Acme Health Service Inc.

“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 for 1 of 1 home health agency. Findings Include: 1. The agency provided a revised April 2017 ACHC Home Health 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, affecting the organization or the community and to ensure the safe management of staff while securing patient and employee records ...” 2. During a review of the Emergency Preparedness binder, it evidenced an undated document titled “Hazard Vulnerability Analysis Worksheet”. A document titled “Emergency Preparedness” dated 10-20-2023 evidenced the agency reviewed education regarding active shooter, tornado, flood, civil unrest, and emergency shelter. There was no evidence an active drill or tabletop exercise was ever completed. There was no evidence the agency’s emergency preparedness plan was reviewed annually or as needed. 3. During an interview with the Executive Director on 02-12-2024 at 5:09 PM, they indicated they had no Emergency Preparedness program and were working on it. They indicated the date April 2017 on the Emergency Preparedness policy was most likely the last time the policy was reviewed and revised. They indicated they had not performed a tabletop exercise and had not collaborated with local, state, and federal officials.”

“Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient’s medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This Condition is not met as evidenced by: Based on record review and interview, the agency failed to ensure they accepted patients needing therapy on the reasonable expectation that they were able to meet the patient’s therapy needs (See G570); the agency failed to ensure services were provided per the plan of care and failed to ensure each patient received an individualized plan of care that identified patient-specific and measurable outcomes and goals that was periodically reviewed and signed by a physician (see G572); failed to ensure all Durable Medical Equipment (DME) and Supplies, specific frequency and duration of visits and treatments, all safety measures to protect against injury, patient specific interventions, measurable outcomes and goals identified by the home health agency and patient (see G574); failed to alert the physician of changes in a patient’s condition (see G590); failed to coordinate care among all agency members that cared for patients (see G606); and failed to ensure they coordinated care delivery with other agencies providing care to ensure they meet the patient’s needs (see G608). These practices affected 6 of 6 active clinical records reviewed, (Patients: #1, 2, 3, 4, 5, and 6) and 6 of 6 focused audits of active clinical records reviewed, (Patients: #9, 10, 11, 12, 13, and 14) The cumulative effect of these 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 42 CFR 484.60 Care Planning, Coordination, Quality of Care. In regards to G570: Findings include: 1. An agency policy, with a revision date of October 2016, titled “Admission Criteria and Process” indicated but was not limited to. “ … A patient will be accepted for care based on consideration. Consideration will be given to the adequacy and suitability of organization personnel, and resources to provide the required services, and the reasonable expectation that the patient’s medical, nursing, rehabilitative, and social needs can be adequately met … Refusal of services will be documented in the clinical record. Notification of the Clinical Supervisor, physician, and referral source will follow with appropriate documentation in the clinical record … ” 2. An agency policy, with a revision date of October 2016, titled “Initial and Comprehensive Assessment” indicated but was not limited to. “ … The assessment will be patient-specific and comprehensive to include the patient’s need for home care, rehabilitative care, social, and discharge planning needs … ” 3. During a home visit on 02-09-2024 at 7:00 AM, Registered Nurse (RN)1, a family member of Patient #1 was observed providing 30 milliliters (ml) of water through Patient#1’s gastrojejunostomy (GJ) tube (a surgically placed soft narrow tube that enters the stomach in the upper part of the abdomen that allows for the passage of liquid feedings, water, and medications to be provided). Patient #1 was smiling and yelling out sounds and had uncontrollable jerky movements of their bilateral arms and legs. The Patient was observed to be on continuous feedings via a kangaroo feeding pump on an IV(Intravenous) pole at the patient’s bedside. The patient had a special ceiling track for their harness to transport the patient to their chair and the adjacent modified bathroom. The patient is totally dependent on positioning and wears a brief for incontinence of bowel and bladder. During an interview on 02-09-2024 at 7:00 AM, RN 1 indicated Patient #1 was recently admitted to Entity 10, for COVID-19, that caused increased muscle weakness, a decline in respiratory function in Patient #1. RN 1 indicated upon Patient#1’s discharge orders stated Patient #1 required physical therapy. When queried regarding Acme Health Services providing the ordered therapy when they admitted Patient #1, RN 1 stated, “No, they did not offer physical therapy.” 4. A review of the clinical record for Patient #1, the start of care date of 11-17-202, included a discharge instructions document from Entity 10, the acute care facility, dated 11-10-202. The discharge instructions indicated the patient’s diagnoses as Acute Hypoxic Respiratory Failure, Community-Acquired Pneumonia, COVID-19, Global Developmental Delay, Impaired Mobility and Activities of Daily Living (ADLs), Localization-related Epilepsy, Neuromuscular Scoliosis, and Sepsis. The document indicated care needs after discharge Home Health Therapy Services and Physical Therapy evaluation and treatment. The record contained agency documents titled, “Client Logging Reports” dated 11-17-2023 through 02-12-2024, which failed to evidence communication notes regarding notification of the family member’s refusal of physical therapy, the Clinical Manager being notified, and the patient’s physician being notified of refusal of services. During an interview on 02-08-2024 at 2:24 PM, the Executive Director, Admin 2, indicated Patient #1’s family member declined physical therapy. When queried regarding the documentation regarding the family member’s refusal of physical therapy, Admin 2 confirmed there no documentation was noted in the record. A review of the Start of Care Assessment dated 11-17-2023 completed by RN 3, indicated Patient #1 was discharged from an acute care facility in the last 14 days. The section titled, “Respiratory Status” indicated the patient had a cough, a past COVID infection, nebulizer treatment with Albuterol (an aerosol medication used in a machine to open up airways making breathing easier) every 6 hours, and required suctioning as needed. The section titled, “ ADLs/IADLs (Activities of Daily Living/Instrumental Activities of Daily Living) indicated Patient #1 was Bedfast, totally dependent on toileting, bathing, dressing, grooming, and transferring. The section titled, “Functional Abilities” indicated the patient was dependent for self-care, indoor mobility, and functional cognition. Patient #1 has a manual and motorized wheelchair for devices used for manual transportation needs. During an interview on 02-12-2024 at 4:38 PM, RN 3, when queried regarding Patient #1’s start of care assessment and need for physical therapy, indicated they were not aware of the patient’s need for therapy. RN 3 further indicated the agency did not provide them with discharge instructions from Entity 10, an acute care facility. RN 3 confirmed if a patient has had a decline in mobility, they needed to obtain a physician order for therapy to evaluate. When queried regarding Patient #1’s recent hospitalization, and decline in mobility, RN 3 indicated Patient #1 needed physical therapy. 5. On 02-12-2024 from 5:25 PM to 6:08 PM, the findings were reviewed with the Administrator, Admin 2, and the Clinical Manager, no further information or documentation was provided.”

“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 ensure they implemented, documented, and maintained an effective, ongoing data-driven Quality Assessment and Performance Improvement (QAPI) program, involved all agency services, utilized quality indicators data, included data from OASIS data, failed to focus on high risk, high volume, or problem-prone areas including the use of emergent care, services, admissions, re-admission, considered incidence, and severity of problems in those areas, take immediate corrective actions identified that could directly or potentially threaten the health and safety of patients; failed to ensure the performance improvement projects analyzed their root cause and implemented appropriate actions and tracked the performance to ensure improvements are achieved; failed to ensure they conducted an annual performance improvement projects to ensure measurable progress had been achieved; and the Governing Body failed to ensure the QAPI program reflected the complexity of its organization and services in the their quality improvement program; failed to document QAPI activities including reasons for Performance Improvement Projects and progress achieved on these projects.; failed to measure, analyze, and track, their monitoring of infections, incidents, and adverse events; failed to keep current and monitoring of their required quality measure; submit reports in mandated format within required timeframes per agency policy; failed to set clear expectations for patient safety: failed to complete self-assessment of the agency organization performance per agency policy; and failed to set clear expectations for patient safety; and that any findings of fraud or waste are addressed. The lack of an effective QAPI program impacts all 54 patients receiving services. The cumulative effect of these systemic problems resulted in the agency’s ability to ensure patients received appropriate services which could result in the agency not providing quality health care for Condition of Participation of 42 CFR 484.65 Quality Assessment Performance Improvement. 1. An agency policy with a revision date of April 2017, titled “ Improving Organizational Performance” indicated but was not limited to, “Purpose: To establish patient outcomes as the primary focus of the organization’s performance improvement activities. To improve organizational performance by focusing on high-risk, high volume, and problem-prone areas … Performance improvement results will be utilized to address problem issues, improve the quality of care and patient safety, and will be incorporated into a program planning and process design and modifications … The governing Body is responsible for ensuring that the performance improvement program is defined, implemented, maintained, and evaluated annually … Identify and set specific outcomes for measurable improvement and acceptable limits for findings. 1. At least one important aspect related to care must be monitored through the use of OASIS data … function or service care must be monitored ….Patient satisfaction surveys will be monitored … Measuring current performance against past performance …The organization must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects … Assure each performance improvement activity contains the following elements: 1. Descriptive indicator (s)/activities to be conducted 2. Frequency of activities 3. Designation of responsible party 4. Method(s) of data collection 5 Acceptable limits for findings … 7. Follow-up plans … Trends identified through performance improvement measurement and analysis will be reported to the Governing Body on a quarterly basis, 5. Results of performance improvement activities will be communicated with all staff via intranet, newsletters, email, etc … ” 2. On 02-12-2024 at 1:51 PM, the Executive Director, Admin 2, provided a folder containing the agency’s QAPI. The folder contained an agency document titled, “QAPI Scheduled Items for Review Tracker 2023/2024” with a revision date of 2-11-2024. The folder contained an agency document titled, “ Quality Assessment and Performance Improvement (QAPI) Plan” from the agency’s policy and procedure book. During an interview on 02-12-2024 at 1:46 PM, Admin 2, confirmed they had completed the revised schedule tracker document over the weekend. Admin 2 further indicated they just did not have time to do an outcome-based QAPI. Admin 2 had no data to show measurable improvements, data collection of patient safety, or health outcomes related to quality of care. 3. On 02-12-2024 at 2:02 PM, Admin 2, provided agency documents titled, “QAPI Planning Meeting Outcomes and Follow Up” dated October 2, 2023, and September 1, 2023. The documents failed to indicate who was at the meetings, and the time of the meetings, and failed to address patient outcomes, trends, and plans. During an interview on 02-12-2024 at 2:09 PM, Admin 2, indicated the agency had no performance improvement projects (PIP) and could provide no further documents regarding the agency’s QAPI program. 4. On 02-12-2024 at 5:25 PM-6:08 PM, the findings were reviewed with the Administrator, Admin 2, and the Clinical Manager, in which they had no further information or documentation to provide.”

“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 record review and interview, the agency failed to ensure the Administrator was managing the day to day operations of the agency (see G948); failed to ensure the Clinical Manager had a signed job description and was aware of their position as Alternate Administrator (see G954); failed to ensure care was coordinated with other providers in the patient’s home and the plan of care was updated, completed, and patient-specific (see G962); and failed to ensure the patient’s needs were assessed as needed through comprehensive assessments (see G966). The cumulative effect of these 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 42 CFR 484.105 Organization and Administration of Services. *”

“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 2 of 2 qualified active skilled records reviewed where OASIS information was collected and transmitted. (Patients: #1, and 2) Findings Include: 1. An agency policy with a revision date of October 2016, titled “OASIS Data Transmission” indicated but was not limited to, “ ... Policy: The organization will adhere to all OASIS data transmission requirements as outlined in the Medicare Conditions of Participation, Reporting of OASIS Information 42 CFR 484.20. Procedure: 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 Agency final validation reports during presurvey preparation, with a reporting period of 10-01-2023 through 02-02-2024, indicated 2 records of Patient #1 with a submission date of 10-17-2023. Record 1 indicated Reason for Assessment (RFA) 04 (a Recertification), with an M0090 date of 11-15-2022. The submission date is more than 30 days after the M0090 date on this record. Record 2 indicated an RFA of 04 (a Recertification), with an M0090 date of 01-12-2023. The submission date is more than 30 days after the M0009 date on this record. The OASIS Agency Final Validation reports failed to evidence records of Patient #2 and failed to evidence timely submission of Patient #1. 3. A review of 2 Oasis Agency final validation reports on 01-12-2024, provided by the Executive Director, Admin 2, with a submission date of 02-10-2024, indicated 2 submissions were completed for a total of 3 records processed. On 02-10-2024 at 11:27 AM, Patient #1 RFA 04 (a Recertification), with a M0090 date of 01-12-2024, was submitted. On 02-10-2024 at 11:13 AM, submission of Patient #2’s RFA 04 (a Recertification), with an M0090 date of 11-29-2023. The submission date is more than 30 days after the M0090 date on this record. The second submission of Patient #2’s RFA 04 (a Recertification), with an M0090 date of 01-29-2024. 4. A review of the active clinical record for Patient #1 was reviewed, with a start of care date of 11-17-2024. The OASIS initial certification assessment was to be submitted for transmission by 12-17-2024. The record failed to evidence that OASIS submission occurred within 30 days of completion. 5. A review of the active clinical record for Patient #2 was reviewed, with a start of care date of 07-08-2017. The record evidence a recertification of 12-04-2023 to 02-01-2024. The OASIS recertification dated 11-29-2023, failed to be submitted for transmission by 12-29-2023. The record failed to evidence the OASIS submission occurred within 30 days of completion. During an interview on 02-12-2024 at 1:00 PM, the Executive Director, Admin 2, indicated they submitted the OASIS into IQIES. Admin 2 confirmed the OASIS had been transmitted late for Patient #1 and 2.”

