Anchor Home Health Care

“Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient’s medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This Condition is not met as evidenced by: Based on observation, record review and interview, the home health agency failed to ensure: the plan of care was individualized to meet the patient needs (see tag G0570), the plan of care was individualized with specific, measurable goals, and followed by all agency staff as directed by the primary care physician (see tag G0572), the plan of care contained all required elements for their patients (see tag G0574), services and treatments were provided only as ordered by the physician (see tag G0580), the plan of care was reviewed / revised by the physician every 60 days, at minimum (see tag G0588), the home health agency staff promptly alerted the primary care physician to changes in the patient’s condition (see tag G0590), the plan of care was revised to reflect the current health status and nursing needs of the patient (see tag G0592), patients / caregivers received necessary education and training (see tag G0610), patients / caregivers received written copies of instructions (see tag G0612), and patients / caregivers were provided a written schedule of visits (see tag G0614). The cumulative effect of these systemic problems has resulted in the home health agency inability to ensure provision of quality health care in a safe environment for the condition of participation 42CFR 484.60 Care Planning, Coordination, Quality of Care. A deficient practice citation was also evidenced at this standard as follows: Based on record review and interview, the agency failed to provide services to meet the patient’s needs in 1 of 1 active patient records receiving physical therapy services only (Patient #4). The findings include: 1. A policy titled “Admission Criteria”, last reviewed 1/28/2023, indicated the agency’s criteria for admission included the expectation that the agency could adequately meet the patient’s needs. 2. A clinical record review evidenced the agency accepted a referral to provide physical therapy services for Patient #4 on 3/22/2024. The nurse completed the start of care assessment on 3/24/2024. The initial physical therapy visit was not completed until 4/5/2024. A communication note by Office Staff 5 on 4/4/2024 indicated the patient requested their physical therapy evaluation to be on 4/5/2024 because they “would not be able to work with PT (Physical Therapist) schedule”. A review of the record failed to evidence communication with the patient prior to 4/4/2024 about starting therapy. During an interview on 4/24/2024 at 2:40 PM, PT 1 indicated they did not know about a delay in initiating therapy. PT 1 indicated someone else started the case and they picked it up a few weeks ago. During an interview on 4/25/2024 at 4:17 PM, Patient #4 indicated they did not request a delay in beginning physical therapy, and they wanted to start right away. 410 IAC 17-13-1(a)”

“HHA Comprehensive Assessment in Disaster CFR(s): 484.102(b)(1) §484.102(b)(1) Condition for Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (1) The plans for the HHA’s patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure each patient had an individualized emergency preparedness plan in 2 of 2 records reviewed of patients with a home visit, not receiving skilled nursing services (Patient #3, 4). The findings include: 2. An observation of care on 4/25/2024 at 8:51 AM Patient #3 was observed using a walker for ambulation. A patient-specific emergency preparedness plan failed to be observed in the patient’s home. A clinical record review of the plan of care for certification period 2/20/2024-4/19/2024 evidenced the patient’s diagnoses included, but were not limited to, epilepsy (a seizure disorder) and indicated the medications included, but were not limited to, levetiracetam (a medication used to prevent seizures). On 4/25/2024, at 8:42 AM, the patient’s caregiver indicated the patient did have a history of seizures and indicated the patient would shake and then sleep and even vomit after seizure activity. The patient’s caregiver indicated no emergency plan had been discussed or provided to the patient or caregiver. The Home Health Emergency Plan in the clinical record failed to evidence completion of the following items: friend/neighbor/family member name, phone number and address for potential evacuation location, the walker required for ambulation, and seizure precautions. A review of the nurse’s comprehensive assessment completed by Registered Nurse (RN) 5 dated 4/15/2024 evidenced an individualized emergency preparedness which failed to evidence friend/neighbor/family member name, phone number and address for potential evacuation location and seizure precautions. On 4/26/2024 at 2:42 PM, RN 5 indicated she was unsure where the patient would evacuate to in the case of an emergency. On 4/29/2024 at 12:28 PM, the Administrator indicated the individualized emergency plan should include equipment and precautions needed but did not. 1. An observation of a home visit on 4/24/2024 at 1:50 PM evidenced Patient #4 used a motorized scooter in the home, a walker for transfers, and was unable to walk. A review of the Home Health Emergency Plan in Patient #4’s home failed to evidence completion of the following items: emergency contact name and phone number, friend/neighbor/family member name, phone number and address for potential evacuation location, physician name and phone number, pharmacy name and phone number, necessary medical equipment, and documentation that the patient was non-ambulatory. A review of the nurse’s start of care assessment dated 3/24/2024 evidenced an individualized emergency preparedness which failed to evidence emergency contact name and phone number, friend/neighbor/family member name, phone number and address for potential evacuation location, physician name and phone number, pharmacy name and phone number, necessary medical equipment, and documentation that the patient was non-ambulatory. During an interview on 4/29/2024 at 2:14 PM, the Administrator indicated the individual emergency plan should be complete, both in the home and in the patient’s record, but it was not.”

