan of care. A record review of the close record of Patient #31 failed to evidence the patient was seen by SN during the week of 11-6-2022 to 11-12-2022. The agency failed to follow the orders on the plan of care. A record review of the closed record of Patient #31 evidenced the patient received only 1 visit from PT during the week of 10-23-2022 to 10-29-2022. The PT visit note dated 11-1-2022 for the visit on 11-1-2022 was signed by Admin #1, who is an RN. The agency failed to follow the orders on the plan of care. A record review of the closed record of Patient #31 evidenced the patient had not received PT services from the week of 11-6-2022 to 11-12-2022 and 12-4-2022 to 12-10-2022. The agency failed to follow the orders on the plan of care. A record review of the closed record of Patient #31 evidenced the patient received only 1 visit from PT during the week of 11-13-2022 to 11-19-2022 and 11-27-2022 to 12-3-2022. The agency failed to follow the orders on the plan of care. A record review of the closed record of Patient #31 evidenced the patient received only 2 visits from PT during the week of 11-20-2022 to 11-26-2022. The agency failed to follow the orders on the plan of care. A record review of the closed record of Patient #31 evidenced the patient had not received OT services from the week of 10-16-2022 to 10-22-2022, 10-16-2022 to 10-22-2022, 10-30-2022 to 11-5-2022, 11-6-2022 to 11-12-2022, 11-13-2022 to 11-19-2022, 11-20-2022 to 11-26-2022, 11-27-2022 to 12-3-2022, and 12-4-2022 to 12-10-2022. The agency failed to follow the orders on the plan of care. A record review of the closed record of Patient #31 evidenced the patient received only 1 visit from OT for the week of 10-23-2022 to 10-29-2022. The agency failed to follow the orders on the plan of care. A record review of the closed record of Patient #31 evidenced no HHA visit notes for the certification period of 10-13-2022 to 12-11-2022. Patient #31 had an active chart, Patient #12, where HHA visits were noted following the plan of care under another payor source, Medicaid. During an interview on 1-10-2023 at 9:15 AM, when queried regarding Patient #31 not being seen for a week according to the clinical record, Admin #1 stated the missed visits are because of staffing.

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: Based on observation and interview, the agency failed to evidence the Governing Body managed the roles and responsibilities of administrator, and alternate administrators/supervisors ( G 942). The agency failed to evidence administrators or the alternate was appointed by the Governing Body (G 946). The agency failed to ensure a qualified alternate administrator was appointed and in place in the event the administrator was not available as noted over 7 of 7 survey days (G 954.). These deficiencies had a potential cumulative effect on all 42 patients and 28 staff. The cumulative effect of these systemic problems resulted in the home health agency's inability to ensure the provision of quality health care in a safe environment for the Condition of Participation of 42 CFR 484.105, Organization and Administration of Services. Findings included: *

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to demonstrate members of the governing body were responsible for the management and operations of the agency 24 hours per day, 7 days per week, 365 days per year as noted over 7 of 7 survey days. Findings include: 1. On 01-03-2023 at 11:10 AM, Administrator #1 (Admin #1) provided a November 2021, Union Healthcare Service policy titled, " Governing Body Policy No. 1-002.1. The policy indicated but was not limited to, "...The Governing Body will assume full legal authority, responsibility, decision making and accountability for the overall management and operations...which will function according to Union Healthcare Inc's Bylaws...The Governing Body will appoint a Governing Body to work with Senior Leadership and the Performance Improvement Committee...The Governing Body will appoint a qualified Executive Director/Administrator and establish procedures of ...communication between the two...The process and documentation will reflect that: A. Relevant findings of performance improvement activities are consistently provided...9 The Governing Body will authorize adequate resources and support..." 2. On 01-03-2023 at 10:15 AM, during the Entrance Conference Admin #1 indicated that their role was the Director of Nursing (DON) and the owner, Corporate Staff #1 (Corp Staff #1) was the Administrator. Admin #1 indicated there was no other clinical support in a supervisory role. Admin #1 further indicated they began their employment in August, 2022, hired as the DON and they were unsuccessful with recruiting other administrative staff. Admin #1 indicated they have never had a budgetary discussion with the Governing Body. 3. On 01-03-2023 at 11:30 AM, Admin #1 provided a document presenting the organizational chart. The organizational chart listed Admin #1 and RN#1 as the Administrator and Alternate Administrator. 