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure services were provided per the plan of care and failed to ensure each patient received an individualized plan of care, identified patient-specific measurable outcomes and goals for 5 of 6 active records reviewed (Patients: #1, 3, 4, 5, and 6) and 2 of 6 focused records reviewed (Patients: #11, and 14) Findings Include: 7. A review of Patient #4’s clinical record evidenced a plan of care with a start of care date of 02-18-2019 and a recertification date from 01-23-2024 to 03-22-2024 and indicated a primary diagnosis of Multiple Sclerosis (a disease of the brain and spinal cord affecting speech and movement), Idiopathic peripheral autonomic neuropathy (a disease causing damage to the nervous system, causing pain and weakness in the body), Hypertensive heart disease (chronic high blood pressure causing changes in the heart), Chronic diastolic heart failure (the main pumping chamber in the heart becomes stiff and fails to fill with blood properly), Hyponatremia (low sodium), Hypokalemia (low potassium), and Hyperlipidemia (high lipid levels, such as cholesterol). The plan of care evidenced the patient had a no-added salt diet. A review of the clinical record evidenced a document dated 08-22-2023, and it evidenced Patient #4 had allergies to the medications Lisinopril (a medication to lower blood pressure and Triamterene (a medication used to help increase the flow of urine and prevents the user from losing too much potassium). The Home Health Aide (HHA) plan of care (POC) dated 07-31-2023, indicated but was not limited to, “ … Allergies … NKA – No Known Allergies …”. The assessment failed to ensure the patient’s allergies were listed. The HHA POC failed to indicate the patient had a no-salt-added diet. The HHA POC failed to be updated every 60 days. The HHA POC failed to evidence patient-specific and measurable goals for the patient. 8. A review of Patient #5’s clinical record evidenced a Home Health Aide (HHA) plan of care (POC) dated 07-31-2023. The HHA POC failed to be updated at least every 60 days according to the agency’s policy. The HHA POC evidenced the patient had a diagnosis of Quadriplegia (paralysis of all 4 limbs). The clinical record evidenced a plan of care, with a start of care date of 11-13-2019 and a recertification date from 12-22-2023 to 02-19-2024, and indicated a primary diagnosis of Quadriplegia (paralysis of all 4 limbs), Multiple Sclerosis (a disease of the brain and spinal cord affecting speech and movement), Ataxia (loss of muscle coordination), and Contracture of muscle. The plan of care, dated 12-18-2023 by the Clinical Manager (Admin) 3, evidenced a section titled “60 Day Summary” and indicated the patient had increased difficulty and pain when swallowing food. The HHA POC failed to evidence the patient was at risk of aspiration (when food or liquid enters a person’s airway). The HHA POC failed to evidence the durable medical equipment (DME) used to care for the patient. The HHA POC failed to evidence the safety measures to promote skin integrity for an individual with a diagnosis of Quadriplegia. The plan of care failed to identify patient-specific measurable goals, identified the patient’s specific needs, and failed to provide direction to the clinicians providing patient care. 9. A review of Patient #14’s POC with a start of care date of 12-30-2023 and a certification period from 12-20-2023 to 02-17-2024. The POC was signed by Registered Nurse (RN) 3 on 01-01-2024. The POC failed to be completed and signed by a physician according to the agency policy. The plan of care failed to include patient-specific and measurable goals, identified the patient’s needs, and failed to direct the clinicians providing care. 10. During an interview with Admin 3 on 02-09-2024 at 12:45 PM, they indicated the HHA POC included frequency and duration of tasks, goals, interventions, and safety measures to ensure the HHA was aware of the patient’s needs. 11. During an interview with Admin 3 on 02-12-2024 at 3:28 PM, they indicated the HHA POC was only updated as needed and as the patient’s condition warranted. 410 IAC 17-13-1(a) 1. An agency policy with a revision date of October 2016, titled “Care Planning Process” indicated but was not limited to, “Purpose: To provide clinical direction to the clinicians providing patient care … A written plan of care will be initiated within five (5) days of start of care and updated at least every 60 days or as patient’s condition warrants … The patient and family/caregiver will participate in decisions regarding the plan of care … The care planning process will be documented on the plan of care, individualized discipline-specific care plans … The plan of care includes: … G. Goals/outcomes to be achieved … ” 2. A review of the clinical record for Patient #1 contained a recertification comprehensive assessment dated 01-12-2024, and electronically signed by the Clinical Manager. The comprehensive reassessment failed to contain patient-specific goals, address progress towards any goals, and discharge plans when services are no longer authorized by the payer. A review of the plan of care for the recertification period from 01-16-2024 to 0-15-2024, The plan of care indicated but was not limited to diagnoses, Spastic quadriplegic cerebral palsy (a condition that affects the ability to control muscles and movement in all four limbs, the trunk, and face), Neuromuscular scoliosis (a sideways curvature of the spine), Localization-related (focal) (partial) symptomatic epilepsy (a condition caused by certain brain activity causing seizure activity). The section titled “Goals/Rehabilitation Potential/Discharge Plans” indicated goals were left blank, rehabilitation potential fair, and discharge plans when services are no longer authorized by payer. The plan of care failed to be patient-specific, failed to provide clinical directions to clinicians providing care, and failed to list any goals for Patient #1. During an interview on 02-09-2024 at 7:10 AM, when queried regarding their involvement in the plan of care, Registered Nurse (RN)1, a family member of Patient #1, indicated the Clinical Manager had come to the home to review Patient 1’s medication but did not review or involve RN 1 in the plan of care. 3. During an interview on 02-08-2024 at 1:57 PM, the Clinical Manager confirmed no goals were listed on the plan of care, and there was not a seizure plan in place for Patient #1. 4. A review of the clinical record for Patient #3, contained a recertification comprehensive assessment dated 01-25-2024, and electronically signed by RN 3. The comprehensive assessment failed to contain patient-specific goals and address progress toward any goals, and discharge planning was marked as not applicable (NA). A review of the plan of care for the recertification period from 01-30-2024 to 03-29-2024, indicated but was not limited to diagnoses, Chronic kidney disease (the failure of the kidney to filter wastes and excess fluid from your blood), Dependence on supplemental oxygen, Diabetes mellitus with diabetic neuropathy (a condition caused by long-term elevated blood sugars causing nerve damage) and Anemia in chronic kidney disease (a condition where the red blood cell count is low due to impaired kidney function). The plan of care indicated orders for Attendant Care for 65 to 60 hours weekly and a Home Health Aide hourly for 91 hours a week but failed to treatment, and patient-specific goals The section titled “Problems/Interventions/Goals” indicated the patient’s stated goal was no hospitalizations or falls, rehabilitation potential fair, and discharge plans when services are no longer authorized by payer. The plan of care failed to identify patient-specific measurable outcomes, and goals that identified the patient’s specific needs and failed to provide direction to the clinicians providing patient care. A review of home health aide visit notes dated 12-26-2023, 12-27-2023, 12-29-2023, 01-03-2024, 01-04, 01-07, 01-08, 01-09, 01-10, 01-11, 001-22, 01-25, 01-30, 01-31, 02-02, 02-04, 02-05, and 02-08-2024 were left blank with no tasks completed. The record failed to contain a home health aide care plan. During an interview on 02-12-2024 at 4:47 PM, RN 3 indicated they did not include discharge planning due to the patients being long-term, and they did not know how to find out if there were other disciplines in the home. RN 3 further indicated they were to include goals in care planning, and they were to complete rehab potential. When queried regarding the Home Health Aide care plan for Patient #3, indicated Patient #3 had an Attendant care for errands, and assists with showers, they were unaware of the Home Health Aide for Patient #3. 5. During an interview on 02-12-2024 at 5:08 PM, the Clinical Manager confirmed Patient #3 had a Home Health Aide. When queried regarding the Home Health Adie care plan the Clinical Manager confirmed there was no Home Health Aide care plan in Patient #3’s record. 6. A review of the clinical record for Patient #6 contained a comprehensive reassessment dated 01-15-2024, electronically signed by the Clinical Manager. The comprehensive assessment indicated in the section titled “Problems/Interventions/Goals” was left blank. The assessment failed to include patient-specific measurable goals and discharge planning. A review of the plan of care for the recertification period from 01-10-2024 to 03-09-2024, indicated The plan of care indicated but was not limited to diagnoses, Chronic combined systolic (congestive) and diastolic heart failure (the heart’s inability to pump blood to the rest of the body), Chronic atrial fibrillation (an irregular and often rapid heart rhythm that can lead to blood clots), Pain in the right knee, and Essential hypertension (high blood pressure). The record contained a recertification comprehensive assessment dated 01-15-2024, electronically signed by the Clinical Manager. The plan of care failed to identify patient-specific measurable outcomes, goals that identified the patient’s specific needs, and failed to provide direction to the clinicians providing patient care. During an interview on 02-12-2024 at 1:00 PM, when they were shown the care plans for the patients, the Executive Director, Admin 2, indicated they saw no goals on the patient’s care plans. 7. A focused review of the clinical record of Patient #11, contained a comprehensive reassessment, dated 02-07-2024 electronically signed by the Clinical Manager. The comprehensive reassessment indicated in the section titled “Problems/Interventions/Goals” was left blank. The comprehensive reassessment failed to contain patient-specific goals, address progress towards any goals, and discharge plans. A review of an incomplete plan of care for the recertification from 02-11-2023 to 04-10-2024, indicated but was not limited to diagnoses, Unspecified symptoms and signs involving functions following cerebral infarction (the effects of a stroke when the brain cells die when they do not get enough blood), Chronic diastolic (congestive) heart failure (the heart’s inability to pump blood to the rest of the body) and Chronic atrial fibrillation ((an irregular and often rapid heart rhythm that can lead to blood clots). During an interview on 08-12-2024 at 12:45 PM, the Executive Director, Admin 2, and the Clinical Manager confirmed there were no goals, or care preferences listed on the plan of care for Patients #1, 3, 6, and 11.”

“Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This Standard is not met as evidenced by: Based on record review and interview, the Case Manager failed to ensure the home health aide care plan was completed, individualized, and patient-specific for 1 of 3 active patient records reviewed. (Patient: #3) Findings Include: 1. An agency policy with a revision date of October 2016, titled “Home Health Aide Plan of Care” indicated, “ … The patient’s Case Manager, upon initialization of aide services, will develop the home health aide plan of care … The home health aide plan of care will be individualized to the specific patient … The Case Manager will review the home health aide plan of care with the aide assigned to the case … ” 2. A review of the clinical record for Patient #3, contained a plan of care for the recertification period from 01-30-2024 to 03-29-2024, electronically signed by the Registered Nurse (RN) 3, dated 01-25-2024. The plan of care indicated but was not limited to in the section titled “Orders for Disciplines and Treatments” orders for Attendant (ATTC) 65-69 hours weekly for 1 certification period and Home Health Aide (HHA) 91 hours weekly for 1 certification period. The plan of care failed to evidence treatments, problems, or interventions to be completed by the HHA. During an interview on 02-12-2024 at 10:45 AM, Patient #3, indicated they did not want to be interviewed and hung up. 3. During an interview on 02-12-2024 at 4:47 PM, when queried about the HHA care being provided to Patient #3, RN 3 indicated they were unaware of the home health aide being assigned to provide care to Patient #3. RN 3 further indicated they were only aware of the Attendant providing care. 4. During an interview on 02-12-2024 at 5:08 PM the Clinical Manager confirmed Patient #3’s clinical record had no HHA plan of care. When queried about how the HHA knew the patient care needs the Clinical Manager indicated the HHA must be that good of a HHA and knew what to do. 410 IAC 17-13-2(a) 410 IAC 17-14-1(m)”

“Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient’s current health, psychosocial, functional, and cognitive status; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessments were complete and accurately reflected the patient’s status, including health, psychosocial, and cognitive status in 4 of 6 active records reviewed (Patients: #1, 3, 4, and 5) and 5 of 6 and focused records reviewed. (Patients: #10 11, 12, 13, and 14) Findings Include: A review of Patient #4’s clinical record evidenced a plan of care with a start of care date of 02-18-2019 and a recertification date from 01-23-2024 to 03-22-2024 and indicated a primary diagnosis of Multiple Sclerosis (a disease of the brain and spinal cord affecting speech and movement), Idiopathic peripheral autonomic neuropathy (a disease causing damage to the nervous system, causing pain and weakness in the body), Hypertensive heart disease (chronic high blood pressure causing changes in the heart), Chronic diastolic heart failure (the main pumping chamber in the heart becomes stiff and fails to fill with blood properly), Hyponatremia (low sodium), Hypokalemia (low potassium), and Hyperlipidemia (high lipid levels, such as cholesterol). The plan of care evidenced the patient had a no-added salt diet. A review of the clinical record evidenced a document dated 08-22-2023, and it evidenced Patient #4 had allergies to the medications Lisinopril (a medication to lower blood pressure and Triamterene (a medication used to help increase the flow of urine and prevents the user from losing too much potassium). The comprehensive assessment dated 01-18-2024, by Registered Nurse (RN) 3, indicated but was not limited to, “ … Allergies … NKA – No Known Allergies …”. The assessment failed to ensure the patient’s allergies were listed. The assessment indicated the patient had a regular diet, and failed to indicate the patient had a no-salt diet. The assessment failed to include a diet for a patient with diagnoses of Hypertensive heart disease, Chronic diastolic heart failure, Hyponatremia, Hypokalemia, and Hyperlipidemia. The comprehensive assessment failed to evidence an assessment was performed on the patient, including but not limited to, the evaluation of the cardiopulmonary, neuromuscular, gastrointestinal, urinary, and integumentary systems. The comprehensive assessment evidenced the patient had incontinence for bowel and bladder but failed to indicate the frequency. The comprehensive assessment failed to evidence the patient’s current health status such as quality of breathing, heart sounds, strength in extremities, bowel movements, nausea, urinary incontinence, and skin integrity. The plan of care evidenced the patient had a history of seizures, but the comprehensive assessment failed to include the assessment of seizure activity. A review of Patient #5’s clinical record evidenced a plan of care with a start of care date of 11-13-2019 and a recertification date from 12-22-2023 to 02-19-2024 and indicated a primary diagnosis of Quadriplegia (paralysis of all 4 limbs), Multiple Sclerosis (a disease of the brain and spinal cord affecting speech and movement), Ataxia (loss of muscle coordination), and Contracture of muscle). The plan of care, dated 12-18-2023 by the Clinical Manager (Admin) 3, evidenced a section titled “60 Day Summary” and indicated the patient had increased difficulty and pain when swallowing food and constipation. The clinical record evidenced a comprehensive assessment dated 12-18-2023 by Admin 3. The comprehensive assessment indicated in the section titled “Physical Evaluation” regarding the patient’s pain, “ … No Pain or Pain does not interfere with activity or movement …”. The assessment failed to include the patient’s increase in pain and difficulty in swallowing food. The assessment failed to evidence an assessment was performed on the patient, including but not limited to, the evaluation of the cardiopulmonary, neuromuscular, and integumentary systems. The comprehensive assessment failed to evidence the patient’s current health status such as quality of breathing, heart sounds, and skin integrity. The assessment indicated the patient was unable to self-administer medications but failed to indicate the individual responsible for assisting the patient with medication administration. A review of Patient #9’s clinical record evidenced a plan of care with a start of care date of 12-01-2018 and a recertification date from 01-04-2024 to 03-03-2024 and indicated a primary diagnosis of aftercare following joint replacement surgery, gait and mobility abnormalities, history of falling, Right artificial hip joint, pain in left hip, pain in right shoulder, Anemia (low level of red blood cells), Hypertension (high blood pressure), and a history of Transient Ischemic Attack (a brief interruption of blood to the brain). The clinical record included a comprehensive assessment dated 01-03-2024, by Admin 3, and included a section titled “Pain Assessment”. The assessment indicated the patient’s current pain was a 3 on a scale from 1 (least amount of pain) to 10 (greatest amount of pain) and was a 7 at the worst. The pain assessment failed to include the onset of the pain, the pain description, if the pain radiated, if there was a pattern to the pain, pain duration, and activities of daily living the pain affected. The comprehensive assessment failed to evidence an assessment was performed on the patient, including but not limited to, the evaluation of the cardiopulmonary, neuromuscular, gastrointestinal, urinary, and integumentary systems. The comprehensive assessment failed to evidence the patient’s current health status such as quality of breathing, heart sounds, strength in extremities, bowel movements, nausea, urinary frequency, and skin integrity. A review of Patient #10’s clinical record evidenced a plan of care with a start of care date of 06-09-2019 and a recertification date from 01-14-2024 to 03-13-2024 and evidenced diagnoses of Autistic disorder (a developmental disability), speech disturbances, and behavioral and emotional disorders. The clinical record evidenced a comprehensive assessment dated 01-10-2024, by Admin 3, and failed to evidence an assessment was performed on the patient, including but not limited to, the evaluation of the cardiopulmonary, neuromuscular, gastrointestinal, urinary, and integumentary systems. The comprehensive assessment failed to evidence the patient’s current health status such as quality of breathing, heart sounds, strength in extremities, bowel movements, nausea, urinary frequency, and skin integrity. The assessment indicated the patient was unable to self-administer medications but failed to indicate the individual responsible for assisting the patient with medication administration. A review of Patient #13’s clinical record evidenced a plan of care with a start of care date of 10-12-2022 and a recertification date from 02-04-2024 to 04-03-2024 and evidenced the diagnoses Chronic kidney disease, stage 5, unilateral osteoarthritis in the right hip (a disease where tissue in the right hip joint breaks down over time), chronic pain, Hypertension (high blood pressure), muscle weakness, and Benign prostatic hyperplasia with lower urinary tract symptoms (enlarged prostate, with frequent urination or a weak stream). The clinical record evidenced a comprehensive assessment dated 01-31-2024, by Admin 3, and failed to evidence an assessment was performed on the patient, including but not limited to, the evaluation of the cardiopulmonary, neuromuscular, gastrointestinal, urinary, and integumentary systems. The comprehensive assessment failed to evidence the patient’s current health status such as quality of breathing, heart sounds, strength in extremities, bowel movements, nausea, urinary frequency, and skin integrity. The assessment evidenced the patient had no pain interfering with activity or movement, but the patient had a diagnosis of chronic pain. The plan of care evidenced in the section titled “60 Day Summary” the patient’s mobility was impaired related to the deteriorated tissue and required a knee brace to help improve pain and ambulation. The patient had a diagnosis of benign prostatic hyperplasia with lower urinary tract symptoms, but the assessment indicated the patient had no urinary incontinence. A review of Patient #14’s clinical record evidenced a comprehensive assessment dated 12-30-2023, by Registered Nurse (RN) 3, and it failed to evidence a list of the patient’s diagnoses. The assessment evidenced a section titled “Pain Assessment”, and the assessment indicated the patient’s current pain was a 6 on a scale from 1 (least amount of pain) to 10 (greatest amount of pain). The pain assessment failed to include the onset of the pain, how the pain numbers were collected, the pain description, if the pain radiated, if there was a pattern to the pain, pain duration, and activities of daily living the pain affected. The assessment indicated the patient used oxygen intermittently but failed to indicate when the patient used the oxygen. During an interview with Admin 3 on 02-12-2024 at 3:28 PM, they indicated during a comprehensive assessment, they assessed every body system including but not limited to, head to toe, skin assessment, weight, appetite, bowels, urine, and vitals. They indicated they completed a full assessment for all recertifications and comprehensive assessments. During an interview with Registered Nurse (RN) 3 on 02-12-2024 at 4:45 PM, they indicated for a comprehensive assessment they received vitals signs, assessed all the body systems from head to toe, recorded any falls, changes in medications, assessed pain, reviewed medications, included durable medical equipment (DME), ensured the caregiver was following the ordered frequency, asked COVID-19 questions. 410 IAC 17-14-1(a)(1)(B) 1. An agency policy with a revision date of October 2016, titled “Initial and Comprehensive Assessment” indicated but was not limited to, “ …The assessment will be patient-specific and comprehensive to include the patient’s needs for home care, rehabilitative care, social, and discharge planning needs … Patient’s functional status, including but not limited to … The patient’s psychosocial status … cognitive limitations … Equipment presently in the home… Any identified symptoms of pain … Patient and family/caregiver support systems and the type of care the family/caregiver is available, capable, and willing to provide care … ” 2. An agency policy with a revision date of October 2016, titled “Ongoing Assessments” indicated but was not limited to, “ …The clinician will reassess the patient for: A. Blood pressure, pulse, respirations, temperature C. Pain status D. Breath sounds E. Skin integrity. F. Bowel sounds; elimination (urinary and bowel) G. Appetite/diet, nutritional status H. Mental status I. Functional Status J. Safety/home environment K. Patient and family/caregiver support L Progress towards goals and patient needs and problems M. Compliance to treatment and/or medications … Patient’s response to care … Changes in patient condition … ” 3. During a home visit at the residence of Patient #1 on 02-09-2024 at 7:00 AM, the patient was observed in bed with a wedge cushion propping the patient on their side. The specialized bed had cushions side against the frame on the bed. The Registered Nurse (RN) 1, a family member of Patient #1, was observed disconnecting Patient #1’s gastrojejunostomy (GJ) tube (a surgically placed soft narrow tube that enters the stomach in the upper part of the abdomen that allows for the passage of liquid feedings, water, and medications to be provided) from the kangaroo feeding pump ( a machine used to deliver hydration and nutrition) and flushed with 30 milliliters (ml) of water. RN 1 indicated Patient #1’s last seizure was in October 2023. RN 1 indicated Patient #1 has Diazepam ( used to treat anxiety, muscle spasms, and seizures) oral and nasal liquid to use as needed for seizures. The patient also receives Baclofen ( used to treat muscle spasms). RN 1 confirmed the Clinical Manager did not review seizure plans or question RN1 regarding the patient’s last seizure during their visit. A review of the clinical record for Patient #1, start of care 11-17-2024, contained a recertification comprehensive assessment dated 01-12-2024, and electronically signed by the Clinical Manager. The comprehensive assessment indicated vital signs listed were a blood pressure of 118/74, but failed to list posture and activity, heart rate listed at 78 and location radial, but failed to list regular or irregular and posture, respiratory status indicated oxygen saturation level of 98% and lung sounds were absent, the nutritional status indicated regular diet, tube feeding 240 cubic centimeters (cc) frequency 3 times daily, pureed diet, thickened liquids, tube feeding continuous, gastrojejunostomy tube type, and size was left blank, neurological status indicated pupils were equal weakness of cerebral palsy (a condition marked by impaired muscle coordination and spasms), and neurological impairments indicated memory loss, but failed to address seizures. A review of the plan of care for the recertification period from 01-16-2024 to 03-15-2024, indicated but was not limited to diagnoses, Spastic quadriplegic cerebral palsy (a condition that affects the ability to control muscles and movement in all four limbs, the trunk, and face), Neuromuscular scoliosis (a sideways curvature of the spine), Localization-related (focal) (partial) symptomatic epilepsy (a condition caused by certain brain activity causing seizure activity). During an interview on 02-08-2024 at 10:38 AM, the Clinical Manager confirmed they did not review or complete a seizure plan for Patient #1. The Clinical Manager indicated they are to complete a head-to-toe assessment on every comprehensive reassessment. 4. A review of the clinical record for Patient #3, start of care 04-05-2023, contained a recertification comprehensive assessment dated 01-25-2024, electronically signed by RN 3. The comprehensive assessment failed to include a physical assessment including respiratory with oxygen needs, vital signs, and diagnoses, diet indicated regular with adequate food supply in the home, failed to indicate Patient #3 was on a renal diet with fluid restrictions, discharge planning indicated not applicable. A review of the plan of care for the recertification period 01-30-2024 to 03-29-2024, indicated but was not limited to diagnoses, Chronic kidney disease (the failure of the kidney to filter wastes and excess fluid from your blood), Dependence on supplemental oxygen, Diabetes mellitus with diabetic neuropathy (a condition caused by long-term elevated blood sugars causing nerve damage) and Anemia in chronic kidney disease (a condition where the red blood cell count is low due to impaired kidney function). During an interview on 02-12-2024 at 4:47 PM, when queried regarding the process of conducting a comprehensive reassessment, RN 3 indicated they were to complete vital signs and system checks. RN 3 further indicated they do not include discharge planning, and they think they may need a refresher in the processes. 5. A focused review of the clinical record of Patient #11, contained a comprehensive reassessment, dated 02-07-2024 electronically signed by the Clinical Manager. The recertification comprehensive assessment failed to evidence a head-to-toe assessment and failed to address medical and psychosocial needs. A review of an incomplete plan of care for the recertification from 02-11-2023 to 04-10-2024, indicated but was not limited to diagnoses, Unspecified symptoms and signs involving functions following cerebral infarction (the effects of a stroke when the brain cells die when they do not get enough blood), Chronic diastolic (congestive) heart failure (the heart’s inability to pump blood to the rest of the body) and Chronic atrial fibrillation ((an irregular and often rapid heart rhythm that can lead to blood clots). 6. A focused review of the clinical record of Patient #12, contained a comprehensive reassessment, dated 01-24-2024 electronically signed by the Clinical Manager. The recertification comprehensive assessment failed to evidence a head-to-toe assessment and failed to address medical and psychosocial needs. A review of an incomplete plan of care for the recertification from 01-26-2023 to 03-25-2024, indicated but was not limited to diagnoses, Cerebral palsy (a condition that affects the ability to control muscles and movement) and Unspecified intellectual disabilities. During an interview on 02-12-2024 at 10:20 AM, the Clinical Manager confirmed that head-to-toe assessments are to be completed during a comprehensive reassessment.”