“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 each patient received services written in an individualized plan of care with patient-specific, measurable goals in 5 of 12 records reviewed receiving skilled nursing services (Patient #4, 5, 7, 8, 13). The findings include: *The clinical record for Patient #13 included orders for physical therapy dated 3/22/24. Services were to be provided once a week for 4 weeks beginning 3/25/24. The record failed to evidence that physical therapy services were provided. The plan of care indicated orders for SN once per week throughout the certification period. Week 6 of the certification period the record failed to evidence the SN provided their weekly visit. The record failed to evidence the agency notified the physician of the change in the Plan of Care. *A clinical record review of Patient #7 evidenced a plan of care for certification period 2/14/2024-4/13/2024, which indicated the agency would provide skilled nursing services 1 time a week for 8 weeks. Review failed to evidence the agency provided skilled nursing services during the weeks of 3/10/2024 and 3/24/2024. A referral from Entity 5 dated 2/2/2024 indicated the patient was seen at the wound clinic weekly and was needing home care services 1 time a week. On 4/26/2024, at 12:31 PM, the Administrator indicated the no skilled nurse was provided during the week of 3/10/2024 because the patient was seen at the wound clinic and indicated no nurse was provided during the week of 3/17/2024. The Administrator indicated the patient’s previous nurse went on medical leave and another nurse had to be scheduled to take over the patient’s care. *A clinical record review for Patient #9 evidenced a plan of care for certification period 3/8/2024-5/6/2024, which indicated the agency was to provide home health aide (HHA) services up to 20 hours per week. Review failed to evidence the agency provided HHA services per the plan of care and indicated the agency provided HHA services 28 hours per week during the weeks of 3/10/2024, 3/17/2024, 3/31/2024, 4/7/2024, and 4/14/2024. On 4/29/2024, at 12:50 PM, the Administrator indicated the agency did not provide up to 20 hours per week of HHA services per the plan of care. The agency policy titled “POLICY CC-30 PATIENT/CLIENT CARE PLANNING PROCESS”, revised 1/28/23, discloses the agency is to provide services based on an individualized, goal-directed plan of care to ensure delivery of quality home care services. The patient care planning process will be demonstrated throughout the physician’s plan of treatment and orders. The agency policy titled “POLICY: CC-15.2 MISSED VISITS PROCEDURE”, reviewed 1/28/23, evidenced it is the policy to make all attempts to provide full service as determined by the physician order frequency. When a staff member does not keep a scheduled visit with a patient, an agency representative will immediately contact the patient or family to reschedule the visit. The clinical record of PATIENT #6 plan of care (POC) evidenced orders for specified wound dressings to be done three times a week. Start of care was dated 1/3/24 and initial plan of care order a skilled nurse (SN)3W9 (three times a week for nine weeks). The order was modified on 4/18/24 to 1-3W3W2 PRN (one to three times a week for three weeks plus two ‘as needed’ visits allowed for wound complications or health decline). The clinical record of SN visits the week 4/14/24 to 4/21/24 evidenced a SN visit by RN 3 on 4/15/24 and an RN cancelled visit on 4/17/24 due to a wound clinic appointment on 4/18/24. A total of two dressing changes were noted that week due to RN cancellation of visit. The record failed to evidence communication of attempts to reschedule the missed visit. The clinical record of Patient #6’s plan of care (POC) evidenced a specified wound care order as follows: wash toes to bilateral feet with soap and water, use antibacterial soap, apply collagen powder(for wound healing and tissue regeneration) to bilateral(left and right) feet excoriated area between toes, place Hydrofera blue (antibacterial wound dressing) dressing to bilateral feet between toes, place ABD (thick, absorbent dressing) over toes, wrap in coban wrap (self-adherent mild compression wrap), 4 inch ace wrap(stretchable compression wrap) from mid foot to above each ankle, Surepress (high compression bandage) wrap bilaterally from above ankle to below knee, tape in place, apply socks followed by 6 inch ace wrap from above ankle to below knee. Interventions included skilled nurse (SN) to perform irrigation. The clinical record of SN visits failed to evidence the specified ordered wound care. The clinical record evidenced verbal physician orders dated 4/23/24 for new wound care orders with a start date (backdated) to 1/3/24. During an interview with RN 3 on 4/24/24 starting at 3:05 PM, when asked who is able to do the wound dressing changes for Patient she stated the wound care or the RN during a home visit, the patient cannot change them and the caregiver does not make any attempt to do it due to back problems. She states she saw him three times a week for a long time and if the wound has more secretions, she will see him three times a week and once the drainage is decreasing, she stated she might go two times a week. 1. A review of the plan of care for certification period 3/12/2024 to 5/10/2024 evidenced the following goals for Patient #8: Patient will have optimal nutritional status without complications, patient will have appropriate response to medications, patient passes stool at a frequency that is normal for the patient, patient will maintain normal bowel habits, and patient will have needs met to maintain optimal health. The plan of care failed to evidence what the optimal nutritional status was for the Patient or how it would be measured, what “appropriate responses” to medications were, what a normal bowel habit was for the patient, what “optimal health” was for the patient and how it would be measured. During an interview on 4/29/2024 at 2:25PM, the Administrator indicated the plan of care should be individualized with measurable goals. When informed of the findings, the Administrator indicated the nurse could look back at previous assessments to determine what was normal for the patient, but the plan of care did not specify what was normal or optimal for the patient. 2. A review of the plan of care for certification period 3/24/2024 to 5/22/2024 evidenced the following 3 physical therapy interventions for Patient #4: Establish / Upgrade home exercise / walking program, therapeutic exercise – impaired strength, and assess / re-assess transfer ability. The plan of care failed to evidence specific exercises, treatments, or modalities to be used by the physical therapist. The plan of care evidenced the following 3 physical therapy goals: Patient / Caregiver able to verbalize activities allowed, limitation, and restrictions, patient / caregiver will be able to verbalize precautions related to transfers, and patient / caregiver will demonstrate compliance with using written home exercise program log. The plan of care failed to evidence measurable physical therapy goals. During an interview on 4/24/2024 at 2:30 PM, PT (Physical Therapist) 1 indicated they created the plan of care based on what the patient needed and was able to do. PT 1 indicated Patient #4’s goal was to gain strength for easier transfers. During an interview on 4/29/2024 at 3:11 PM, the Administrator indicated the plan of care should be individualized and contain measurable goals, and PT 1 could have been more specific in creating interventions and goals. 3. A review of the plan of care for certification period 3/9/2024 to 5/7/2024 evidenced the following goals for Patient #5: Urinary elimination pattern within baseline, adherence to health teaching regarding present illness, patient / caregiver demonstrates ability to cope with limitations, knowledgeable of signs / symptoms to report to nurse / doctor, and patient / caregiver verbalize understanding / demonstrate adequate fluid intake. The plan of care failed to evidence what the baseline elimination pattern was, what “health teaching” was being adhered to and how that could be measured, what signs and symptoms were to be reported, and what was adequate fluid intake for the patient. During an interview on 4/25/2024 at 3:30 PM, the Administrator indicated the plan of care should be individualized with measurable goals. When informed of the findings, the Administrator indicated the nurse could look back at previous assessments to determine what was normal for the patient, but the plan of care did not specify what was normal or optimal for the patient. 410 IAC 17-13-1(a)”

“Written instructions to patient include: CFR(s): 484.60(e) Standard: Written information to the patient. The HHA must provide the patient and caregiver with a copy of written instructions outlining: This Standard is not met as evidenced by: Based on observation and interview the agency failed to provide the patient and caregiver with a copy of written instructions in one of five active patient records with home visits (Patient #6). Findings include: During a home visit of Patient #6 with RN 3 on 4/29/24 starting at 3:57 PM, the agency folder was observed to be present failed to evidence a plan of care or care summary. During an interview with Other #3, caregiver for Patient #6, during a home visit observation, he/she stated that all the paperwork provided by the agency is present in the folder and indicated RN 3 did not provide any additional information including treatments or visit frequencies. During an interview on 4/24/24 beginning at 4:30 PM, Administrator 1 relayed all patients should be given a plan of care summary that includes visit frequency and treatments.”

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on observation, interview, and record review the agency nursing staff failed to follow acceptable standards of practice to prevent the transmission of infection during the provision of care in two of five active patient records with home visits (Registered nurse [RN] 2 and RN 3). Findings include: The agency policy titled “POLICY: HHC-02 INFECTION CONTROL”, revised 3/15/22, implements all staff with patient contact to follow universal precautions: gloves worn if contact with blood or fluids, handling soiled items and changed after contact with blood/body fluids. Wash hands immediately after gloves are removed. Patient care surfaces and equipment should be cleaned/decontaminated after contact with potentially infectious materials using soap and water or a bleach solution. The agency policy titled “POLICY: HHC-11 BAG TECHNIQUE”, revised 1/25/24, indicates a waterproof bag with 2-3 compartments to store items should be clean, using a waterproof non permeable barrier between the bag and surface. Wash hands or use hand sanitizer each time before entering bag. During an observation of a home visit on 4/29/24 of Patient #6 with RN 3 starting at 3:57 PM, the RN’s supply bag for the visit was a plastic bag containing an ipad and scissors which she placed on a non-decontaminated surface. A barrier was not used when placing bag on a table during the home visit. RN used copious amount of hand sanitizer and dried hands with a paper towel then prepared for wound care by placing paper towels on a clean table as a barrier for dressing supplies; some items did not fit on the barrier. She donned gloves and proceeded to clean bandage scissors (from her supply bag) with hand sanitizer. RN removed the towel and washcloth from Patient’s drawer, then lifted both lower legs and the towel was placed under them on the recliner. After placing two shopping bags on the floor (for discarded dressings), RN removed soiled dressings from both legs/feet. RN discarded dressings into bags while parts of soiled dressings landed on Patient’s floor. RN 3 removed gloves and prepared a basin of water. RN used hand sanitizer then dried hands with a paper towel and donned new gloves. RN proceeded to wash slough (dead skin) and irrigate (rinse with saline) both left and right legs / wounds while verbalizing a foul smell from wounds. RN removed their right glove and then applied two new gloves to their right hand without hand hygiene. Lotion was applied to the right and left legs, then gloves were removed and new gloves were donned without hand hygiene prior to don new gloves. RN opened sterile dressing supplies on a table and used bandage scissors to cut open the alginate (absorbent dressing) while letting the cut bandage package land on the sterile supplies. Without decontaminating the scissors, she used the scissors to then cut some of the (previously) sterile alginate dressings that were placed directly on Patient’s wounds. RN placed dressings to both legs and foot wounds. Before completion of right leg/foot dressing, RN took off the gloves from their right hand. RN then used hand sanitizer to their right hand and left gloved hand then proceeded to place a new glove to their right hand. After dressings were completed, RN cleansed scissors with hand sanitizer and placed inside of a clean glove then placed them in the plastic bag. During an interview on 4/24/24 starting at 3:30 PM, the Administrator indicated hands should be sanitized before and after glove change and before staff get into their supply bag. During a home visit observation of registered nurse (RN) 2 on 4/23/24 beginning at 1:45 p.m. with Patient #2, RN 2 placed a paper barrier on a chair, placed their visit bag on barrier, and after completing hand hygiene, RN 2 assembled vital sign equipment on a different, new barrier. RN 2 then applied alcohol - based hand sanitizer to his / her gloved hands. RN 2 then applied their face mask; patient was wearing a face mask. RN 2 gloves tore and they removed the torn gloves, and donned a clean pair of gloves, without completing hand hygiene. RN 2 then reapplied alcohol based hand sanitizer to their gloved hands and then performed a dressing change to Patient #2’s Hickman catheter, without utilizing sterile gloves and was observed to reapply alcohol-based hand sanitizer to his/her gloved hands throughout procedure. During an interview on 4/24/24, beginning at 3:30 p.m., the Administrator verbalized that agency staff expectation is to apply hand sanitizer before glove change and after glove change. 410 IAC 17-12-1(m)”

“Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This Standard is not met as evidenced by: Based on observation, record review, and interview, the agency failed to assign tasks appropriately to the home health aide in 1 of 2 active clinical records reviewed with home health aide (HHA) services. (Patient #3) The findings include: During an observation of care at the home of Patient #3 on 4/25/2024, at 9:09 AM, the patient was observed ambulating with the use of a walker. The patient was not observed to use oxygen. A clinical record review of the “Multidisciplinary Care Plan” with an effective date of 3/12/2020 indicated the HHA was to assist the patient with ambulation with the use of a cane, crutches, walker, and oxygen. The HHA care plan indicated the HHA was to assist with a home exercise program and failed to evidence directions to what was included in the home exercise program. On 4/25/2024, at 9:09 AM, HHA 1 indicated the patient used a walker to ambulate and did not use oxygen. HHA 1 indicated the home exercise plan was developed by a physical therapist “a long time ago” and did not know what was included since she had not looked at it. On 4/26/2024, at 2:42 PM, Registered Nurse (RN) 5 (case manager for the patient) indicated the patient did not use oxygen and used a walker to ambulate. RN 5 indicated she was unsure why the HHA care plan included ambulation with the use of a cane, crutches, and oxygen. RN 5 indicated she was unsure if there was a written home exercise plan. 410 IAC 17-14-1(m)”

“Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure all clinical record entries were legible, clear, complete and appropriately authenticated in 5 of 12 records reviewed receiving skilled nursing or therapy services (Patient #4, 5, 6, 7, 10). Findings include: The clinical record for Patient #6, included verbal orders obtained and entered by RN 3, noted signature on file. One of the orders was dated 4/23/24 at 4:16 PM for wound care that was back dated to start 3/03/24; this order changed the frequency of the skilled nurse visits, decreased the visits from 3 times a week to 2 for week [1, 2, 3, 4, 5, 6, 7, 8, or 9] of the certification period where there was a missed skilled nurse visit. Another verbal order was entered on 4/24/24 at 4:14 PM, for wound care that was back dated to begin on 01/03/24. During an interview with RN 3 on 4/24/24 starting at 3:05 PM, when asked how she obtained orders for wound care of Patient #6 on 4/23/24, RN relayed she didn’t contact the doctor. She recalled the last time she called the doctor to obtain an order for Patient was at the beginning of March (2024). RN stated she did not obtain these orders. During an interview with Administrator 1 on 4/24/24 starting at 12:42 PM, when asked about orders entered on 4/23 and 4/24 by RN 3 that were denied being entered by RN 3, she indicated that Administrator 2 was entering the orders for patients with wounds. The clinical record of Patient #6 evidenced a plan of care for certification period 1/3/24 to 3/2/24 that was signed by Administrative staff #4 with a title of RN on 3/17/24. Personnel records evidenced Administrative staff #4 is not an RN. During an interview on 4/29/24 with Administrative staff #4, she relayed her (RN) license is expired therefore she cannot take orders. Her part in the plans of care for patients is to verify diagnoses, interventions and goals. * Clinical record for Patient #10 with start of care date of 1/6/24 for certification period 1/6/24 – 3/5/24 failed to evidence all orders within the plan of care were obtained by a licensed clinician. This plan of care was signed by a non-clinical staff. 42 CFR 484.115 (k) defines a registered nurse as a graduate of an approved school of professional nursing who is licensed in the state they are practicing. During an interview on 5/1/24 beginning at 2:30 pm the Administer indicated that the non-clinical staff that signed the document was previously a Registered Nurse but due to issues in another state they were not licensed in Indiana. *A clinical record review for Patient #7 evidenced a plan of care for certification period 2/14/2024-4/13/2024, which was signed by Administrative Staff 4 on 2/27/2024 and failed to be signed by a clinician. On 4/29/2024, at 11:19 AM, Administrative Staff 4 indicated she did not have a current nursing license or other clinical licensure. 1. A policy titled “Contents of the Clinical Record”, revised 1/28/2023, indicated all clinical record entries were to be legible, clear, complete, and appropriately authenticated, and authentication must include signatures or “secured computer entry of POT’s [plan of treatment] obtained master”. 2. A review of a skilled nurse visit note dated 3/5/2024 by the Administrator evidenced a section titled “Patient Signature”, which stated, “Visit date and time confirmed by [Patient #8] with signature captured on 3/5/2024 12:41 CST”, followed by a signature by LPN (licensed practical nurse) 1. During an interview on 4/29/2024 at 2:38 PM the Administrator indicated the patient should sign the clinician’s electronic device to confirm the visit. If unable to sign, a family member may sign for the patient. The administrator indicated Patient #8 was cognitively unable to confirm a visit. 3. A review of an Interdisciplinary Group Meeting note for Patient #4 on 3/27/2024 evidenced a narrative note describing Person 4, a patient who was bedbound, had multiple wounds, and a leg amputation. Observation of a home visit on 4/24/2024 at 1:50 PM evidenced Patient #4 was not bedbound, had no wounds, and no amputations. During an interview on 4/29/2024 at 3:00 PM, the Administrator indicated the narrative in the note was about the wrong patient. 4. A review of the plan of care for certification period 3/9/2024 to 5/7/2024 indicated Patient #5 was homebound due to the following assessment: unable to ambulate more than a few minutes or a few feet without falling due to poor balance and extreme fatigue, very short of breath with minimal exertion and needed to stop and sit to rest every few minutes, required the assistance of another person to ambulate at all times due to unsafe gait pattern and cardiopulmonary disease. The plan of care failed to evidence a cardiopulmonary diagnosis or medications. In a comprehensive assessment dated 3/8/2024, RN (Registered Nurse) 4 indicated the Patient was paraplegic and non-ambulatory. During an interview on 4/24/2024 at 11:26 AM, LPN 2 indicated the Patient was able to transfer self with assistance but could not ambulate. During an interview on 4/25/2024 at 12:23 PM, RN 4 (case manager for Patient #5) indicated they were not aware of the Patient having cardiovascular problems. On 4/29/2024 at 3:41 PM, when informed of the findings, the Administrator indicated the homebound assessment in the plan of care did not describe Patient #5, and it was probably incorrectly transferred from another patient’s assessment.”