4. On 01-06-2023 at 12:25 PM, Admin #3 provided an unsigned job description for RN #1. The job description was titled, "Assessment Nurse, Registered Nurse." During an interview on 01-06-2023 at 11:00 AM, Corp Staff #1 indicated Admin Staff #1 was the Administrator. Admin Staff #1 verbalized they were unaware of this role. When queried about the agency's clinical leadership, Corp Staff #1 indicated Registered Nurse (RN #1) was the Alternate Administrator and Clinical Supervisor/Director of Nursing. During an interview on 01-06-2023 at 2:00 PM, RN #1 indicated they were hired in July, 2022 as a Field Nurse and not in a supervisory role. RN #1 indicated they have only worked in the field with patients and had not supervised other employees. 410 IAC 17-12-1(b)

Administrator appointed by governing body CFR(s): 484.105(b)(1)(i) (i) Be appointed by and report to the governing body; This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to evidence the Governing Body established a line of authority inclusive of an Administrator as noted over 7 of 7 survey days. Findings include: 1. On 01-03-2023 at 11:10 AM, Administrator #1 (Admin #1) provided a November 2021, Union Healthcare Service policy titled, " Governing Body Policy No. 1-002.1. The policy indicated but was not limited to, "...The Governing Body will assume full legal authority, responsibility, decision making and accountability for the overall management and operations...which will function according to Union Healthcare Inc's Bylaws...The Governing Body will appoint a Governing Body to work with Senior Leadership and the Performance Improvement Committee...The Governing Body will appoint a qualified Executive Director/Administrator and establish procedures of ...communication between the two...The process and documentation will reflect that: A. Relevant findings of performance improvement activities are consistently provided...9 The Governing Body will authorize adequate resources and support..." 2. On 01-06-2023 at 12:25 PM, Admin #3 provided a job description titled, " Director of Nursing." The job description was signed on 08-01-2022 by Admin #1. 3. On 01-03-2023 at 10:15 AM, during the Entrance Conference Admin #1 indicated that their role was the Director of Nursing (DON) and the owner, Corporate Staff #1 (Corp Staff #1) was the Administrator. Admin #1 indicated there was no other clinical support in a supervisory role. Admin #1 further indicated they began their employment in August, 2022, and they were unsuccessful with recruiting other administrative staff. Admin #1 indicated they were not a member of the Governing Body and never participated in meetings. 410 IAC 17-12-1 (b) (1)

Ensures qualified pre-designated person CFR(s): 484.105(b)(2) When the administrator is not available, a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator. The pre-designated person may be the clinical manager as described in paragraph (c) of this section. This ELEMENT is not met as evidenced by: Based on observation and interview the agency failed to evidence in writing administrative coverage that was approved by the Governing Body when the Administrator was unavailable as noted over 7 of 7 survey days. Findings include: 1. On 01-03-2023 at 11:15 AM, Admin #1 provided a November, 2021 Union Healthcare Services policy titled, "Governing Body, Policy No. 1-002.1". The policy indicated but was not limited to, "... All new Governing Body members will participate in and evaluate an orientation program that includes: ...C. Review of their responsibilities and accountability...D. Review of the organizational structure, the values, mission and goals: overview of program services... 18. Documentation of each member's orientation will be maintained by the organization..." 2. On 01-03-2023 at 10:15 AM, during the Entrance Conference Admin #1 indicated that their role was the Director of Nursing (DON) and the owner, Corporate Staff #1 (Corp Staff #1) was the Administrator. Admin #1 indicated there was no other clinical support in a supervisory role. Admin #1 further indicated they began their employment in August 2022, and they were unsuccessful with recruiting other administrative staff. 3. On 01-06-2023 at 12:25 PM, Admin #3 provided an unsigned job description for RN #1. The job description is titled, "Assessment Nurse, Registered Nurse". There was no documentation for the role of Clinical Supervisor, Alternate Administrator or documentation in the Governing Body minutes dated 12-02-2022 approving RN #1 in those roles. RN #1 was hired in February 2022, as a Field Nurse. During an interview on 01-06-2023 at 11:00 AM, Corp Staff #1 indicated Admin Staff #1 was the Administrator. Admin Staff #1 verbalized they were unaware of this role. When queried about the agency's clinical leadership. Corp Staff #1 indicated Registered Nurse (RN #1) was the Alternate Administrator and Clinical Supervisor. During an interview on 01-06-2023 at 2:00 PM, RN #1 indicated they were hired in July, 2022 as a Field Nurse and not in a supervisory role. RN #1 indicated they worked in the field with patients and had not supervised other employees. 410 IAC 17-12-1(d)(8)