“Strengths, goals, and care preferences CFR(s): 484.55(c)(2) The patient’s strengths, goals, and care preferences, including information that may be used to demonstrate the patient’s progress toward achievement of the goals identified by the patient and the measurable outcomes identified by the HHA; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure all patients received a comprehensive assessment reflecting their current strengths, patient-specific and measurable goals, and care preferences for 5 of 6 active clinical records reviewed (Patients #1, 3, 4, 5, and 6) and 5 of 6 active focused records reviewed (Patients #9, 10, 11, 13, and 14) Findings Include: 10. A review of the clinical record for Patient #1, start of care date of 11-17-2024, contained a plan of care for the recertification period from 01-16-2024 to 03-15-2024. The plan of care indicated but was not limited to diagnoses, Spastic quadriplegic cerebral palsy (a condition that affects the ability to control muscles and movement in all four limbs, the trunk, and face), Neuromuscular scoliosis (a sideways curvature of the spine), Localization-related (focal) (partial) symptomatic epilepsy (a condition caused by certain brain activity causing seizure activity). The record contained a recertification comprehensive assessment dated 01-12-2024, electronically signed by the Clinical Manager. The comprehensive assessment failed to contain patient-specific measurable goals, failed to include Patient #1’s strengths, and failed to include care preferences. During an interview on 02-02024 at 7:10 AM, Registered Nurse (RN) 1, the family member of Patient #1 indicated Patient #1 does not like loud noises. RN 1 further indicated Patient #1 enjoys swimming in the hot tub, loves to be talked to, and likes to listen to music. 11. During an interview on 02-12-2024 at 1:50 PM, the Clinical Manager confirmed Patient #1’s comprehensive assessment and plan of care did not contain strengths, goals, and care preferences. 12. A review of the clinical record for Patient #3, start of care 04-05-2023, contained a plan of care for the recertification period from 01-03-2024 to 03-29-2024. The plan of care indicated but was not limited to diagnoses, Chronic kidney disease (the failure of the kidney to filter wastes and excess fluid from your blood), Dependence on supplemental oxygen, Diabetes mellitus with diabetic neuropathy (a condition caused by long-term elevated blood sugars causing nerve damage) and Anemia in chronic kidney disease (a condition where the red blood cell count is low due to impaired kidney function). The record contained a recertification comprehensive assessment dated 01-25-2024, signed by RN 3. The comprehensive assessment indicated in the section titled “Problems/Interventions/Goals” indicated the patient’s stated goal was no hospitalizations or falls. The assessment failed to include the patient’s strengths, measurable patient-specific goals, and care preferences. During an interview on 02-12-2024 at 4:47 PM, RN 3 indicated they could use a refresher in training. RN 3 further indicated they were instructed they did not have to do goals and interventions. 13. A review of the clinical record for Patient #6, start of care 01-05-2024, contained a plan of care for the recertification period from 01-10-2024 to 03-09-2024. The plan of care indicated The plan of care indicated but was not limited to diagnoses, Chronic combined systolic (congestive) and diastolic heart failure (the heart’s inability to pump blood to the rest of the body), Chronic atrial fibrillation (an irregular and often rapid heart rhythm that can lead to blood clots), Pain in the right knee, and Essential hypertension (high blood pressure). The record contained a recertification comprehensive assessment dated 01-15-2024, electronically signed by the Clinical Manager. The comprehensive assessment indicated in the section titled “Problems/Interventions/Goals” was left blank. The assessment failed to include the patient’s strengths, patient-specific and measurable goals, and care preferences. During a home visit at Patient #6’s residence on 02-12-2024 at 10:00 AM, Patient #6 indicated they had short-term memory. Patient #6 indicated they had difficulty remembering to take their medication and doing their eye drops, until the patient and the Medical Social Worker (MSW), came up with the plan to do it at prayer time. Patient #6 is Muslim and prays 5 times a day. The MSW confirmed agency staff visits must be scheduled around the patient’s daily prayers. 14. A focused review of the clinical record of Patient #11, start of care 06-16-2023, contained an incomplete plan of care for the recertification from 02-11-2023 to 04-10-2024. The plan of care indicated but was not limited to diagnoses, Unspecified symptoms and signs involving functions following cerebral infarction (the effects of a stroke when the brain cells die when they do not get enough blood), Chronic diastolic (congestive) heart failure (the heart’s inability to pump blood to the rest of the body) and Chronic atrial fibrillation ((an irregular and often rapid heart rhythm that can lead to blood clots). The record contained a recertification comprehensive assessment dated 02-07-2024, electronically signed by the Clinical Manager. The comprehensive assessment indicated in the section titled “Problems/Interventions/Goals” was left blank. The assessment failed to include the patient’s strengths, patient-specific and measurable goals, and care preferences. During an interview on 08-12-2024 at 12:45 PM, the Executive Director, Admin 2, and the Clinical Manager confirmed there were no goals, or care preferences listed on the plan of care for Patients #1, 3, 6, and 11. 1. A review of an ACHC Home Health policy revised October 2016 titled “Initial and Comprehensive Assessment” Policy No. 4-018.1 indicated but was not limited to, “ … 4. A. Patient problems/needs/strengths … E. Baseline information to be used to measure the patient’s progress toward achievement of desired outcomes …” 2. A review of Patient #4’s clinical record evidenced a plan of care with a start of care date of 02-18-2019 and a recertification date from 01-23-2024 to 03-22-2024 and indicated a primary diagnosis of Multiple Sclerosis (a disease of the brain and spinal cord affecting speech and movement), Idiopathic peripheral autonomic neuropathy (a disease causing damage to the nervous system, causing pain and weakness in the body), Hypertensive heart disease (chronic high blood pressure causing changes in the heart), Chronic diastolic heart failure (the main pumping chamber in the heart becomes stiff and fails to fill with blood properly), Hyponatremia (low sodium), Hypokalemia (low potassium), and Hyperlipidemia (high lipid levels, such as cholesterol). The clinical record evidenced a comprehensive assessment dated 01-18-2023, by Registered Nurse (RN) 3, and indicated the patient required assistance from the Home Health Aide (HHA) and Homemaker for assistance including, but not limited to, personal care, grooming, bathing, dressing, and mobility. The assessment included a section titled “Problems/Interventions/Goals” and it evidenced the patient was to perform Instrumental Activities of Daily Living (IADLS) safely with assistance and indicated the goal was to be met by the first week of the start of the service. The goal was dated 09-21-2022. The agency failed to ensure the goal was patient-specific and measurable. A goal indicated the patient was to ambulate safely from the bedroom to the living room with their rollator/cane but failed to include when the goal was to be met. A goal indicated the activity tolerance was to be assessed. The agency failed to ensure the goal was patient-specific and measurable. The assessment failed to include seizure assessment and precaution goals. The comprehensive assessment failed to have patient-specific and measurable goals, the patient’s strengths, and care preferences related to the patient’s diagnoses. 3. A review of Patient #5’s clinical record evidenced a plan of care, with a start of care date of 11-13-2019 and a recertification date from 12-22-2023 to 02-19-2024 and indicated a primary diagnosis of Quadriplegia (paralysis of all 4 limbs), Multiple Sclerosis (a disease of the brain and spinal cord affecting speech and movement), Ataxia (loss of muscle coordination), and Contracture of muscle). The clinical record evidenced a comprehensive assessment dated 12-18-2023, by the Clinical Manager (Admin) 3, and indicated the patient required assistance from a home health aide for assistance including, but not limited to, personal care, grooming, bathing, dressing, and mobility. A section titled “Problems/Interventions/Goals” evidenced the patient was to receive assistance with ADLs (Activities of Daily Living) 5 days a week and their satisfaction with the agency. The comprehensive assessment failed to evidence patient-specific, measurable, and pertinent goals related to the patient’s diagnosis and need for home health aide (HHA) services, patient strengths, and any patient care preferences. 4. A review of Patient #9’s clinical record evidenced a plan of care with a start of care date of 12-01-2018 and a recertification date from 01-04-2024 to 03-03-2024 and indicated a primary diagnosis of aftercare following joint replacement surgery, gait and mobility abnormalities, history of falling, Right artificial hip joint, pain in left hip, pain in right shoulder, Anemia (low level of red blood cells), Hypertension (high blood pressure), and a history of Transient Ischemic Attack (a brief interruption of blood to the brain). The clinical record included a comprehensive assessment dated 01-03-2024, by Admin 3, and indicated the patient required assistance from the HHA for assistance including but not limited to grooming, bathing, dressing, and mobility. A section titled “Problems/Interventions/Goals” evidenced the patient’s goal was fall prevention through assessment and instruction with their mobility device. The goal failed to be patient-specific and measurable. A goal indicated the patient’s needs were met safely but failed to evidence how the goal was to be assessed. The assessment failed to include all necessary goals for a patient with a recent joint replacement, right artificial hip joint, pain in the left hip, and pain in the right shoulder. The assessment failed to include the patient’s strengths, patient-specific and measurable goals, and care preferences. 5. A review of Patient #10’s clinical record evidenced a plan of care with a start of care date of 06-09-2019 and a recertification date from 01-14-2024 to 03-13-2024 and evidenced diagnoses of Autistic disorder (a developmental disability), speech disturbances, and behavioral and emotional disorders. The clinical record evidenced a comprehensive assessment dated 01-10-2024, by Admin 3, and included a section titled “Problems/Interventions/Goals”. The goals indicated the patient received safe care during the certification period. The goals failed to indicate how the patient was safe during the care provided by the agency. The goals failed to be patient-specific and measurable for a patient with a developmental disorder, speech disturbances, and behavioral and emotional disorders. The assessment failed to include the patient’s strengths, patient-specific and measurable goals, and care preferences. 6. A review of Patient #13’s clinical record evidenced a plan of care with a start of care date of 10-12-2022 and a recertification date from 02-04-2024 to 04-03-2024 and evidenced the diagnoses Chronic kidney disease, stage 5, unilateral osteoarthritis in the right hip (a disease where tissue in the right hip joint breaks down over time), chronic pain, Hypertension (high blood pressure), muscle weakness, and Benign prostatic hyperplasia with lower urinary tract symptoms (enlarged prostate, with frequent urination or a weak stream). The clinical record evidenced a comprehensive assessment dated 01-31-2024, by Admin 3, and evidenced a section titled “Problems/Interventions/Goals”. The section evidenced a goal to assess and instruct on fall risks. The goal failed to be patient-specific and measurable. The assessment failed to include the patient’s strengths, patient-specific and measurable goals, and care preferences. 7. A review of Patient #14’s clinical record evidenced a comprehensive assessment dated 12-30-2023, by Registered Nurse (RN) 3, and it failed to evidence a list of the patient’s diagnoses. The assessment failed to include the patient’s strengths, patient-specific and measurable goals, and care preferences. 8. During an interview with Admin 3 on 02-12-2024 at 3:35 PM, they indicated the comprehensive assessment was to include the patient’s individualized goals and care preferences. 9. During an interview with Registered Nurse (RN) 3 on 02-12-2024 at 4:45 PM, they indicated they included the patient’s goals and any education needed in the comprehensive assessment.”