“Property and person treated with respect CFR(s): 484.50(c)(1) Have his or her property and person treated with respect; This Element is not met as evidenced by: Based on record review, observation, and interview the agency failed to evidence patient care was free from verbal, mental, and physical abuse in one of five active patients with home visit observations (Patient #6). Findings include: “Standards of Professional Nursing Practice”, an agency training reference, indicates RN competencies include demonstrating caring behaviors towards people receiving care and provide holistic care that is sensitive to the needs of consumers. During a home visit observation of Patient #6 by RN 3 on 4/29/24 starting at 3:57 PM, RN stated that Patient’s wounds ‘stink’ on several occasions during the visit. When new wounds were identified to Patient’s backside, RN stated “if it was my parent, I would make sure it (the wound) was being treated.” During an interview with Patient #6 caregiver, Other #3 on 4/25/24 starting at 4:02 PM, he/she referred to RN 3 as mean and rude in her general demeanor during care to Patient. Other examples given were walking in the home without knocking multiple times, not parking where asked, and not adhering to appointment times. During an interview on 5/1/24 starting at 11:15 AM, the Administrator relayed there is a personality conflict between RN 3, Patient and caregiver, Other #3; the RN will not be returning to care for Patient. 410 IAC 17-12-3(b)(2)(A)”

“HHA can no longer meet the patient’s needs CFR(s): 484.50(d)(1) The transfer or discharge is necessary for the patient’s welfare because the HHA and the physician or allowed practitioner, who is responsible for the home health plan of care agree that the HHA can no longer meet the patient’s needs, based on the patient’s acuity. The HHA must arrange a safe and appropriate transfer to other care entities when the needs of the patient exceed the HHA’s capabilities; This Element is not met as evidenced by: Based on record review and interview the agency failed to evidence the physician was consulted for the purpose of discharge prior discharge for 1 of 4 discharge records reviewed (Patient #11) The record for Patient #11 reviewed on 4/25/24 included a Plan of Care dated 1/27/24 – 3/26/2024 which indicated Skilled Nursing orders 1 to 2 times per week for 9 weeks. The record further indicated Patient #11 was discharged from services on 3/5/24. The record failed to evidence the attending physician was consulted in plan of the discharge. The record included an undated verbal order indicating was obtained 3/7/24 for discharge of Patient #11. During an interview on 4/25/24 beginning at 3:45 p.m., Patient #11 indicated the skilled nurse conducted the discharge over the telephone. During an interview on 5/1/24 beginning at 2:30 p.m. the Administrator indicated the nurse conducted an in person visit for discharge of Patient #11 and provided as evidence the coordinates for the nurse at the time of discharge. The record revealed two different sets of coordinates, neither was identified as Patient #11’s known address. The Administrator was unable to determine why the coordinates were not Patient’s address and further indicated the clinician is unable to open the visit unless they are within 1000 feet of patient address.”

“Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This Element is not met as evidenced by: Based on record review and interviews, the agency failed to document the existence and resolution of a complaint in one of five active patient records with home visits (Patient #6). Findings include: On 5/1/2024, at 11:15 AM, the Administrator indicated the agency had conversations with both RN 3 and the patient’s caregiver but nothing was documented related to the complaint and investigation of the personality conflict with RN 3. The Administrator indicated a complaint form should have been completed, but RN 3 had since submitted her resignation. The agency policy titled “POLICY: CC-09 PATIENT CLIENT COMPLAINTS AND CONCERNS”, revised on 1/28/03, establishes a vehicle for patients and families to communicate concerns or complaints regarding their care. The Clinical Supervisor will investigate and document the complaint and provide the Administrator with a copy for review then the Quality Assurance manager is responsible for logging all complaints in the agency Occurrence log. During an interview with Other #3, caregiver and family member for Patient #6, on 4/25/24 at 4:02 PM, he/she contacted the agency regarding inappropriate behavior and care from RN 3 on six occasions and relayed the complaints to Administrator #5 since 1/3/24. During an interview with Administrative 5 on 4/30/24 starting at 4:25 PM, she revealed the caregiver for Patient complained two times regarding the care and behavior from RN 3 during a home visit. During an interview with Administrative 1, clinical manager, on 5/1/24 starting at 11:15 PM, she stated there was one complaint made by Patient’s caregiver about the RN. When asked about the lack of complaints from Patient #6 or his family in the complaint log, no answer was given. The agency’s complaint log records failed to evidence documentation or investigation of complaint from Patient #6 and/or his/her family/caregivers. 410 IAC 17-12-3(c )(2)”

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on record review and interview, the agency failed to conduct an initial assessment visit within 48 hours of referral in two out of nine active patient records reviewed (Patient # 6, 7). Findings include: The agency policy titled, “POLICY CC-25 INITIAL PATIENT/CLIENT ASSESSMENT”, revised on 1/28/23, indicated a qualified professional must complete an initial assessment within 48 hours of initiation of services to determine support needs of patient. The policy titled, “POLICY: HHC-06.2 EMERGENCY AND DISASTER PREPAREDNESS PLAN- PANDEMIC INFECTIOUS DISEASE”, revised March 2023, indicated to minimize exposure the agency all staff will have access to protective equipment and staff should follow droplet precautions for patients with suspected or confirmed COVID-19. The clinical record of Patient #6 revealed a referral date of 12/22/23 with an ordered start of care date of 12/26/23. An initial assessment visit was conducted on 1/3/24. The record failed to evidence the initial assessment and care began on 12/26/23 as ordered. During an interview with Administrator 1 on 4/30/24 starting at 4:17 PM, she relayed they did not complete the initial assessment as ordered, due to Patient with COVID and there was no evidence in the clinical record that the referring physician and patient were notified of the delay. During an interview on 5/01/24, beginning at 10:45 AM, Other 3 relayed Patient did not have COVID in December of 2023 and relayed they were not able to change Patient’s dressings, as they were not physically able. 410 IAC 17-14-1(a)(1)(A) * A clinical record review for Patient #7 evidenced a document titled “Referral” which indicated the date of referral was 2/2/2024. The start of care comprehensive assessment was dated 2/14/2024, which was greater than 48 hours since time of referral. The “Interdisciplinary Communication” dated 2/9/2024 indicated the patient was ready for admission on 2/13/2024, and review failed to evidence any documentation of attempts to schedule the admission prior to 2/9/2024. On 4/26/2024, at 11:43 AM, the Administrator indicated there was no other documentation regarding attempts to schedule the admission with the patient prior to 2/9/2024. * On 4/22/2024, at 10:06 AM, the Administrator indicated the initial visit is the start of care comprehensive assessment and should be completed within 48 hours from time of referral.”