Coordinate patient care CFR(s): 484.105(c)(2) Coordinating patient care, This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patient’s clinical record included information about the services the patient received from other agencies and failed to ensure they coordinated care delivery to meet the patient’s needs for 5 of 5 active patient records reviewed receiving outside services. (Patients #1, 2, 15, 22, 23) Findings Include: 1. A review of a Union Healthcare Services Inc. policy revised date November 2021, titled, “Care/Service Coordination, Policy No. 4-067.2", was received from the Administrator on 01-03-2023. The policy indicated but was not limited to “…4. Care Coordination will include, but not be limited to…F. Timely documentation of coordination of care activities…I. Integration of services, whether services are provided directly or under the arrangement, to assure identification of patient needs and factors that could affect patient safety and treatment effectiveness…J. Care of care delivery to meet the patient’s needs and involve the patient…8. Written evidence of care coordination may be found in the plan of care/service, case conference summary forms, and clinical notes in the patient’s clinical record...”. 2. During the Entrance Conference on 01-03-2023 at 9:15 AM, when queried regarding shared patients and coordination of care, the Administrator/Director of Nursing, Admin 1, indicated the agency did not have any shared patients. Admin 1 further indicated they only had shared referrals with another agency who could not provide skilled services. 3. During a home visit at Patient #2’s residence on 01-04-2023 at 10:16 AM, Registered Nurse (RN), RN #3, was observed completing wound care. Patient #2 indicated that the Personal Care Agency (PSA), Entity 3, was sending out a different attendant to help them this afternoon. During a daily conference on 01-04-2023 at 3:52 PM, the Administrator/Director of Nursing, Admin 1, confirmed there should be coordination of care in the communication notes or on the Conference Notes when reviewing Patient #4’s home visit. 4. During a phone interview on 01-04-2023 at 1:39 PM, Patient #15 confirmed they went to outpatient therapy at Entity 4. Patient #15 indicated they received 40 hours of waiver service for housekeeping, errands, meals, shopping, and care assistance from Entity 6, a PSA agency. The agency failed to evidence documentation of care coordination in Patient #15’s plan of care, clinical notes, or case conferences. During an interview on 01-05-2023 at 1:45 PM, the owner of Entity 6, Peron 7, confirmed that Patient #15 was receiving services from their agency and that Union Healthcare Services did not reach out to them to coordinate care. 5. During a phone interview on 01-10-2023 at 3:50 PM, Patient #22 confirmed they had waiver services through Entity 22, a PSA agency. Patient #22 stated, “My niece works for them and takes care of me.”. The agency failed to evidence documentation of care coordination in Patient #22’s plan of care, clinical notes, or case conferences. During an interview on 01-11-2023 at 9:40 AM, the personal care attendant for Entity 22, Person 26, indicated they worked 35 hours a week for Entity 22 with Patient #22. Person 26 stated, “No, I did not know about Union Healthcare Services. This is the first time I have heard of this.”. During a phone interview on 01-10-2023 at 11:34 AM, Patient 23’s caregiver, Person 27, indicated they provided full-time care to Patient #23. Person 27 stated, “I am a paid family caregiver for Entity 54.”. The agency failed to evidence documentation of care coordination in Patient #22’s plan of care, clinical notes, or case conferences. 6. During a home visit on 01-04-2023 at 1:09 PM, at Patient #1's residence, Person #58, a caregiver, was observed opening the door for Physical Therapist (PT) #1. Person #58 was present at the patient's residence for the entire PT visit. Person #58, indicated they were a paid caregiver from Entity #12. During a phone interview on 1-5-2023 at 11:13 AM, with Entity #12, when queried regarding the agency's communication with the entity, Entity #12 had stated, "No one has ever contacted us from the agency about what care we are providing for the patient or told us of the care they are providing the patient.".