“Patient’s needs CFR(s): 484.55(c)(4) The patient’s medical, nursing, rehabilitative, social, and discharge planning needs; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure a complete and accurate assessment of the patient’s medical nursing, rehabilitative, social, and discharge planning needs in 5 of 6 active records reviewed (Patients: #1, 3, 4, 5, and 6) and 5 of 6 focused records reviewed. (Patients: #9, 10, 11, 13, and 14) Findings Include: A review of Patient #4’s clinical record evidenced a plan of care with a start of care date of 02-18-2019 and a recertification date from 01-23-2024 to 03-22-2024 and indicated a primary diagnosis of Multiple Sclerosis (a disease of the brain and spinal cord affecting speech and movement), Idiopathic peripheral autonomic neuropathy (a disease causing damage to the nervous system, causing pain and weakness in the body), Hypertensive heart disease (chronic high blood pressure causing changes in the heart), Chronic diastolic heart failure (the main pumping chamber in the heart becomes stiff and fails to fill with blood properly), Hyponatremia (low sodium), Hypokalemia (low potassium), and Hyperlipidemia (high lipid levels, such as cholesterol). The clinical record evidenced a comprehensive assessment dated 01-18-2023, by Registered Nurse (RN) 3, and it failed to evidence the patient’s rehabilitative needs, treatments, or goals related to the patient’s diagnoses of Multiple Sclerosis, Hypertensive heart disease, Chronic diastolic heart failure, Hyponatremia, Hypokalemia, and Hyperlipidemia. The comprehensive assessment failed to evidence the patient’s social planning needs, for a patient who was homebound with mobility issues. The assessment indicated “NA- Not Applicable” for the patient’s discharge planning needs. The agency failed to ensure the patient’s discharge planning needs were included in the comprehensive assessment. A review of Patient #5’s clinical record evidenced a plan of care, with a start of care date of 11-13-2019 and a recertification date from 12-22-2023 to 02-19-2024 and indicated a primary diagnosis of Quadriplegia (paralysis of all 4 limbs), Multiple Sclerosis (a disease of the brain and spinal cord affecting speech and movement), Ataxia (loss of muscle coordination), and Contracture of muscle). The plan of care, dated 12-18-2023 by the Clinical Manager (Admin) 3, evidenced a section titled “60 Day Summary” and indicated the patient had increased difficulty and pain when swallowing food and constipation. The clinical record evidenced a comprehensive assessment dated 12-18-2023 by Clinical Manager (Admin) 3 and it failed to evidence the patient’s medical needs were addressed to reduce the increased difficulty and pain with swallowing. The assessment failed to evidence the patient’s rehabilitative needs, treatments, or goals related to the patient’s diagnoses of Multiple Sclerosis and Quadriplegia. The comprehensive assessment failed to ensure the patient’s social planning needs were assessed for an alert and oriented individual, who had difficulty communicating their needs verbally, as evidenced in the assessment. A review of Patient #9’s clinical record evidenced a plan of care with a start of care date of 12-01-2018 and a recertification date from 01-04-2024 to 03-03-2024 and indicated a primary diagnosis of aftercare following joint replacement surgery, gait and mobility abnormalities, history of falling, Right artificial hip joint, pain in left hip, pain in right shoulder, Anemia (low level of red blood cells), Hypertension (high blood pressure), and a history of Transient Ischemic Attack (a brief interruption of blood to the brain). The clinical record included a comprehensive assessment dated 01-03-2024, by Admin 3, and it failed to evidence the patient’s rehabilitative needs, treatments, or goals related to the patient’s diagnoses of a recent joint replacement, right artificial hip joint, pain in the left hip, and pain in the right shoulder. The comprehensive assessment failed to evidence the patient’s social planning needs, for a patient who was homebound with mobility issues. A review of Patient #10’s clinical record evidenced a plan of care with a start of care date of 06-09-2019 and a recertification date from 01-14-2024 to 03-13-2024 and evidenced diagnoses of Autistic disorder (a developmental disability), speech disturbances, and behavioral and emotional disorders. The clinical record evidenced a comprehensive assessment dated 01-10-2024, by Admin 3, and it failed to evidence the patient’s rehabilitative needs, treatments, or goals related to the patient’s diagnoses for an Autistic disorder, speech disturbances, and behavioral and emotional disorders. The comprehensive assessment failed to evidence the patient’s social planning needs, for a patient who was homebound with mobility and developmental issues. The assessment evidenced in the sub-section titled “Discharge planning needs identified: Yes …” The agency failed to ensure the patient’s discharge planning needs were included in the comprehensive assessment. A review of Patient #13’s clinical record evidenced a plan of care with a start of care date of 10-12-2022 and a recertification date from 02-04-2024 to 04-03-2024 and evidenced the diagnoses Chronic kidney disease, stage 5, unilateral osteoarthritis in the right hip (a disease where tissue in the right hip joint breaks down over time), chronic pain, Hypertension (high blood pressure), muscle weakness, and Benign prostatic hyperplasia with lower urinary tract symptoms (enlarged prostate, with frequent urination or a weak stream). The clinical record evidenced a comprehensive assessment dated 01-31-2024, by Admin 3, and it failed to evidence the patient’s rehabilitative needs, treatments, or goals related to the patient’s diagnoses. The comprehensive assessment failed to evidence the patient’s social planning needs. A review of Patient #14’s clinical record evidenced a comprehensive assessment dated 12-30-2023, by Registered Nurse (RN) 3, and it failed to evidence a list of the patient’s diagnoses. The assessment failed to have the patient’s medical, rehabilitation, social, and discharge planning needs. During an interview with Admin 3 on 02-12-2024 at 3:35 PM, they indicated the comprehensive assessment was to include medical, rehabilitation, social, and discharge planning individualized to the patient. During an interview with RN 3 on 02-12-2024 at 4:45 PM, they indicated they included discharge planning in the comprehensive assessment. 410 IAC 17-14-1(a)(1)(B) 1. An agency policy with a revision date of October 2016, titled “Initial and Comprehensive Assessment” indicated but was not limited to, “ …The assessment will be patient-specific and comprehensive to include the patient’s needs for home care, rehabilitative care, social, and discharge planning needs … Patient’s functional status, including but not limited to … The patient’s psychosocial status … cognitive limitations … ” 2. An agency policy with a revision date of October 2016, titled “Discharge Planning” indicated but was not limited to, “ … Discharge planning will be initiated for every patient upon admission … The patient’s continuing care needs will be assessed on an ongoing basis … ” 3. A review of the clinical record for Patient #1, start of care date of 11-17-2024, contained a plan of care for the recertification period from 01-16-2024 to 03-15-2024. The plan of care indicated but was not limited to diagnoses, Spastic quadriplegic cerebral palsy (a condition that affects the ability to control muscles and movement in all four limbs, the trunk, and face), Neuromuscular scoliosis (a sideways curvature of the spine), Localization-related (focal) (partial) symptomatic epilepsy (a condition caused by certain brain activity causing seizure activity). The record contained a recertification comprehensive assessment dated 01-12-2024, electronically signed by the Clinical Manager. The comprehensive assessment failed to contain patient-specific interventions related to the patient’s diagnosis of cerebral palsy, and epilepsy. The comprehensive assessment indicated in the section titled “Problems/Interventions/Goals” was left blank. The section titled “Discharge Plan” indicated when services are no longer authorized by the payer. The assessment failed to include patient-specific interventions, social, rehabilitative, and discharge planning needs. During an interview on 02-09-2024 at 7:10 AM, Registered Nurse (RN) 1, a family member of Patient #1, indicated the Clinical Manager did not review the plan of care with RN 1. 4. A review of the clinical record for Patient #3, start of care 04-05-2023, contained a plan of care for the recertification period from 01-03-2024 to 03-29-2024. The plan of care indicated but was not limited to diagnoses, Chronic kidney disease (the failure of the kidney to filter wastes and excess fluid from your blood), Dependence on supplemental oxygen, Diabetes mellitus with diabetic neuropathy (a condition caused by long-term elevated blood sugars causing nerve damage) and Anemia in chronic kidney disease (a condition where the red blood cell count is low due to impaired kidney function). The record contained a recertification comprehensive assessment dated 01-25-2024, signed by RN 3. The comprehensive assessment indicated in the section titled “Problems/Interventions/Goals” indicated the patient’s stated goal was no hospitalizations or falls. The assessment failed to include patient-specific interventions, social, rehabilitative, and discharge planning needs. During an interview on 02-12-2024 at 4:47 PM, RN 3 indicated they could use a refresher in training. RN 3 further indicated they were instructed they did not have to do goals interventions, and discharge planning. 5. A review of the clinical record for Patient #6, start of care 01-05-2024, contained a plan of care for the recertification period from 01-10-2024 to 03-09-2024. The plan of care indicated but was not limited to diagnoses, Chronic combined systolic (congestive) and diastolic heart failure (the heart’s inability to pump blood to the rest of the body), Chronic atrial fibrillation (an irregular and often rapid heart rhythm that can lead to blood clots), Pain in the right knee, and Essential hypertension (high blood pressure). The record contained a recertification comprehensive assessment dated 01-15-2024, electronically signed by the Clinical Manager. The comprehensive assessment indicated in the section titled “Problems/Interventions/Goals” was left blank. The section titled “Discharge Plan” indicated when services are no longer authorized by the payer. The assessment failed to include patient-specific interventions, social, rehabilitative, and discharge planning needs. During an interview on 02-12-2024 at 1:16 PM, when queried where to find interventions and goals in the clinical records, the Clinical Manager indicated they were unsure. 6. A focused review of the clinical record of Patient #11, start of care 06-16-2023, contained an incomplete plan of care for the recertification from 02-11-2023 to 04-10-2024. The plan of care indicated but was not limited to diagnoses, Unspecified symptoms and signs involving functions following cerebral infarction (the effects of a stroke when the brain cells die when they do not get enough blood), Chronic diastolic (congestive) heart failure (the heart’s inability to pump blood to the rest of the body) and Chronic atrial fibrillation ((an irregular and often rapid heart rhythm that can lead to blood clots). The record contained a recertification comprehensive assessment dated 02-07-2024, electronically signed by the Clinical Manager. The comprehensive assessment indicated in the section titled “Problems/Interventions/Goals” was left blank. The section titled “Discharge Plan” indicated Not Applicable (NA). The assessment failed to include e patient-specific interventions, social, rehabilitative, and discharge planning needs. During an interview on 02-09-2024 at 1:13 PM, RN 3 indicated they were unsure where to put interventions and that they needed more training. 7. On 02-12-2024 from 5:25 PM to 6:08 PM, the findings were reviewed with the Administrator, Admin 2, and the Clinical Manager, which they had no further information or documentation to provide.”

“Primary caregiver(s), if any CFR(s): 484.55(c)(6)(i,ii) The patient’s primary caregiver(s), if any, and other available supports, including their: (i) Willingness and ability to provide care, and (ii) Availability and schedules; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patient’s caregivers along with their frequency and willingness to assist in care were included in the comprehensive assessment for 3 of 6 (Patients: #1, 2, and 5) active clinical records reviewed and 1 of 6 (Patients: #10) active focused records reviewed. Findings Include: 4. A review of the clinical record for Patient #1 start of care 11-17-2024, contained a recertification comprehensive assessment dated 01-12-2024, and electronically signed by the Clinical Manager. The section Primary Caregiver indicated RN 1 the family member of Patient #1, was the caregiver for Patient #1, was willing, available, and lives with Patient #1. The comprehensive assessment failed to include the scheduled availability. During an interview on 02-09-2024 at 7:10 AM, RN 1, the family member of Patient #1, indicated they have a full-time job for another company. 5. A review of the clinical record for Patient #2, start of care 07-08-2017, contained a recertification comprehensive assessment dated 01-27-2024, electronically signed by RN 2. The comprehensive assessment indicated Person 2, the family member of Patient #2, was Patient 2’s mother and guardian. The section Primary Caregiver indicated no caregiver available. The comprehensive assessment indicated Patient #2 had a cognitive impairment, was physically disabled, and totally dependent on care to the diagnosis of Cerebral palsy (a condition that affects the ability to control muscles and movement. The comprehensive assessment failed to include the patient’s primary caregiver, willingness and ability to provide care, and availability and schedule. During an interview on 02-12-2024 at 1:30 PM, the Clinical Manager indicated they called Patient #2’s home and spoke to Person 2, the family member of Patient #2. Peron 2 had taken Patient #2 to the emergency room, at Entity 24, an acute care facility for treatment for COVID-19. 1. A review of an ACHC Home Health policy revised October 2016 titled “Initial and Comprehensive Assessment” Policy No. 4-018.1 indicated but was not limited to, “ … C. O. Patient and family/caregiver support systems and the type of care the family/caregiver is available, capable, and willing to provide …” A review of Patient #5’s clinical record evidenced a plan of care, with a start of care date of 11-13-2019 and a recertification date from 12-22-2023 to 02-19-2024 and indicated a primary diagnosis of Quadriplegia (paralysis of all 4 limbs), Multiple Sclerosis (a disease of the brain and spinal cord affecting speech and movement), Ataxia (loss of muscle coordination), and Contracture of muscle). The clinical record evidenced a comprehensive assessment dated 12-18-2023, by Clinical Manager (Admin) 3, and indicated the patient’s primary caregiver was Person 20, Patient #5’s relative. The comprehensive assessment evidenced Person 20 lived with the patient, but the assessment failed to evidence the relative’s willingness and availability to provide care for the patient. The patient was fully dependent on another individual providing care for them as evidenced by their diagnoses of Quadriplegia and Multiple Sclerosis. A review of Patient #10’s clinical record evidenced a plan of care with a start of care date of 06-09-2019 and a recertification date from 01-14-2024 to 03-13-2024 and evidenced diagnoses of Autistic disorder (a developmental disability), speech disturbances, and behavioral and emotional disorders. The clinical record evidenced a comprehensive assessment dated 01-10-2024, by Admin 3, and indicated the patient’s primary caregiver was Person 19, Patient #10’s relative. The comprehensive assessment evidenced Person 19 lived with the patient, but the assessment failed to evidence the relative’s willingness and availability to provide care for the patient. The patient was fully dependent on another individual providing care for them as evidenced by their diagnosis of Autistic disorder. During an interview with Admin 3 on 02-12-2024 at 3:35 PM, they indicated the comprehensive assessment was to include who the patient lived with and if the individual was willing and able to provide care for the patient.”

“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 the Registered Nurse (RN) completed a comprehensive discharge assessment on 1 of 2 discharge records reviewed. (Patient: #7) Findings Include: 1. An agency policy with a revision date of October 2016, titled “Discharge Criteria and Process” indicated but was not limited to, “ … The clinician will update the comprehensive … All discharge paperwork will be due in the office within 72 hours of the discharge date. This will include the discharge order, discharge summary, medication profile, and OASIS … ” 2. A review of the inactive clinical record for Patient #7, on 02-08-2024, with a discharge date of 10-20-2023, failed to contain a discharge comprehensive assessment, discharge order, and discharge summary. 3. On 02-08-2024 at 2:58 PM, requested the discharge assessment, orders, and summary for Patient #7. During an interview on 02-09-2024 at 4:00 PM, with the Intake/Medical Records Coordinator, Admin 6, when queried regarding the discharge records requested for Patient #7, indicated the record did not contain a discharge comprehensive assessment, discharge order, or discharge summary. 4. On 02-12-2024 at 9:02 AM, Admin 6, provided 2 agency documents dated 10-20-2023, titled “Discharge Assessment.” One of the discharge assessments dated 10-20-2023, indicated the assessment status was incomplete and waiting on a signature. The second discharge assessment dated 10-20-2023, was electronically signed by the Clinical Manager and dated 10-25-2025, indicated it was incomplete waiting on QA(Quality Assurance) review. During an interview on 02-12-2024 at 9:02 AM, the Clinical Manager indicated they were completing the discharge assessment, summary, and order. 5. A review of agency documents, an agency letter dated 02-12-2024, and a fax confirmation, addressed to Patient #7’s physician. The letter indicated the agency discovered during a chart audit they had not notified the physician of Patient #7’s discharge and were sending them the required documents today. 6. On 02-12-2024 from 5:25 PM to 6:08 PM, the findings were reviewed with the Administrator, Admin 2, and the Clinical Manager, which they had no further information or documentation to provide.”