“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 interview, record review, observation, the comprehensive assessment failed to accurately reflect the patient’s health status in two of nine active records reviewed (Patient #6, 7). Findings include: * A clinical record review for Patient #7, evidenced a start of care comprehensive assessment for 2/14/2024, which indicated the patient had 2 open wounds to the right leg and failed to include an assessment of the depth of the wounds. The recertification comprehensive assessment on 4/12/2024 indicated the patient had an open wound to the right leg and failed to evidence the assessment of the wound size. On 4/26/2024, at 12:25 PM, the Administrator indicated the comprehensive assessment did not include the wound measurements to include depth and indicated the agency was educating nursing staff about wound documentation since the measurements should be included. The agency policy titled “POLICY: CC-59 RISK ASSESSMENT AND WOUND ASSESSMENT”, revised 1/25/24, indicates upon patient admission the wound should be assessed in order to plan and implement wound care treatment, the use of uniform descriptions is recommended to facilitate communication. The clinical record of Patient #6 evidenced a comprehensive assessment completed for the start of care on 1/3/24 and for recertification on 3/2/24 by RN 3, documentation evidenced a right foot/toe wound assessment and failed to evidence wound measurements. The comprehensive assessments failed to evidence left foot/toe wound assessment and measurements. RN visit documentation indicated left foot/toe wounds on 1/12/24, 1/15/24, 1/19/24, 1/22/24, 1/24/24, 1/26/24, 1/29/24, 1/31/24, 2/3/24, 2/5/24, 2/10/24, 2/12/24, 2/16/24, 2/20/24, 2/23/24, 2/26/24, 3/2/24, and subsequent visits. During an interview with RN 3 on 4/24/24 starting at 3:05 PM, when asked how often she measures the patient’s wounds she stated she should be measuring every first visit (of each week) but hasn’t seen a change and cannot recall when the wounds were last measured. She indicated she thought the doctor measures the wounds though she did not have the physicians’ documentation. RN relayed the patient had wounds to the right and left feet since the start of care with Patient #6 and referred to the left foot/toe wound as broken skin and excoriated (skin injury). During an interview with Administrator (admin) 1 on 4/26/24 starting at 12:42 PM, she stated wounds should be measured weekly. 410 IAC 17-14-1(a)(1)(B)”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on observation, record review, and interview the agency failed to include a review of all medications to identify potential adverse effects, significant drug reactions, duplicate drug therapy, and noncompliance with drug therapy in 3 out of 9 active records (Patient #6, 7, 9). Findings include: The agency policy titled “POLICY: CC-25 INITIAL PATIENT/CLIENT ASSESSMENT”, revised on 1/28/23, indicates a qualified professional must complete an initial assessment, to determine immediate care and support needs of the patient. The clinical record of Patient #6 evidenced a major medication interactions between Nifedipine (calcium channel blocker that lowers blood pressure) and Phenytoin (anticonvulsant to treat epilepsy) stating “GENERALLY AVOID”. During an observation of a recertification home visit with Patient and RN 3 on 4/29/24 starting at 3:57 PM, the RN asked if there are any new medications, Patient answered no. The observation failed to evidence evaluation of medication interactions nor medication compliance. During an interview on 4/24/24 beginning at 3:05 PM, when asked how RN 3 knows two medications interact, she relayed it would depend on what the patient reports. When asked how a review of medication interactions was done with Patient, RN indicated the daughter helps Patient with his medications. 410 IAC 17-14-1(a)(1)(B) * A clinical record review for Patient #7, start of care 2/14/2024, evidenced a plan of care for certification period 2/14/2024-4/13/2024, which indicated the medications included, but were not limited to, bupropion (antidepressant) and tramadol (pain medication). The document titled “Medication Interaction” dated 4/25/2024 indicated a potential severe interaction between bupropion and tramadol, which could increase the risk of seizures. The start of care comprehensive assessment on 2/14/2024 failed to evidence a review of the medications to include potential drug interactions with the patient/caregiver. On 4/26/2024, at 12:19 PM, the Administrator indicated the comprehensive assessment did not include the potential drug interactions. *A clinical record review for Patient #9, start of care 1/8/2024, evidenced a plan of care for certification period 1/8/2024-3/7/2024, which indicated the patient’s medications included, but were not limited to, aspirin (a medication used to prevent blood clots) and apixaban (a medication used to treat/prevent blood clots). The document titled “Medication Interation” dated 4/26/2024 indicated a potential sever interaction between aspirin and apixaban, which could increase the risk of bleeding complications. The start of care comprehensive assessment completed by RN 6 on 1/8/2024 indicated the medications were reviewed and no issues were found. Review failed to evidence the comprehensive assessment included a review of the medications to include potential drug interactions. On 4/26/2024, at 2:42 PM, RN 6 indicated she was unaware of any potential medication interactions. *On 4/29/2024, at 12:34 PM, the Administrator indicated the nurses did not use the comprehensive assessment to review medication interactions and needed additional training on how to answer that question on the comprehensive assessment.”

“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 comprehensive assessment failed to accurately reflect the patient’s primary caregiver’s willingness, availability nor their ability to provide care in one of five home visit patients (Patient #6). Findings include: The clinical record of Patient #6 revealed an initial comprehensive assessment dated 01/3/24, completed by RN 3, which evidenced a family member was the primary caregiver and that they managed Patient’s care. The record evidenced documentation that the caregiver provided assistance “several times during the day and night,” with willingness and ability to provide care and availability noted to be continuous. Patients’ goals evidenced an inability to ambulate and decreased ability to perform activities of daily living. During an interview on 4/26/2024 beginning at 4 PM, Other #3, Patient #6’s caregiver and family member indicated they cannot lift Patient (for ambulation) or lift the leg to change the wound dressing due to their back condition. During an interview at time of a home visit on 4/29/24, starting at 6:30 PM, Patient #6 indicated their caregiver, Other #3, cannot come every day. During an interview on 4/24/24 starting at 3:05 PM, RN 3 relayed that Patient #6 cannot ambulate alone. When asked if the caregiver changed Patient’s wound dressings, RN 3 indicated the caregiver does not make any attempt due to their back problems.”

“Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment was performed in the last 5 days of every 60-day episode in 1 of 1 active records reviewed receiving LPN (Licensed Professional Nurse) services (Patient #8). The findings include: A policy titled “Reassessment / Update of the Comprehensive Assessment” revised 1/28/2023, indicated the comprehensive assessment would be updated, at minimum, during the last 5 days of every 60-day episode of care. A clinical record review evidenced the comprehensive assessment for Patient #8, certification period 3/12/2024 to 5/10/2024, was performed on 3/5/2024 by the Administrator. During an interview on 4/29/2024 at 2:38 PM, the Administrator indicated the comprehensive assessment should be updated during the last 5 days of the certification period. When informed of the findings, the Administrator indicated they sometimes would do the comprehensive assessment early in non-OASIS patients (patients who do not require OASIS assessment, i.e. pediatric, obstetric, or personal-care only patients).”