Assure patient needs are continually assessed CFR(s): 484.105(c)(4) Assuring that patient needs are continually assessed, and This ELEMENT is not met as evidenced by: Based on record review and interview, the Administrator/Director of Nursing, Admin 1, failed to ensure the patient’s needs were continuously assessed for 16 of 25 active clinical records (Patients #2, 4, 5, 6, 7, 10, 11, 12, 15, 16, 20, 22, 23, 24, and 25) and 2 of 6 closed records (Patients #29 and 30) Findings Include: 1. A review of a Union Healthcare Services Inc. policy revised date November 2021, titled, “Home Health Administrator,” Policy No. 1-019.1, was received from the Administrator on 01-06-2023. The policy indicated, “… Policy: The Executive Director/Administrator position will be responsible for the direction, coordination, and general supervision of all home health services….” 2. After review of the clinical records, the Administrator/Director of Nursing indicated on 1-03-2023 at 3:32 PM, having failed to ensure that the comprehensive assessments of Patients #2, 4, 6, 7, 10, 11, 12, 13, 15, 16, 20, 21, 22, 23, 24, 29, and 30) were completely filled out, accurately reflected past medical history, failed to ensure each assessment included and updated each patient’s medical, nursing, therapy, rehabilitation and discharge planning needs, and failed to ensure medications and treatments were reconciled and updated with each patient and physician. 3. During an interview on 01-03-2023 at 3:32 PM, the Administrator/Director of Nursing, Admin 1, indicated they had completed a plan of correction from their review of clinical records on 08-06-2022, related to the above findings when discussed concerns. Admin 1 confirmed the agency had failed to take any action based on the 08-06-2022 agency record review.

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 discharge summaries were written and sent to the attending physician who was responsible for the patient’s care within 5 business days of the patient’s discharge for 7 of 7 (Patients #6, 7, 18, 21, 29, 30, and 31) discharged patients whose clinical record was reviewed. Findings Include: On 01-06-2023 at 1:15 PM, a clinical record review was completed for Patient #7 with a start of care date of 10-7-2022. Patient #7 had orders for skilled nursing 3 times per week for 9 weeks for wound care, home health aide visits 5 times per week and Physical Therapy 3 times per week for 9 weeks. The Registered Nurse (RN) #1 completed the admission on 10-07-2022 and submitted the start of care OASIS documentation. There was no documentation or communication to the patient regarding a transfer to another agency or discharge from the agency. Patient #7 had no further visits. Patient #7 was admitted to Entity #16 on 10-24-2022 and on 10-26-2022 had their right lower extremity amputated below the knee. On 01-06-2023 at 12:30 PM, a clinical record review was completed for Patient #6 for the certification period 11-29-2022 through 01-27-2023. Patient #6 had a status of Pending Discharge in the agency's electronic medical record. Patient #6 had a start of care date of 09-30-2022. The services to be provided were skilled nursing 1 time per week for 9 weeks and Physical Therapy (PT) 2 times per week for 8 weeks. The last PT visit was on 10-30-2022. There was no discharge notification or communication evident to the physician. An agency document titled, "OASIS-D1 Recertification" was completed on 11/25/2022 by Registered Nurse (RN) #1. RN #1 did not complete further visits. There was no completion of a discharge notification or communication evident to the patient or physician. On 01-11-2023 at 11:30 AM, a clinical record review was completed for Patient #30 for the certification period 11-03-2022 through 12-27-2022. Patient #30 had PT visits ordered 3 times per week for 9 weeks. The PT visit notes for 11-04, 11-07, 11-09, 11-11, 11-14, 11-16, 11-18, 11-21, 11-23, 11-25, 11-30 and a PT discharge noted dated 11-02-2022 were blank. There was no documentation of further visits or a discharge notice to the physician recorded. A review of the closed clinical record for Patient #31 on 1-9-2023 at 9:00 AM with a start of care date of 10-13-2022, the electronic clinical record and paper charts failed to evidence a discharge summary to the physician and failed to complete an OASIS discharge. A review of Patient #31's electronic medical record and paper chart had failed to evidence a discharge summary to the physician regarding the patient not receiving services from Skilled Nursing (SN), Physical Therapy (PT), and Occupational Therapy (OT). Attempted to call Patient #31 on 1-5-2023 at 12:02 