“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 observation, record review, and interview, the agency failed to ensure the individualized plan of care included all diagnoses, all supplies and equipment, frequency and duration of visits made, prognosis, rehabilitation potential, functional limitations, activities permitted, nutritional requirements, all medications and treatments, safety measures to protect against injury, a description of the patient’s risk for emergency department visits and hospital readmission, and all underlying risk factors, patient and caregiver education and training, and patient-specific interventions and education, measurable outcomes and goals identified by the agency in 5 of 6 active records reviewed (Patients: #1, 2, 3, 4, and 5) and 6 of 6 focused records reviewed. (Patients: #9, 10, 11, 12, 13, and 14) Findings Include: 10. During a home visit at the residence of Patient #1 on 02-09-2024 at 7:00 AM, the Registered Nurse (RN) 1, a family member of Patient #1, indicated they manage the feedings, and patient’s medications (given by g-tube). RN 1 was observed demonstrating Patient#1’s specialty bed that assists with repositioning. RN 1 indicated the ceiling track surrounding the bed and bathroom facilitates safe transfers in a sling to lift Patient #1 from their bed to a standing position or their wheelchair, shower chair, or the bathroom. RN 1 indicated Patient #1 had a manual Hoyer in the other room. Patient #1 was observed in bed wearing depends and was lying on a chuck. RN #1 indicated Patient #1 had their last seizure in October 2023 and has as-needed Diazepam nasal and oral that can be given. Observed a Jacuzzi hot tub with a ramp and handicapped accessibility in the back of the house in another room. RN 1 indicated they had the addition to the house to assist in meeting Patient #1’s needs. RN 1 confirmed Patient #1 loves getting in it. Observed Patient#1’s bedroom led to their bathroom. The Bathroom had floor drains with a wall shower with a handheld shower head, a whirlpool tub, a washer and dryer, a toilet, and a large utility sink basin. Observed on the top of the dresser a nebulizer and suction machine. A review of a plan of care for the recertification period from 01-16-2024 to 03-15-2024, indicated but was not limited to diagnoses, Spastic quadriplegic cerebral palsy (a condition that affects the ability to control muscles and movement in all four limbs, the trunk, and face), Neuromuscular scoliosis (a sideways curvature of the spine), Localization-related (focal) (partial) symptomatic epilepsy (a condition caused by certain brain activity causing seizure activity). The plan of care section (Durable Medical Equipment) DME and Supplies evidenced wheelchair, hospital bed, shower bench, Hoyer lift, and feeding pump; Orders for Discipline and Treatment (Specify Amount /Frequency/Duration) evidenced Respite RN 60 hours monthly for 1 certification period, RN hourly 76 hours weekly for 1 certification period, and RN recertification OASIS 1 visit for 1 certification period; Problems and Interventions evidenced no documented interventions and no problems; Goals/Rehabilitation Potential/Discharge Plans evidenced no goals, fair rehabilitation potential, and discharge plans indicated when services are no longer authorized. The plan of care failed to include all DME and medical supplies including, feedings, feeding supplies, briefs, pads, ceiling tracking slip, Jacuzzi tub, whirlpool bath, handheld wall shower, nebulizer, suction machine, and motorized wheelchair; failed to include specific frequency, treatments, and duration; failed to include RN interventions, patient-specific problems, and risk factors to include addressing seizure plans; failed to include measurable goals; failed to include Patient #1’s risk for emergency room visits and hospital admissions; failed to address specific education and training provided. 11. A review of the clinical record on 02-12-2024, for Patient #2, with a start of care date of 07-08-2017, contained a plan of care for the recertification period of 02-02-2023 through 04-01-2024. The plan of care indicated but was not limited to diagnoses, Cerebral palsy (a condition that affects the ability to control muscles and movement), Moderate intellectual disabilities, and Epilepsy (a condition caused by certain brain activity causing seizure activity). The plan of care section Orders for Discipline and Treatments (specify Amount/Frequency/Duration) evidenced Respite RN 27 hours weekly on Sunday, and Friday for 1 certification period; failed to give a specific frequency and duration; the section Goals evidenced fluid intake and output with expected range; failed to address the patient-specific goals; the section Discharge plans evidenced when services are no longer needed; failed to list patient-specific discharge planning; failed to include Patient #2’s risk for emergency room visits and hospital admissions; failed to address specific education and training provided. On 02-12-2024 at 11:20 AM, a call was placed to RN 2, and a voicemail was left for a return call. No return calls were received. 12. A review of the clinical record for Patient #3 contained a plan of care for the recertification period 01-30-2024 to 03-29-2024. The plan of care indicated but was not limited to diagnoses, Chronic kidney disease (the failure of the kidney to filter wastes and excess fluid from your blood), Dependence on supplemental oxygen, Diabetes mellitus with diabetic neuropathy (a condition caused by long-term elevated blood sugars causing nerve damage) and Anemia in chronic kidney disease (a condition where the red blood cell count is low due to impaired kidney function). The section Medications/Dose/Route/Frequency indicated but was not limited to, Humalog ( medication to lower blood sugar) Pen Injector 100 units/milliliter (ml)/100 units/1ml subcutaneous once a day, and Insulin Glargine (a medication used to lower blood sugar) 100units/ml subcutaneous/give 77 units once a day; (Durable Medical Equipment) DME and Supplies evidenced cane, walker, shower bench, bath safety bars, hazardous waste container, oxygen, and electric wheelchair; Orders for Disciplines and Treatments (Specify Amount/Frequency/Duration) evidenced Attendant 65-69 hours weekly for 1 certification period, and Home Health Aide (HHA) Hourly 91 hours weekly for 1 certification period; Problems and Interventions evidenced Patient #3’s main goal is to be able to remain in their apartment and not go to an assisted living; Goals/Rehabilitation Potential/Discharge Plans evidenced no goals, fair rehabilitation potential, and discharge plans indicated when services are no longer authorized by payer. The plan of care failed to include all DME and medical supplies including, insulin pen needles, glucometer, lancets, and glucometer strips; failed to include specific HHA and Attendant frequency, treatments, and duration; failed to include HHA and Attendant care interventions, patient-specific problems, and risk factors to include diabetes and renal function; failed to include measurable goals; failed to include Patient #3’s risk for emergency room visits and hospital admissions; failed to address specific education and training provided. 13. A focused review of the clinical record of Patient #11 plan of care for the recertification from 02-11-2023 to 04-10-2024, indicated but was not limited to diagnoses, Unspecified symptoms and signs involving functions following cerebral infarction (the effects of a stroke when the brain cells die when they do not get enough blood), Chronic diastolic (congestive) heart failure (the heart’s inability to pump blood to the rest of the body) and Chronic atrial fibrillation ((an irregular and often rapid heart rhythm that can lead to blood clots). The section DME and Supplies left blank; Safety Measures left blank; Functional Limitations left blank; Activities Permitted left blank; Metal status left blank; Order for Disciplines and Treatments (Specify Amount/Frequency/Duration) evidenced HHA 56 hours weekly for 1 certification period, RN Recertification non-oasis 1 visit for the certification period; and Problems and Interventions, left blank; Goals/Rehabilitation Potential/Discharge Plans left blank. The plan of care failed to include DME and medical supplies; failed to have Safety Measures; failed to have Functional Limitations; failed to have Activities permitted; failed to include specific HHA frequency, treatments, and duration; failed to include HHA interventions, patient-specific problems, and risk factors to include diabetes and renal function; failed to include measurable goals; failed to include Patient #11’s risk for emergency room visits and hospital admissions; failed to address specific education and training provided. 14. A focused review of the clinical record of Patient #12 contained an incomplete plan of care for the recertification from 01-26-2023 to 03-25-2024, indicated but was not limited to diagnoses, Cerebral palsy (a condition that affects the ability to control muscles and movement) and Unspecified intellectual disabilities. The section Order for Disciplines and Treatments (Specify Amount/Frequency/Duration) evidenced HHA 42 hours weekly for 1 certification period, RN Recertification non-oasis 1 visit for the certification period; but failed to have specific HHA frequency and duration. During an interview on 02-12-2024 at 1:00 PM, the Executive Director, Admin 2, and the Clinical Manager confirmed the plan of cares were incomplete. Admin 2 further indicated the nurses were completing the incorrect assessments. 410 IAC 17-13-1(a)(1)(D)(i, ii, iii, iv, v, vi, vii, vii, ix, x, xi, xii, xiv) 1. An agency policy revised October 2016 and titled “Care Planning Process”, Policy No. 4-001.1, indicated but was not, “ … Policy … the patient plan of care will be developed or revised within five (5) working days of initiation of each service or of the reassessment of the patient … 1. Plan of Care … includes: … D. Pertinent primary and secondary diagnoses, E. Food or drug allergies, F. Homebound status, G. Goals/outcomes to be achieved, H. Patient’s mental status, I. Functional limitations, J. Activities permitted, K. Safety measures, L. Nutritional requirements, M. Medications including dose/frequency/route, N. orders for specific home health services and disciplines, treatments and procedures, including amount/frequency/duration, O. Supplies and equipment required, P. Discharge or referral plans, Q. Discharge teaching, R. Frequency and duration of visits, S. Prognosis, T. Rehabilitation potential …” 2. A review of Patient #4’s clinical record evidenced a POC with a start of care date of 02-18-2019 and a recertification date from 01-23-2024 to 03-22-2024 and indicated a primary diagnosis of Multiple Sclerosis (a disease of the brain and spinal cord affecting speech and movement), Idiopathic peripheral autonomic neuropathy (a disease causing damage to the nervous system, causing pain and weakness in the body), Hypertensive heart disease (chronic high blood pressure causing changes in the heart), Chronic diastolic heart failure (the main pumping chamber in the heart becomes stiff and fails to fill with blood properly), Hyponatremia (low sodium), Hypokalemia (low potassium), and Hyperlipidemia (high lipid levels, such as cholesterol). A review of the clinical record evidenced a document dated 08-22-2023, and it evidenced Patient #4 had allergies to the medications Lisinopril (a medication to lower blood pressure and Triamterene (a medication used to help increase the flow of urine and prevents the user from losing too much potassium). The Home Health Aide (HHA) POC dated 07-31-2023, indicated but was not limited to, “ … Allergies … NKA – No Known Allergies …” The POC failed to include all the patient’s allergies. The POC indicated the patient had Home Health Aide (HHA) services 20 hours a week. The POC failed to indicate the frequency and duration of each visit and the care provided to the patient. The interventions failed to evidence the treatments and education provided to the patient. The POC evidenced the patient’s goal was to be free from seizures and free from falls. The goals listed in the POC included, the patient performed tasks with assistance safely, demonstrated proper body mechanics with transfers and ambulating, and followed their home exercise program. The goals failed to be patient-specific and measurable. 3. A review of Patient #5’s clinical record evidenced a POC, with a start of care date of 11-13-2019 and a recertification date from 12-22-2023 to 02-19-2024 and indicated a primary diagnosis of Quadriplegia (paralysis of all 4 limbs), Multiple Sclerosis (a disease of the brain and spinal cord affecting speech and movement), Ataxia (loss of muscle coordination), and Contracture of muscle. The POC indicated the patient had the supplies, a wheelchair, shower bench, and Hoyer lift. The POC failed to include the supplies observed in the patient’s home during a home visit of a Home Health Aide (HHA) on 02-09-2024 at 2:10 PM. The patient had a Hoyer lift sheet, briefs, chux pads, and a box of gloves. The plan of care evidenced fall and standard precautions. The POC indicated the patient had increased difficulty and pain when swallowing food. The POC failed to evidence all safety precautions needed for a patient with difficulty swallowing and paralyzed in all 4 extremities. The POC indicated the patient had HHA ordered for 40 hours a week and respite HHA 60 hours weekly. The POC failed to indicate the frequency and duration of each visit and the care provided to the patient. The POC evidenced the HHA provided personal care and assistance with activities of daily living. The interventions failed to evidence the treatments and education provided to the patient. The POC evidenced the goal was for the patient to receive safe care 5 days a week, but the goal failed to be patient-specific and measurable. The POC failed to contain patient-specific and measurable goals related to the patient’s diagnoses. 4. A review of Patient #9’s clinical record evidenced a POC with a start of care date of 12-01-2018 and a recertification date from 01-04-2024 to 03-03-2024 and indicated a primary diagnosis of aftercare following joint replacement surgery, gait and mobility abnormalities, history of falling, Right artificial hip joint, pain in left hip, pain in right shoulder, Anemia (low level of red blood cells), Hypertension (high blood pressure), and a history of Transient Ischemic Attack (a brief interruption of blood to the brain). The POC evidenced the patient received 16 hours weekly of Attendant Care Services, 8 hours weekly of HHA services, and 16 hours of IHCC monthly. The agency failed to indicate the frequency and duration of each visit and the care provided to the patient. The POC indicated the agency provided the patient assistance with personal care and activities of daily living (ADLs). The interventions failed to evidence the treatments and education provided to the patient. The POC evidenced the goal for the patient was for the patient to remain safe while care was provided for them. The goals failed to be patient-specific and measurable to the patient’s diagnoses. 5. A review of Patient #10’s clinical record evidenced a plan of care with a start of care date of 06-09-2019 and a recertification date from 01-14-2024 to 03-13-2024 and evidenced diagnoses of Autistic disorder (a developmental disability), speech disturbances, dependence on a wheelchair, and behavioral and emotional disorders. The DME failed to include the patient’s wheelchair. The POC evidenced the patient received 39 hours weekly of HHA services. The POC failed to indicate the frequency and duration of each visit and the care provided to the patient. The interventions failed to evidence the treatments and education provided to the patient. The POC evidenced the goal for the patient was for the patient to remain safe while care was provided for them. The goals failed to be patient-specific and measurable according to the patient’s diagnoses. 6. A review of Patient #13’s clinical record evidenced a plan of care with a start of care date of 10-12-2022 and a recertification date from 02-04-2024 to 04-03-2024. It evidenced the diagnoses of Chronic kidney disease, stage 5, unilateral osteoarthritis in the right hip (a disease where tissue in the right hip joint breaks down over time), chronic pain, Hypertension (high blood pressure), muscle weakness, and Benign prostatic hyperplasia with lower urinary tract symptoms (enlarged prostate, with frequent urination or a weak stream). The POC indicated the patient received 5 hours of HHA weekly and 16 hours of IHCC monthly. The POC failed to indicate the frequency and duration of each visit and the care provided to the patient. The interventions failed to evidence the treatments and education provided to the patient. The POC failed to evidence patient-specific and measurable goals related to the patient’s diagnoses and needs. 7. A review of Patient #14’s POC with a start of care date of 12-30-2023 and a certification period from 12-20-2023 to 02-17-2024. The POC was signed by Registered Nurse (RN) 3 on 01-01-2024. The POC failed to evidence all pertinent diagnoses, medications and their dose and frequency, DME and supplies, safety measures, nutritional requirements, functional limitations, activities permitted, mental status, prognosis, treatments and interventions, goals, rehabilitation potential, discharge planning, and the physician’s signature. The POC evidenced the patient received 40 hours of Attendant Care services but failed to indicate the services they provided for the patient. 8. During an interview with the Clinical Manager (Admin 3) and the Executive Director (Admin 2) on 02-12-2024 at 12:45 PM, they indicated all DME was to be listed on the POC. Admin 3 indicated interventions for patients with HHA services or limited mobility included turning the patient, remaining injury-free, bathing, incontinent care, hair care, and oral care. Admin 3 indicated goals for the patients may include but not limited to skin breakdown and no aspiration. Admin 3 indicated they included education and training on the POCs. Admin 2 indicated the POC was to indicate how many days a week the patient received services and for how long they received the services. 9. During an interview with Admin 3 on 02-12-2024 at 3:35 PM, they indicated the POC included diagnoses, DME, safety, fall risk, nutritional requirements, tube feedings, allergies, limitations, activity level, frequency and duration, goals, rehabilitation potential, discharge planning, interventions, care preferences, and caregivers.”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on record review and interview, the skilled nurse failed to promptly notify the physician of changes in the patient’s condition in 1 of 1 patients with a change in condition. (Patient: #2) Findings include: 1. An agency policy, with a revision date of October 2016, titled “Monitoring Patient’s Response/Reporting To Physician” indicated but was not limited to. “ … 3. The patient’s physician will be contacted on the same day when any of the following occur: A. Significant changes in condition … 4. All conferences or attempts to communicate with the physician will be documented in the clinical record … ” 2. A review of the clinical record on 02-12-2024, for Patient #2, with a start of care date of 07-08-2017, and a recertification period of 02-02-2023 through 04-01-2024, evidenced by an agency document titled, “Client Logging Report” dated 02-07-2024. The document indicated a call had been placed to contact the family regarding permission for a Surveyor visit on 02-09-2024. The document further indicated the home health aide just found out Patient #2 and their family all had COVID. The record failed to evidence any documentation of notification to the physician regarding Patient #2’s change in condition. During an interview on 02-12-2024 at 10:24 AM, the Clinical Manager, when queried regarding Patient #2’s physician being notified by the nurse or agency of the Patient’s change in condition confirmed there had been no notification to the physician regarding Patient #3 having COVID. The Clinical Manager further indicated the Registered Nurse (RN) for Patient #2, RN 2, had been in earlier that day at the agency to pick up Personal Protective Equipment for their visit. 3. On 02-12-2024 at 11:20 AM, a call was placed to RN 2, received no answer, and a voicemail was left for a return call. No return calls. 4. On 02-12-2024 at 11:22 AM, a call was placed to Person 2, Patient #2’s family member, received no answer, and a voicemail was left for a return call. No return calls. 5. During an interview on 01-12-2024 at 12:45 PM, the Clinical Manager notified the surveyor that Patient #2 was seen at Entity 10, an acute care facility, on 02-07-2024 and tested positive for COVID-19. 410 IAC 17-13-1(a)(2)”

“Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patients’ overall health and goals were discussed in the multidisciplinary team for 5 of 6 active clinical records reviewed (Patients #1, 2, 3, 4, and 5) and 4 of 6 focused audit clinical records reviewed. (Patients: # 9, 10, 13, and 14) Findings Include: 10. On 02-07-2024 at 10:55 AM, during the Entrance Conference, when queried on how care is coordinated within the agency, the Executive Director, Admin 2, indicated the nurses and social worker address coordination of care in the section of their electronic medical record titled “Client Logging.” 11. A review of the clinical record for Patient #1, start of care date of 11-17-2024, contained a plan of care for the recertification period from 01-16-2024 to 03-15-2024. The plan of care indicated but was not limited to diagnoses, Spastic quadriplegic cerebral palsy (a condition that affects the ability to control muscles and movement in all four limbs, the trunk, and face), Neuromuscular scoliosis (a sideways curvature of the spine), Localization-related (focal) (partial) symptomatic epilepsy (a condition caused by certain brain activity causing seizure activity). A review of the comprehensive reassessment dated 01-12-2023 and electronically signed by the Clinical Manager contained a section titled “Interdisciplinary Communication” indicated that communication with the physician was answered no, and communication with others was answered no. The clinical record failed to evidence case conference between the Clinical Manager and RN 1 discussing the patient’s progress toward their goals and any changes needed to the plan of care. During a home visit at Patient#1’s residence on 02-12-2024 at 7:10 AM, RN 1, when queried if they were aware of goals on the plan of care and progress towards those goals, indicated they were not involved in the plan of care reviews. 12. A review of the clinical record for Patient #2, start of care 07-08-2017, contained a plan of care for the recertification period from 02-02-2024 to 04-01-2024. The plan of care indicated but was not limited to diagnoses, Cerebral palsy (a condition that affects the ability to control muscles and movement), Moderate intellectual disabilities, Contracture left hand (a permanent tightening of the muscles, tendons, skin, and surrounding tissues that cause the joints to shorten and stiffen), Contracture right hand, and Epilepsy (a condition caused by certain brain activity causing seizure activity). A review of the comprehensive reassessment dated 01-27-2024, electronically signed by RN 2, contained a section titled “Interdisciplinary Communication” indicated that communication with the physician was answered no, and communication with others was answered no. The clinical record failed to evidence case conference between the Clinical Manager and RN 2 discussing the patient’s progress toward their goals and any changes needed to the plan of care. On 02-12-2024 at 11:20 a call was placed to RN 2, and a message was left for a return call. No return calls. 13. A review of the clinical record for Patient #3, start of care 04-05-2023, contained a plan of care for the recertification period from 01-03-2024 to 03-29-2024. The plan of care indicated but was not limited to diagnoses, Chronic kidney disease (the failure of the kidney to filter wastes and excess fluid from your blood), Dependence on supplemental oxygen, Diabetes mellitus with diabetic neuropathy (a condition caused by long-term elevated blood sugars causing nerve damage) and Anemia in chronic kidney disease (a condition where the red blood cell count is low due to impaired kidney function). A review of the comprehensive reassessment dated 01-25-2024, electronically signed by RN 3, contained a section titled “Interdisciplinary Communication” indicated that communication with the physician was answered no, and communication with others was answered no. The clinical record failed to evidence case conference between the Clinical Manager, RN 3, the Home Health Aide (HHA) 1, HHA 5, and Attendant 4, discussing the patient’s progress toward their goals and any changes needed to the plan of care. During an interview on 02-12-2024 at 4:47 PM, RN 3 indicated they did not know Patient #3 had around-the-clock care being provided by a HHA and Attendant. 410 IAC 17-12-2(g) 1. An agency policy revised October 2016 titled “Case Conference/Progress Summary” indicated but was not limited to, “ … Case conferences will be held at the start of care and at least every 60 days to review and discuss all multidisciplinary cases … Procedure … 2. For each patient, the Case Manager will lead the conference and discuss: A. Physical status of the patient … E. Interventions for all disciplines and patient response, F. Teaching plan and its effectiveness, G. Progress toward goals …” 2. A review of Patient #4’s clinical record evidenced a plan of care with a start of care date of 02-18-2019 and a recertification date from 01-23-2024 to 03-22-2024 and indicated a primary diagnosis of Multiple Sclerosis (a disease of the brain and spinal cord affecting speech and movement), Idiopathic peripheral autonomic neuropathy (a disease causing damage to the nervous system, causing pain and weakness in the body), Hypertensive heart disease (chronic high blood pressure causing changes in the heart), Chronic diastolic heart failure (the main pumping chamber in the heart becomes stiff and fails to fill with blood properly), Hyponatremia (low sodium), Hypokalemia (low potassium), and Hyperlipidemia (high lipid levels, such as cholesterol). The clinical record failed to evidence a case conference between the agency team members discussing the patient’s progress toward their goals and any necessary changes to their treatment. 3. A review of Patient #5’s clinical record evidenced a plan of care, with a start of care date of 11-13-2019 and a recertification date from 12-22-2023 to 02-19-2024 and indicated a primary diagnosis of Quadriplegia (paralysis of all 4 limbs), Multiple Sclerosis (a disease of the brain and spinal cord affecting speech and movement), Ataxia (loss of muscle coordination), and Contracture of muscle. The clinical record failed to evidence a case conference between the agency team members discussing the patient’s progress toward their goals and any necessary changes to their treatment. 4. A review of Patient #9’s clinical record evidenced a plan of care with a start of care date of 12-01-2018 and a recertification date from 01-04-2024 to 03-03-2024 and indicated a primary diagnosis of aftercare following joint replacement surgery, gait and mobility abnormalities, history of falling, Right artificial hip joint, pain in left hip, pain in right shoulder, Anemia (low level of red blood cells), Hypertension (high blood pressure), and a history of Transient Ischemic Attack (a brief interruption of blood to the brain). The clinical record failed to evidence a case conference between the agency team members discussing the patient’s progress toward their goals and any necessary changes to their treatment. 5. A review of Patient #10’s clinical record evidenced a plan of care with a start of care date of 06-09-2019 and a recertification date from 01-14-2024 to 03-13-2024 and evidenced diagnoses of Autistic disorder (a developmental disability), speech disturbances, and behavioral and emotional disorders. The clinical record failed to evidence a case conference between the agency team members discussing the patient’s progress toward their goals and any necessary changes to their treatment. 6. A review of Patient #13’s clinical record evidenced a plan of care with a start of care date of 10-12-2022 and a recertification date from 02-04-2024 to 04-03-2024 and evidenced the diagnoses Chronic kidney disease, stage 5, unilateral osteoarthritis in the right hip (a disease where tissue in the right hip joint breaks down over time), chronic pain, Hypertension (high blood pressure), muscle weakness, and Benign prostatic hyperplasia with lower urinary tract symptoms (enlarged prostate, with frequent urination or a weak stream). The clinical record failed to evidence a case conference between the agency team members discussing the patient’s progress toward their goals and any necessary changes to their treatment. 7. A review of Patient #14’s clinical record evidenced a comprehensive assessment dated 12-30-2023, by Registered Nurse (RN) 3, and it failed to evidence a list of the patient’s diagnoses. The clinical record failed to evidence a case conference between the agency team members discussing the patient’s progress toward their goals and any necessary changes to their treatment. 8. During an interview with the Clinical Manager (Admin) 3 on 02-12-2024 at 1:43 PM, they indicated they had never done a case conference with the team for patients. 9. During an interview with Registered Nurse (RN) 3 on 02-12-2024 at 4:38 PM, they indicated they had never done a case conference with the team for patients.”