“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 plan of care included all required components in 7 of 9 active records reviewed (Patient #3, 4, 5, 6, 7, 8, 9). The findings include: The agency policy titled “POLICY: CC-03.1 PHYSICIAN’S PLAN OF CARE”, revised on 1/28/23, indicates the plan of care is established and periodically reviewed by the doctor to ensure appropriate care relative to patient’s condition. All clinical services are implemented only in accordance with physician’s orders including goals, nutrition requirements, medications and treatments, and safety measures. During a home visit observation with Patient #6 on 4/29/24 starting at 3:57 PM with RN 3, Patient was on oxygen at 4L (liters per minute). A plan of care (POC) present in Patient’s room for Entity 1, another home health agency caring for Patient, revealed a medication list that included one dose of lisinopril 40mg daily, Dilantin (AKA Phenytoin: a seizure medication) 530 milligrams(mg) daily. The POC indicated aide services provided to Patient #6. During an interview with Patient on 4/29/24 starting at 6:30 PM, when asked about pain control, he/she revealed pain medication at the bedside: Oxycodone (narcotic pain medication) and Ibuprofen (non-narcotic pain medication) that was prescribed by a physician. Patient verified oxygen dosage of 4L that is required around the clock, a dosage of Dilantin (seizure medication) that is 530mg daily, and one dose of Lisinopril (blood pressure medication) 40mg daily. He/she verified a diagnosis of Epilepsy (a seizure disorder). The clinical record of Patient #6 revealed a plan of care (POC) medication list that failed to include Patient’s oxygen. A dosage for Lisinopril 40mg daily was listed two times indicated two dosages and daily Dilantin dose of only 30mg daily. The POC failed to list Epilepsy as a diagnosis and seizure precautions as a safety measure. During an interview on 4/25/24 starting at 3:32 PM, Administrator 1 indicated patient with known seizures, or a seizure diagnosis should be on seizure precautions. During an interview with RN 3 on 4/24/24 starting at 3:05 PM, she stated that Patient #6 was on oxygen when she first started caring for him/her at the dose of 4L. When asked how many doses of lisinopril does the patient take per day, she stated only one. RN 3 stated patient doesn’t know why he is on Dilantin and said he has been taking it for a long time. During an interview on 4/24/24 starting at 3:30 PM, Administrator 1 indicated that a full medication reconciliation is done every recertification by the nurse. If there are changes in medication, it will be updated on the medication profile. An agency policy titled “POLICY: CC-13.1 COORDINATION OF CARE”, revised on 1/28/23, requires coordination of care for all patients, staff to act as case manager to coordinate services to implement the plan of care including other health service providers serving the patient. During an interview with Other #3, caregiver for Patient #6, on 4/26/24 starting at 16:02, he/she revealed that Patient had been receiving care from another home care agency for home aide services and from a wound care clinic. The clinical record for Patient #6 revealed a plan of care that failed to include coordination of services from Entity 1 and a wound care clinic. During an interview with RN 3 on 4/24/24 starting at 3:05 PM, she indicated knowledge of home health aid from a separate agency providing care to Patient along with care from a wound care clinic. *A clinical record review of Patient #7 evidenced a plan of care for certification period 2/14/2024-4/13/2024, which indicated the patient’s medications included, but were not limited to, warfarin (blood thinner medication used to treat/prevent blood clots). Review failed to evidence bleeding precautions in the safety measures in the plan of care. On 4/26/2024, at 12:29 PM, the Administrator indicated the bleeding precautions were not included but should be in the safety measures on the plan of care. Review of the referral documents from the wound clinic at Entity 5 indicated the patient received wound treatment from the wound clinic weekly. Documents from Entity 5 indicated the patient received wound treatment at the wound clinic on 2/15/2024, 3/21/2024, and 4/18/2024. The plan of care failed to include the wound care services and frequency of services provided by the wound clinic. On 4/26/2024, at 12:31 PM, the Administrator indicated the agency did not include wound clinics on the plan of care. *A clinical record review for Patient #9 evidenced a plan of care for certification period 3/8/2024-5/6/2024, which evidenced the patient’s medications included bisacodyl (a medication used to treat constipation) and a fleets enema (a medication used to treat constipation) as needed and failed to evidence the individual indication for use as needed. The plan of care indicated the patient’s goals included, but were not limited to, promote skin integrity and maintain usual bowel patterns and failed to evidence how the goals were to be measured. On 4/29/2024, beginning at 12:30 PM, the Administrator indicated the as needed medications were for constipation and the as needed indications for use should be included in the plan of care but were not. The Administrator indicated the goals would be measured by having no new open areas and the patient would have bowel movements during the administration of the bowel program and indicated it was not included on the plan of care. *A clinical record review for Patient #3 evidenced a plan of care for certification period 2/20/2024-4/19/2024 which evidenced the patient’s diagnoses included, but were not limited to, epilepsy (a seizure disorder) and indicated the medications included, but were not limited to, levetiracetam (a medication used to prevent seizures). The plan of care failed to evidence seizure precautions were include in the safety measures. On 4/25/2024, at 8:42 AM, the patient’s caregiver indicated the patient did have a history of seizures and indicated the patient would shake and then sleep and even vomit after seizure activity. On 4/29/2024, at 12:14 PM, the Administrator indicated seizure precautions were not included on the plan of care but should be since the patient had a diagnosis of epilepsy. 1. A review of the plan of care for certification period 3/12/2024 to 5/10/2024 indicated Patient #8 had a feeding tube that was to be changed every 3 months by the family / caregiver every 3 months and as needed. The plan of care failed to evidence if the agency caregiver was changing the feeding tube, when the tube was to be changed next, and indications for why the tube would need to be changed. During an interview on 4/29/2024 at 2:25 PM, the Administrator indicated the Patient’s family member changed the tube every 3 months, and the schedule for changing the tube was kept on a board in the patient’s home. The Administrator indicated the plan of care should have included all information about care of the feeding tube. 2. A review of the plan of care for certification period 3/24/2024 to 5/22/2024 indicated Patient #4 was taking Xarelto (a blood thinner) daily, but failed to evidence Bleeding Precautions. During an interview on 4/24/2024 at 3:35 PM, the Administrator indicated the plan of care should have included Bleeding Precautions. 3. During a home visit on 4/24/2024 at 11:18 AM, Patient #5 was observed wearing bilateral AFO’s (braces for the feet to lower legs). A review of the plan of care for certification period 3/9/2024 to 5/7/2024 evidenced Patient #5 had a diagnosis of Epilepsy. The plan of care failed to evidence seizure precautions and AFO’s. During an interview on 4/25/2024 at 12:22 PM, RN (Registered Nurse) 4 indicated the Patient had been using AFO’s for as long as she knew the patient. During an interview on 4/29/2024 at 3:41 PM, the Administrator indicated AFO’s and seizure precautions should have been included in Patient #5’s plan of care.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on record review and interview, the agency failed to implement services and treatments administered as ordered by a physician in four out of nine active records reviewed (Patient #3, 6, 7, 9). Findings include: * A clinical record review for Patient #7 failed to evidence an order for the home care services provided which began 2/14/2024 before the plan of care for certification period 2/14/2024-4/13/2024 was signed by the physician on 4/22/2024. Review failed to evidence an order for continuation of services for care that began at the start of the certification period of 4/14/2024. On 4/25/2024, at 11:54 AM, Registered Nurse (RN) 3 (nurse case manager for the patient) indicated she did not contact the physician for start of care or recertification orders for home health care because she assumed the office did that. On 4/26/2024, at 11:48 AM, the Administrator indicated the start of care order was the face sheet of the referral from Entity 5, which indicated the patient needed home care services 1 time per week. The Administrator indicated the face sheet was not from/signed by the physician, and indicated the fax included the additional documents which were signed by the physician but did not include a home care order but just the wound care order. *A clinical record review for Patient #9 failed to evidence an order for the home care services which began on 1/8/2023 before the plan of care for certification period 1/8/2024-3/7/2024 was signed by the physician on 2/5/2024. On 4/26/2024, at 2:42 PM, RN 5 (nurse case manager for the patient) indicated she did not contact the physician for a start of care order and indicated she thought the office did that. On 4/29/2024, at 12:44 PM, the Administrator indicated she could not locate a start of care order for home care services in the clinical record and would look for an order in the hospital referral information in Epic (an electronic health record for the hospital) but no additional documentation or information was provided prior to survey exit on 5/1/2024. *A clinical record review for Patient #3 failed to evidence an order for the continuation of home care services that began upon recertification on 2/20/2024 before the plan of care signed and dated by the Alternate Clinical Manager on 3/13/2024 for certification period 2/20/2024-4/19/2024 was signed by the physician on 3/18/2024. Review failed to evidence documentation of communication with the physician regarding the recertification of home health services. On 4/29/2024, at 12:06 PM, the Administrator indicated the agency did not write a recertification order because the clinician’s entry of a date on the plan of care for verbal start of care as the continuation of care order. On 4/30/2024, at 11:45 AM, the Alternate Clinical Manager indicated she did not contact the physician for a recertification order for continuation of home care services and signed the plan of care since she assisted in reviewing the plan of care. The agency policy titled “POLICY: CC-31 DOCUMENTATION OF PATIENT/CLIENT CARE”, revised on 1/28/23, indicates physician orders must be obtained for all patients receiving skilled home care services. The clinical record of Patient #6 evidenced an initial certification period of 1/3/24 (start of care) to 3/2/24 with a plan of care (POC) that was signed by his physician 1/18/24. The recertification period 3/3/24 to 5/1/24 included a recertification visit 3/2/24 and a POC signed by the physician 3/12/24. The records failed to evidence verbal orders for skilled nurse care implemented on 1/6/24, 1/8/24, 1/10/24, 1/12/24, 1/15/24, 1/17/24, 3/5/24, 3/8/24, and 3/11/24. The record review of Patient # 6 revealed a referral for patient home health care on 12/22/23 but failed to evidence a start of care (SOC) order which was completed on 1/3/24 by RN 3 for a certification period of 1/3/24 to 3/2/24. The record failed to evidence a recertification order for recertification visit completed on 3/2/24 by RN 3 for a certification period 3/3/24 to 5/1/24. During an interview with RN 3 on 4/24/24 starting at 3:05 PM, when asked how she obtained certification orders for start of care of Patient #6, she indicated she refers to the (previous) discharge orders. During an interview on 4/23/24 starting at 4:42 PM, Administrator 1 relayed the start of care order is on the cover sheet of the fax. She continued that the fax cover sheet is considered an order because the doctor attached documents to it and even though the cover sheet is not signed by the doctor. 410 IAC 17-13-1(a)”

“Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient’s condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the physician reviewed the plan of care at least every 60 days in 1 of 7 active clinical records reviewed with more than 1 certification period. (Patient #7) The findings include: A clinical record review for Patient #7, start of care 2/14/2024, evidenced a plan of care for certification period 2/14/2024-4/13/2024, signed by the physician on 4/22/2024, which was greater than 60 days. On 4/26/2024, at 12:10 PM, the Administrator indicated there was no other documentation the physician reviewed the plan of care other than the date he signed it on 4/22/2024 and indicated the plan of care should be reviewed by the physician at least every 60 days.”