PM, the patient had answered the phone and was informed the call was regarding some questions about the patient being seen by the agency and the patient had ended the call. Attempted to call Entity #16, a hospital, on 1-6-2023 at 12:14 PM, a voicemail was left for the social worker to return the call. Attempted to call Person #11, physician, on 1-9-2023 at 11:35 AM, a voicemail was left for the physician to return the call. Attempted to call Entity #16 again on 1-9-2023 at 11:40 AM, a voicemail was left for public affairs and communication to return the call. During an interview on 1-9-2023 at 3:34 PM with Admin #1, he/she was queried regarding where the patients were discharged. Admin #1 stated all the discharged patients were discharged home. A review of the closed clinical record for Patient #29 with a start of care date of 10-25-2022 had a document titled "Home Health Discharge Summary" and the document had stated the patient's "Condition at Discharge: Improved". The agency had provided a document titled "OASIS-D1 Discharge" in the patient's clinical record and the document had stated the reason for discharge was, "Other: Patient is being referred to a wound care agency to provide further treatment for (the patient's) pressure ulcer." During an interview with Patient #29 on 1-10-2023 at 1:48 PM, the patient stated they are still a client with the agency and had an HHA. The patient stated the nurse informed the patient they did not feel confident taking care of the patient’s wound. The patient stated they saw a wound care nurse from another agency until about a week ago because the wound care nurse informed the patient the wound was healing. The patient stated they were never seen by physical therapy. The patient provided the wound care nurse’s telephone number. A voicemail was left for a return call. Attempted to call Entity #42 to request to speak with Person #43 on 1-10-2023 at 2:15 PM, a voicemail was left for a return call. 1. A review of a Union Healthcare Services Inc. policy revised date November 2021, titled “Discharge Summary” Policy No. 4-046.1, was received from the Administrator on 1-3-23. The policy indicated but was not limited to, “…Policy: Each patient discharged from a service and/or from the organization will have a written discharge summary completed and filed in the clinical record…2. The discharge summary…will be completed and submitted within 72 hours of discharge from service…3. A copy of the discharge summary and any necessary medical information will be provided to the patient’s primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge… within five (5) business days of the patient’s discharge… 2. A review of the clinical record for Patient #18, the start of care 10-04-22, contained an agency document dated 12-28-22, titled “OASIS D-1 Discharge Non-Visit.” The discharge comprehensive assessment section titled “Discharge Notices” indicated the reason for discharge was marked “Other,” Other was marked “Certification period expired,” and Discharge Notification was marked “Patient/Caregiver in agreement with the plan to discharge for the stated reason.” The “Physician in agreement with the plan to discharge” was left blank. The clinical record failed to evidence a discharge summary and order and evidence that it was sent to the physician within 5 business days. During an interview on 1-9-23 at 11:00 AM, the Administrative Assistant, Admin 2, confirmed the agency could not provide a discharge summary in the clinical record. 3. A review of the clinical record for Patient #21, with the start of care date of 10-14-22, indicated a document from a rehabilitation facility, Entity 5, titled “Transfer/Discharge Report.” The transfer/discharge report indicated that Patient #21 was admitted to Entity 5 on 12-2-22 from an acute care facility, Entity 16. The transfer discharge further indicated that Patient #21 had a discharge date from Entity 5 on 1-6-23 and was discharged with home health services. During an interview on 1-9-23 at 11:34 AM, Person 8, the Business Office Manager for Entity 5, the rehabilitation center, indicated Patient #21 was admitted to their facility from an acute care facility on 12-2-22. Person 8 further indicated that Patient #21 was discharged to their home on 1-6-23 from the facility, Entity 5. During an interview on 1-10-23 at 9:18 AM, the Administrator/Director of Nursing, Admin 1, indicated Patient #21 was at Entity 16. Admin 1 stated, “Truth is there is no transfer to hospital, no hold order, no transfer OASIS, and there was no coordination of care between Union Healthcare Services, the physician, or the acute healthcare facility."