“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 that the patient’s clinical records included information about the services the patient received from other health providers and failed to ensure they coordinated care delivery to meet the patient’s needs for 3 of 6 active patient records reviewed. (Patients: #2, 3, and 5) Findings Include: 7. During a home visit on 02-09-2024 at 2:10 PM, Person 20, Patient #5’s relative, indicated Patient #5 had a case manager with Entity 1, an adult social services agency, and a personal services agency, Entity 12. A review of Patient #5’s clinical record failed to evidence communication notes with Entity 1 and Entity 12. During an interview with Entity 12’s owner, Person 13, on 02-12-2024 at 9:32 AM, they indicated the agency had never contacted them regarding Patient #5. They indicated Person 20 was the only individual they communicated with regarding Patient #5’s care. During an interview with Patient #5’s case manager, Person 11, with Entity 1 on 02-12-2024 at 9:42 AM, they indicated the agency had never contacted them regarding the patient. Person 11 indicated they were the ones to reach out to the agency. They indicated the agency was to follow up with Person 11 quarterly, but the agency had not contacted them. During an interview with the Executive Director (Admin) 2 on 02-12-2024 at 11:45 AM, they indicated they were unable to find communication notes for Patient #5. 410 IAC 17-14-1(a)(1)(F) 1. An agency policy with a revision date of October 2016, titled “Coordination of Services with Other Providers” indicated but was not limited to, “ … A Case Manager will be assigned to be responsible for coordinating services provided to the patient by the organization, including services provided directly and through contract. The Case Manager will act as a liaison with other organizations or individuals also providing care to the patient to assure effective coordination of related services … ” 2. On 02-07-2024 at 10:55 AM, during the Entrance Conference, when queried on how care is coordinated with other agencies, the Executive Director, Admin 2, indicated the nurses and social worker address coordination of care in the section of their electronic medical record titled “Client Logging.” 3. A review of the clinical record for Patient #3, the start of care of 07-08-2017, contained a plan of care for the recertification period of 02-02-2024 to 04-01-2024. The plan of care indicated that Patient #2 attends Entity 3, an adult day care facility when services as available staffing permits. A review of agency documents titled “Client Logging Report” dated 01-23-2024 to 02-12-2024, failed to evidence documentation of coordination of care with Entity 3. During an interview on 02-12-2024 at 4:07 PM, Person 4, a Registered Nurse (RN) at Entity 3, an adult day care, indicated Patient #3 attends their daycare program when transportation is available. Person 4 further confirmed they had no documentation of communication from Acme Health Services Incorporated coordinating care. 4. On 02-12-2024 at 11:20 AM, a call was placed to RN 2, the nurse for Patient #3. A voicemail was left for a return call. No return calls. 5. On 02-12-2024 at 11:22 AM, a call was placed to Person 2, the caregiver and family member of Patient #3. A voicemail was left for a return call. No return calls. 6. A review of the clinical record for Patient #6, the start of care of 04-05-2023, contained a plan of care for the recertification period of 01-30-2024 to 03-29-2024. The plan of care indicated that Patient #6 goes to Entity 8, an incenter dialysis treatment facility, three times a week. A review of agency documents titled “Client Logging Report” dated 01-23-2024 to 02-12-2024, failed to evidence documentation of coordination of care with Entity 8. During an interview on 02-12-2024 at 5:00 PM, Person 9, the Clinical Manager for Entity 8, confirmed Patient #6 received dialysis treatment every Tuesday, Thursday, and Saturday for 5 hours at Entity 8. Person 9 further confirmed Acme Health Services Incorporated, had not contacted them to coordinate care regarding Patient #6.”

“Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patient or the patient’s caregiver were provided with a medication schedule/instructions, including medication name, dosage, and frequency in plain language in 3 of 3 home visit patients. (Patients: #1, 5, and 6) Findings Include: 3. During a home visit at Patient #5’s residence on 02-09-2024 at 2:10 PM for a home health aide (HHA) observation, the patient’s admission packet failed to include the patient’s medication list and schedule in layman’s terms. 4. During an interview with the Clinical Manager (Admin) 3 on 02-12-2024 at 12:31 PM, they indicated they had never printed off and brought medication lists to the home. 1. During a home visit at the residence of Patient #1 on 02-09-2024 at 7:00 AM, RN 1, a family member of Patient #1, indicated they could not locate their binder. RN 1 when queried regarding a medication list being given, indicated the agency had not provided a medication list. 2. During a home visit at the residence of Patient #6 on 02-09-2024 at 10:30 AM, reviewed the patient’s agency folder. When queried regarding a plan of care and medication list Patient #6 indicated there is not one. The Medical Social Worker (MSW) indicated they did not bring the medication list or plan of care for Patient #6. During an interview on 02-12-202402-12-2024 at 10:20 AM, the Clinical Manager confirmed medication lists are not taken to the patients.”

“Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This Element is not met as evidenced by: Based on record review and interview, the Administrator failed to ensure they were responsible for day-to-day operations, had a data-driven Quality Assessment and Performance Improvement (QAPI) program, a current Emergency Preparedness plan reviewed, and a tabletop exercise at least annually, ensured public information was accurate regarding the services they provided, and trained the Alternate Administrator according to the job description for 1 of 1 home health agency. Findings Include: 1. An agency policy revised October 2016 titled “Organizational Planning” indicated but was not limited to, “ ... Policy ... leaders will be responsible for developing and implementing an effective organization wide planning process ... 2. Clearly defining long-range, strategic, and operational plans ... The planning process includes: 1. the needs of individuals served, personnel, internal and external resources ... 4. Resources needed to provide and support care and services. 5. Recruitment, retention, development, and continuing education needs for all personnel. 6. The data needed to measure the performance of the processes and outcomes of care and services. 7. Results of organization quality assessment performance improvement activities ...” 2. On 02-12-2024 at 1:51 PM, the Executive Director, Admin 2, provided a folder containing the agency’s QAPI. The folder contained an agency document titled, “QAPI Scheduled Items for Review Tracker 2023/2024” with a revision date of 2-11-2024. The folder contained an agency document titled, “ Quality Assessment and Performance Improvement (QAPI) Plan” from the agency’s policy and procedure book. During an interview on 02-12-2024 at 1:46 PM, Admin 2, confirmed they had completed the revised schedule tracker document over the weekend. Admin 2 further indicated they just did not have time to do an outcome-based QAPI. Admin 2 had no data to show measurable improvements, data collection of patient safety, or health outcomes related to quality of care. 3. A review of the Emergency Preparedness binder evidenced an undated document titled “Hazard Vulnerability Analysis Worksheet”. A document titled “Emergency Preparedness” dated 10-20-2023 evidenced the agency reviewed education regarding active shooter, tornado, flood, civil unrest, and emergency shelter. There was no evidence an active drill or tabletop exercise was ever completed. There was no evidence the agency’s emergency preparedness plan was reviewed annually or as needed. During an interview with Admin 2 on 02-12-2024 at 5:09 PM, they indicated they had no Emergency Preparedness program and were working on it. They indicated the date April 2017 on the Emergency Preparedness policy was most likely the last time the policy was reviewed and revised. They indicated they had not performed a tabletop exercise and had not collaborated with local, state, and federal officials. 4. On the agency’s website, agency vehicle, and the Admission packet, it was evidenced the agency offered Skilled Nursing, Home Health Aide, Physical Therapy, Occupational Therapy, Speech Therapy, Medical Social Work, and Companion services. During an interview with Admin 2 on 02-08-2024 at 8:50 AM, they indicated they had no Medicare or therapy patients or therapists since August of 2022. 5. During an interview with the Clinical Manager (Admin 3) on 02-09-2024 at 1:36 PM, they indicated they were unaware they were the Alternate Administrator until they just saw the state letter. They indicated they had no training as the Alternate Administrator. 6. The Administrator failed to ensure marketing materials represented the actual therapies and services provided by the agency as evidenced by the Executive Director (Admin 2). Admin 2 indicated, on 02-09-2024 at 12:45 PM, they no longer offered Physical Therapy, Occupational Therapy, and Speech Therapy. 410 IAC 17-12-1(c)(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 record review and interview, the agency failed to ensure the Alternate Administrator, was aware of their role as the Alternate Administrator and had a signed job description for the position of 1 of 1 Alternate Administrator. (Clinical Manager (Admin) 3) Findings Include: 1. An ACHC Home Health Human resources policy, revised October 2016, titled “Job Descriptions”, Policy No. 1-011.1 indicated but was not limited to, “ … Procedure … 2. … each individual will receive and sign a job description specific to his/her position. …” 2. During a review of the Governing body meeting minutes binder, it evidenced Admin 3 was appointed and approved as the Alternate Administrator. The document dated 03-14-2023 was signed by the Board of Directors and failed to evidence Admin 3’s signature. 3. During a review of Admin 3’s employee file, it failed to evidence a job description for the position of the Alternate Administrator. Admin 3’s employee file evidenced a letter from the state, and it indicated Admin 3 was the Alternate Administrator. 4. During an interview with Admin 3 on 02-09-2024 at 1:36 PM, they indicated they were unaware they were the Alternate Administrator until they saw the state letter. Admin 3 indicated they had never received training for the Alternate Administrator position. 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 Clinical Manager failed to ensure the coordination of care with other providers in the patient’s home for 1 of 1 home health agency. Findings Include: 1. The Clinical Manager’s job description titled “Clinical Director” and dated 03-21-2023 indicated but was not limited to, “ ... 1. Coordinates and oversees all direct and indirect patient services provided by clinical organization personnel ... 4. Provides help in assessment, planning, implementation and evaluation of patient and family/caregiver care to all clinical personnel as indicated ...” 2. A review of 4 of 6 active clinical records (Patients 2, 5, and 6), failed to evidence any coordination of care notes with the other providers providing care for the patients. The agency failed to coordinate care with Patient #2’s adult day care facility, Entity 3. The agency failed to coordinate care with Patient #5’s case manager with an adult social services agency, Entity 1, and the patient’s personal services agency, Entity 12. The agency failed to coordinate care with Patient #6’s incenter dialysis treatment facility, Entity 8. 3. During interviews with the Executive Director on 02-12-2024 at 11:45 AM, they indicated if the coordination of care notes were not in the charts, then they had no coordinated care with Entity 1, Entity 3, Entity 8, and Entity 12. 4. During a review of 6 of 6 active clinical records (Patients #1, 2, 3, 4, 5, and 6) and 6 of 6 focused audits of active clinical records (Patients #9, 10, 11, 12, 13, and 14), the Clinical Manager failed to ensure plans of care were updated, complete, patient-specific, and contained all pertinent diagnosis, patient’s mental, psychosocial, and cognitive status, types of services, durable medical equipment (DME), frequency and duration of visits, prognosis, rehabilitation potential, functional limitations, activities permitted, nutritional requirements, all medications and treatments, safety measures, risk for hospitalization, patient and caregiver education and training, interventions, and advanced directives. 5. During an interview with the Clinical Manager (Admin 3) on 02-09-2024 at 12:45 PM, they indicated the plans of care needed to be patient-specific and individualized.”

“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 Clinical Manager failed to ensure needs were continuously assessed for 6 of 6 active clinical records (Patients: #1, 2, 3, 4, 5, and 6) and 6 of 6 focused clinical records reviewed (Patients: #9, 10, 11, 12, 13, and 14) and 2 of 2 closed records reviewed. (Patients: #7, and 8) Findings Include: 1. The Clinical Manager’s job description titled “Clinical Director” and dated 03-21-2023 indicated but was not limited to, “ ... The clinical manager is responsible for the overall direction of home health services ... 1. Coordinates and oversees all direct and indirect patient services provided by clinical organization personnel ... 4. Provides help in assessment, planning, implementation and evaluation of patient and family/caregiver care to all clinical personnel as indicated ...” 2. The Clinical Manager failed to ensure the comprehensive assessments and plan of cares of Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14 were complete, timely, reflected the patient’s current health, history and status, failed to ensure each patient’s strengths, goals, and care preferences were included, failed to ensure each assessment included the patient’s medical, nursing, rehabilitation, social, and discharge planning needs, failed to ensure coordination of care with the interdisciplinary team and outside agencies to ensure the patients’ needs were met, failed to ensure each assessment identified the patient’s caregiver, support, availability and schedule, willingness to provide care, failed to ensure the patients’ physicians were informed of changes in condition and services being provided, and failed to ensure the training of nursing staff regarding the documentation process for the plan of care elements, and comprehensive assessments. During an interview on 02-07-2024 at 1:11 PM, the Executive Director, Admin 2 indicated the Clinical Manager required a lot of guidance in their job.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure a discharge and transfer summary was written and sent to the primary care provider who is responsible for the patient’s care after discharge within 72 hours of discharge (Patient: #7) and within 48 hours of transfer to another facility (Patient: #8) for 2 of 2 discharged records reviewed. Findings Include: 1. An agency policy with a revision date of October 2016, titled “Discharge Summary” indicated but was not limited to, “ … The discharge summary and other relevant clinical record documents will be completed and submitted within 72 hours of discharge from service … ” 2. An agency policy with a revision date of October 2016, titled “Transfer Summary” indicated but was not limited to, “ … Within 48 hours of transfer, the transferring clinician will complete a transfer summary … ” 3. A review of the inactive clinical record for Patient #7, on 02-08-2024, with a discharge date of 10-20-2023, failed to contain a discharge summary. During an interview on 02-12-2024 at 9:02 AM, the Clinical Manager indicated they were completing the discharge assessment, summary, and order. 4. A review of the inactive clinical record for Patient #8, on 02-08-2024, with a transfer discharge date of 10-25-2023, contained a signed physician order dated 10-29-2023, signed by the Clinical Manager. The order indicated Patient #8 had missed their recertification due to an unplanned hospitalization and was being discharged. The record failed to evidence a transfer discharge summary was completed and sent to the primary care provider. During an interview on 02-12-2024 at 8:30 AM, the Intake/Medical Records Coordinator, Admin 6, indicated Patient #8’s record did not contain a transfer/discharge summary. 5. A review of agency documents, an agency letter dated 02-12-2024, and a fax confirmation, addressed to Patient #8’s physician. The letter indicated the agency discovered during a chart audit that they had not notified the physician of Patient #8’s transfer and discharge and were sending them the required documents today. 410 IAC 17-15-1(a)(6)”