“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, interview, and observations the agency failed to promptly alert the physician to any changes in the patient’s condition or needs in three of nine active patient records reviewed (Patient #5, 6, 7) Findings include: A review of the plan of care for certification period 3/9/2024 to 5/7/2024 indicated the nurse was to assess Patient #5 for signs and symptoms of a UTI (urinary tract infection) and to notify the physician of significant changes. During an interview on 4/24/2024 at 11:47 AM, LPN (Licensed Practical Nurse) 1 indicated they thought the Patient might have had a UTI based on the appearance of the urine and how the patient was behaving during daily weekday visits between 3/25/2024 and 4/5/2024 LPN 2 indicated she did not notify the physician, she notified the Patient’s family member who notified the physician. 410 IAC 17-13-1(a)(2) * A clinical record review for Patient #7, start of care 2/14/2024, evidenced a plan of care for certification period 2/14/2024-4/13/2024, which indicated the medications included, but were not limited to, bupropion (antidepressant) and tramadol (pain medication). The document titled “Medication Interaction” dated 4/25/2024 indicated a potential severe interaction between bupropion and tramadol, which could increase the risk of seizures. Review failed to evidence the physician was notified of the potential severe interaction. On 4/26/2024, at 12:12 PM, the Administrator indicated the severe interaction should have been included on the plan of care to notify the physician and indicated it was not included. The Administrator indicated there was no other documentation of physician notification of the potential severe drug interaction. A skilled nurse visit note completed by Registered Nurse (RN) 3 on 4/22/2024 indicated the patient was diagnosed with a urinary tract infection and was prescribed an antibiotic effective 4/18/2024. Review failed to evidence the physician responsible for the plan of care was notified. On 4/25/2024, at 11:54 AM, RN 3 indicated the patient’s primary care physician (not the physician responsible for the plan of care) ordered the antibiotic and RN 3 did not notify the physician responsible for the plan of care of the infection and prescribed antibiotic. The agency policy titled “POLICY: CC-25.1 ASSESSMENT AND REASSESSMENT GUIDELINES”, last reviewed 1/28/23, indicates pertinent assessment and reassessment data will be communicated to team members including the patient’s physician with the use of appropriate Standards of Practice. “Standards of Professional Nursing”, an agency training reference, indicates the registered nurse collects comprehensive data assessments in an ongoing process, prioritize data collected, and collaborate with healthcare providers to implement a plan for the promotion and restoration of health. The clinical note of Patient #6 initial start of care assessment on 1/3/24 by RN 3 evidenced a right toe wound assessment and no other wounds. Starting on 1/12/24 the RN visit notes evidenced a left toe and right toe wound assessment with continued documentation of left and right toe wounds to current visits. The clinical noted failed to evidence communication with physician reporting the new wound. The clinical note of Patient #6 evidenced skilled nurse visit documents indicated Patient’s wound developed a foul odor (a sign of bacterial infection) to the left foot/toe wound on 1/12/24, 1/31/24, 2/10/24, 2/12/24, and 3/5/24. A foul odor to the right foot/toe wound was charted by the RN on 1/31/24, 2/10/24, 2/12/24, and 3/5/24. The clinical note failed to evidence communication with the physician to report changes in wound status. During an interview with RN 3 on 4/24/24 starting at 3:05 PM, when asked if she contacted the physician about the changes in wound odor she indicated she did not call the doctor. During an interview with Other #3, caregiver of Patient #6, on 4/25/24 starting at 4:02 PM, he/she indicated Patient has several wounds on his/her backside that RN 3 does not tend to. During a home visit observation with Patient #6 on 4/29/24 starting at 3:57 PM with RN 3, RN indicated that Patient has no additional wounds other than the right and left toes. Other #3, caregiver for Patient, entered and asked Patient to stand up and lesions to both sides of buttocks were evidence with redness to backside and scrotum. RN 3 indicated that she knew about the (backside) wounds two months ago. When asked if the physician is aware, RN relayed she did not report the wounds. During an interview with Patient #6 after his home visit on 4/29/24 starting at 6:30 PM, he/she indicated that RN 3 knew about the wound (on backside) two months ago and never asked to see it. The clinical note of Patient #6 failed to evidence any assessment, education, or communication with the physician regarding wounds to backside. During an interview with Administrator 1 on 4/26/24 starting at 12:42 PM, she indicated the doctor should be notified of any changes in wounds.”

“Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient’s updated comprehensive assessment, and contain information concerning the patient’s progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This Element is not met as evidenced by: Based on record review, interview, and observation the agency failed to provide a revised plan of care that reflects current information from the patient’s updated comprehensive assessment and contain information concerning the patient’s progress towards goals in two of five active patient records with wounds (Patient #4, 6). Findings include: XX. A review of the plan of care for certification period 3/24/2024 to 5/22/2024 indicated the physical therapist was to establish a home exercise / walking program for aerobic capacity / activity tolerance. During an interview on 4/24/2024 at 2:40 PM, PT (Physical Therapist) 1 indicated they were working on strength training for Patient #4 to ease transferring, and that Patient #4 was not on a walking program because they were unable to ambulate. PT 1 indicated they would revise the plan of care based on a patient’s needs and progress. The agency policy titled “POLICY: CC-30 PATIENT/CLIENT CARE PLANNING PROCESS”, revised 1/28/23, indicated an individualized, goal-directed plan demonstrated through the physician’s plan of treatment and orders is reviewed and revised whenever necessary based on client needs. During an observation of a home visit with Patient #6 with RN 3 on 4/29/24 starting at 3:57 PM, open wounds were observed to right and left toes during wound dressing changes and wounds were observed to Patient’s backside. Patient indicated the RN knew about the wounds and did not assess them previously. RN 3 revealed she knew about the (backside) wounds but did not assess them during prior assessments. The clinical note of Patient #6 failed to evidence a plan of care that included care for wounds to Patient’s backside or communication with the physician to report wounds. The clinical record of Patient 6’s referral for home health dated 11/16/23 evidenced the patient had a wound to the right foot with previously healed wounds including to left foot. Documentation of Patient’s start of care (SOC) was on 1/3/24 by RN 3 with a wound assessment of the right toe and no other documented wounds. RN assessment included documentation of left toe wound as reddened, with slough (dead cells accumulated from drainage), and scaly with moderate to heavy drainage on 1/12/24 throughout patient. The clinical record failed to evidence communication with the physician regarding new wounds. During an interview with RN 3 on 4/24/24 starting at 3:05 PM, when asked if the physician was aware of changes to the wounds, she said she didn’t contact the physician’s office. When asked about the left foot/toe wound, she stated it’s draining and excoriated (raw, irritated lesion).”