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure all entries were clear, complete, authenticated, dated, and timed for 8 of 25 (Patients #1, 2, 5, 7, 11, 12, 16, 26 ) active records reviewed and 2 of 7 (Patients #29 and 31) closed records reviewed. Findings include: 1. A review of the clinical record for Patient #2, with the start of care date 10-27-2022, for the recertification period of 12-26-22 to 02-23-23, contained an agency document dated 12-23-22, titled, “OASIS-D1 Recertification.” The recertification had no time in, time out, or signature. The recertification assessment contained on page 1, a subtitled section titled “Demographics,” which was completed with Patient #2’s name, address, phone number, date of birth, insurance, insurance number, agency name, the agency’s certification number, the patient’s start of care, certification period, physician’s name, race, and ethnicity. The section titled “Clinical Records” with the subtitled section titled “Discipline of Person Completing Assessment” marked Registered Nurse (RN). The subtitled section titled “Date of Assessment” was left blank. The subtitled section titled “This Assessment is Currently Being Completed for the Following Reason” was marked Recertification. The subtitled section titled “Episode Timing” was marked N/A. the Subtitled section titled “Diagnosis Symptom Control indicated the following diagnoses: a primary diagnosis of non-pressure chronic pressure ulcer in another part of the left foot with a severity of 2; other diagnoses were essential hypertension with a severity of 2; type 2 diabetes with other diabetic neurological complication with a severity of 2; and peripheral vascular disease with a severity of 2. The recertification assessment pages 2-10 were incomplete and left blank. 2. A review of the clinical record for Patient #15, the start of care date of 09-19-2022, contained a plan of care for the initial certification period of 09-19-2022 to 11-17-2022. The plan of care in the section titled, “Orders for Discipline and Treatment,” indicated Patient #15 had orders for a Home Health Aide (HHA), 3 times a week 3 hours a day on Mondays, Wednesdays, and Fridays. A review of an agency document titled, "HHA Visit," dated 09-28-2022, time in at 8:17 AM to 12:17 PM, no electronic signature, and the note was incomplete. 3. A review of the clinical record for Patient #25, the start of care date of 12-19-2022, contained a signed plan of care for the initial certification period 12-19-2022 to 02-16-2023. The plan of care in the section titled, “Orders for Discipline and Treatment,” indicated Patient #25 had orders for SN 1 time a week for 1 week, for the start of care assessment, PT evaluation and treatment, and OT evaluation and treatment. A review of an agency document titled, “PT Evaluation,” dated 01-02-2023, time in at 8:00 AM to 9:00 AM, no electronic signature, pages 6-8, was incomplete, and the visit was assigned to the Physical Therapist, PT 1. On 01-04-2023 at 11:00 AM, Patient #12’s clinical record was reviewed. The plan of care with the start of care date of 04-19-2022 for the certification period of 10-16-2022 to 12-14-2022 was not signed and dated by the physician. The clinical record failed to evidence a signed and dated Home Health Aide (HHA) visit notes for the visit dates: 10-17, 10-18, 10-21, 10-24, 10-31-2022. The HHA visit notes indicated the services the patient had received but were not signed and dated by the clinician. On 01-04-2023 at 10:00 AM, Patient #11’s clinical record, on hold, was reviewed. The plan of care with the start date of 04-19-2022 for the certification period of 10-16-2022 to 12-14-2022 was not signed and dated by the physician. The documents titled, “Physician Order”, were not signed and dated by the physician for the dates: 10-14-2022 and 11-22-2022. The clinical record failed to evidence a signed and dated Home Health Aide (HHA) visit note for the visit date of 10-31-2022. The HHA visit notes indicated the services the patient had received but were not signed and dated by the clinician. The document titled, “Communication Note”, dated 11-30-2022 in the patient’s clinical record was not signed by the clinician. On 01-04-2023 at 2:30 PM, Patient #16’s clinical record was reviewed. The document titled, “OASIS-D1 Start of Care”, was completed, but the document was not signed or dated by the clinician. For the subtitle, “Visit information”, the section was blank except for the visit date listed as 12-28-2022. On 01-10-2023 at 12:30 PM, Patient #29’s clinical record, discharged patient, was reviewed for the certification period of 10-25-2022 to 12-23-2022. The document titled, “Physician Order”, was unsigned and undated by the physician for the wound care orders for the patient. A box on the document indicated, “Order read back and verified”, was left blank. A review of the clinical record evidenced Skilled Nursing (SN) wound care visit notes submitted blank and were not signed and dated by the clinician for the visit dates: 11-09, 11-17, 11-25, 11-26, 12-03, and 12-04-2022. On 01-04-2022 at 9:00 AM, Patient #1’s clinical record was reviewed with a start of care of 12-12-2022. A document titled, “Physician Order”, on 12-14-2022 was not signed and dated by the physician. On 01-09-2023 at 9:00 AM, Patient #31’s clinical record was reviewed. The plan of care with the start of care date of 10-13-2022 for the certification period of 10-13-2022 to 12-11-2022 was not signed and dated by the physician. A review of the record indicated 2 Physical Therapy (PT) visits were signed and dated by the Administrator, Admin #1. The PT visit notes were dated 11-01-2022 and 11-03-2022. A review of the clinical record evidenced a blank PT visit note dated 11-08, 12-07, and 12-09-2022 and not signed and dated by the clinician. A review of the clinical record evidenced a blank PT Re-evaluation dated 11-11-2022 which was not signed and dated by the clinician. A review of the clinical record evidenced a completed PT visit note on 12-05-2022 but was not signed and dated by the clinician. A review of the clinical record evidenced a blank SN visit note dated 11-09-2022 and not signed and dated by the clinician. 1. On 01-03-2023 at 12:01 PM, a November 2021 revised policy titled, " Care/Service Coordination, policy No. 4-067.1," was provided by the Director of Nursing (DON), Administrator #1. The policy indicated but was not limited to, "Timely and ongoing communication is the responsibility of each team member of the interdisciplinary group and will be appropriate to the needs and abilities of the patient, and relevant to the care/service provided. The clinician will be responsible for facilitating communications and changes in the patient's status among the assigned personnel ... 4. Care coordination will include but not be limited to: clearly outlining each clinician's responsibilities ... planned face-to-face conferences ... timely documentation of coordination of care activities, appropriate involvement of the patient and caregivers, integration of services ... coordination of care delivery to meet the patient's needs, and involve the patient, representative, and caregivers as appropriate, in the coordination of care activities ... Organization personnel will communicate changes timely ...". On 01-03-2023 at 11:45 AM, a clinical record review was completed on Patient #5. Patient #5 had a start of care (SOC) date of 08-19-2022. The period reviewed was 10-18-2022 through 12-16-2022. A document titled, "OASIS-D1 Recertification" was completed by Administrator #1 (Admin#1) on 10-14-2022. The section titled, "Risk Assessment, Shingles Vaccination" was blank. The section titled, "Hospitalization Risk Assessment Tools and Emergency Preparedness" was blank. The section titled, "Risk for Hospitalization", was blank. The section titled, "Integumentary status", was blank. The section titled, Plan of Care: Durable Medical Equipment", was blank. The section titled, "Labs and Infection Control", was blank. The section titled, "Patient Rights", was blank. The section titled, "Visit Interventions", was blank. The section titled, "Medications", was blank. The section titled, "Plan of Care: Rehabilitation Potential and Discharge Plans", was blank. On 01-05-2023 at 10:15 AM, a clinical record review was completed on Patient #26. Patient #26 had a SOC date of 09-30-2021. The certification reviewed was for period11-24-2022 through 01-22-2023. A document titled, "OASIS-D1 Recertification" was found to be incomplete by Registered Nurse (RN#1). The section titled, "Risk Assessment", was blank. The section titled, "Hospitalization Risk Assessment Tools", was blank. The section titled, "Sensory Status", was blank. The section titled, "Integumentary Status", was blank. The section titled, "Cardiac Status", was blank. The section titled, "Functional Status", was blank. The section titled, "Nutrition", was blank. On 01-06-2023 at 11:30 AM, a clinical record review was completed on Patient #7. Patient #7 had a SOC date of 10-07-2022. The SOC OASIS-D1 was found to be incomplete by RN #1. The section titled, "Cultural Preferences", was blank. The section titled, "Genitourinary", was blank.