“Patients receive education and training CFR(s): 484.60(d)(5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge. This Element is not met as evidenced by: Based on observation, interviews, and record review the agency failed to ensure that the patient and his/her caregiver receive ongoing education and training as appropriate to plan of care in two of five active patient records with home visits (Patient #6, 7). Findings include: * A clinical record review for Patient #7 evidenced a skilled nurse visit note completed by Registered Nurse (RN) 3 on 4/22/2024, which indicated the patient was diagnosed with a urinary tract infection and was prescribed an antibiotic effective 4/18/2024. Review failed to evidence the RN provided education on the signs and symptoms of the urinary tract infection and the education on direction and compliance with the antibiotic therapy and potential side effects. Documents from the wound clinic at Entity 5 dated 2/15/2024, 3/21/2024, and 4/18/2024 indicated the patient was to increase the protein in the diet to promote wound healing. Review failed to evidence the agency educated the patient on the diet recommendation. On 4/25/2024, at 11:54 AM, RN 3 indicated she did not educate the patient on the antibiotic therapy because the patient got the medication information sheet from the pharmacy. RN 3 indicated she did not educate the patient on the increased protein in the diet because she was not aware of any special diet instructions. The agency policy titled “POLICY: CC-36 PATIENT/CLIENT EDUCATION”, reviewed 1/28/23, indicates the agency is to provide interdisciplinary patient education based on needs and includes communication with family to facilitate patient’s educational objectives. The agency policy titled “POLICY: CC-59 RISK ASSESSMENT AND WOUND ASSESSMENT”, revised 1/25/24, indicates the patient’s knowledge related to conditions should be assessed in order to identify and implement a teaching plan including the patient or caregivers’ ability and willingness to follow instructions in order to meet goals. This assessment should be repeated at periodic intervals and compliance with interventions should be assessed at every nursing visit. A clinical record review of Patient #6 evidenced a plan of care listing a medical history of severe weakness, falls with injuries, wounds, lung disease, diabetes, Parkinson’s disease (nervous system disease affecting movement), heart failure, neuropathy (damaged nerves), lymphedema (swelling disorder),high blood pressure, and is on medications with major interactions. Comprehensive assessments completed on 1/3/24 and 3/5/24 indicated Patient is on home oxygen. 410 IAC 17-14-1(a)(1)(G) During an observation of a home recertification visit with Patient #6 and RN 3 on 4/29/24 starting at 3:57 PM, previously undocumented wounds were noted to Patient’s backside. RN 3 failed to evidence teaching to Patient or caregiver related to Patient’s diagnoses, wounds including new wounds, or medication interactions. During the visit, RN relayed that the patient and caregiver are not open to teaching. During an interview with Patient #6 after a home visit on 4/29/24 starting at 6:30 PM, Patient verified a diagnosis of Epilepsy (a seizure disorder). During an interview with Other #3, caregiver and family member of Patient #6, on 4/25/24 starting at 4:02 PM, he/she relayed RN 3 has never provided education to Patient or family.”

“Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on observation and interview, the agency failed to provide the patient and caregiver a copy of written instructions including visit schedule and frequency of visits in three of five home visit patients (Patient #4 and 6). Findings include: XX. During a home visit on 4/23/24, beginning at 7:45 a.m., the home health agency folder in Patient #1’s home failed to evidence written instructions or treatments included in the plan of care. During an interview on 4/24/24, beginning at 3:30 p.m., the Administrator verbalized that the nurse places a care plan summary in the patient folder after admission and recertification. XX. An observation of a home visit for Patient #4 on 4/24/2024 at 1:50 PM failed to evidence a written schedule of visits. A review of the agency folder in the home evidenced a blank calendar of visits. During an interview on 4/24/2024 at 2:15 PM, Patient #4 indicated they did not receive a written schedule of visits from the agency. During an interview on 4/24/2024 at 2:15 PM, PT (Physical Therapist) 1 indicated they informed the patient of the visit schedule by calling before the visit. During an observation of a home visit on 4/29/24 for Patient #6 by RN 3, the folder contents did not include a written schedule nor a plan of care. During an interview with Patient #6 on 4/29/24 starting at 6:30 PM, it was stated that the RN informs him/her of the home visit by calling the same day. No written schedule provided. During an interview with Other #6, caregiver for Patient #6, on 4/25/24 at 4:02 PM, when asked how appointments are set up, it was stated he/she will attempt to set up times but the RN comes whenever she wants. During an interview with RN 3 on 4/24/24 starting at 3:05 PM, she stated she schedules her own visits and usually tries to work around the patient’s needs. During an interview on 4/24/24 starting at 3:30 PM, when asked if a visit schedule should be placed in the patient’s home folders, Administrator 1 indicated the nurse is responsible for filling out written schedules for patients.”

“Treatments and therapy services CFR(s): 484.60(e)(3) Any treatments to be administered by HHA personnel and personnel acting on behalf of the HHA, including therapy services. This Element is not met as evidenced by: Based on observation and interview, the agency failed to provide the patient and caregiver in writing a calendar of the visit schedule for 1 of 1 home visit conducted with the home health aide. (Patient #3). The findings include: XX. During a home visit observation for Patient #1 on 4/23/24, beginning at 7:45 a.m., the home health agency folder was reviewed and there were no visit calendars found inside the folder. There was not a calendar of planned visits by agency staff present at the home. During an interview on 4/24/24, beginning at 3:30 p.m., the Administrator verbalized that the nurse fills out the patient’s monthly visit calendar located in the patient home folder. *During an observation of care at the home of Patient #3 on 4/25/2024, at 8:30 AM, the agency documents were reviewed and there failed to evidence in writing the treatments to be provided by the agency. On 4/25/2024, at 8:42 AM, the patient’s caregiver indicated there were no other agency documents in the home and could not recall receiving anything in writing about the treatments to be provided by the agency. On 4/24/2024, at 3:30 PM, the Administrator indicated the patients should be provided a plan of care summary for their written notice of treatments to be provided by the agency. During an observation of care at the home of Patient #3 on 4/25/2024, at 8:30 AM, the agency documents were reviewed and there failed to evidence in writing the treatments to be provided by the agency. On 4/25/2024, at 8:42 AM, the patient’s caregiver indicated there were no other agency documents in the home and could not recall receiving anything in writing about the treatments to be provided by the agency. On 4/24/2024, at 3:30 PM, the Administrator indicated the patients should be provided a plan of care summary for their written notice of treatments to be provided by the agency.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on observation, interview, and record review the agency’s skilled professionals failed to provide services that are ordered by the physician as indicated in the plan of care in one of five active patient records with home visits (Patient #6) Findings include: The clinical record of Patient #6’s plan of care (POC) evidenced a specified wound care order as follows: wash toes to bilateral feet with soap and water, use antibacterial soap, apply collagen powder(for wound healing and tissue regeneration) to bilateral(left and right) feet excoriated area between toes, place Hydrofera blue (antibacterial wound dressing) dressing to bilateral feet between toes, place ABD (thick, absorbent dressing) over toes, wrap in coban wrap (self-adherent mild compression wrap), 4 inch ace wrap(stretchable compression wrap) from mid foot to above each ankle, Surepress (high compression bandage) wrap bilaterally from above ankle to below knee, tape in place, apply socks followed by 6 inch ace wrap from above ankle to below knee. Interventions included skilled nurse (SN) to perform irrigation. During an observation of Patient #6 with RN 3 on 4/29/24 starting at 3:57 PM, wound care provided to Patient’s right and left lower leg/foot/toes was not consistent with specified wound care orders. RN failed to evidence use of antibacterial soap, collagen powder, or Hydrofera blue for wound care. The clinical record evidenced verbal physician orders dated 4/23/24 for new wound care orders with a start date (backdated) to 1/3/24. During an interview with RN 3 on 4/24/24 starting at 3:05 PM, RN denies use of Hydrofera Blue, indicating she washes the wound with baby soap and uses alginate (absorbent wound dressing) on the wounds instead.”

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on observation, record review and interview, the agency failed to ensure skilled professionals prepared complete and accurate visit notes in 2 of 2 records reviewed of patients with a home visit, not receiving skilled nursing services (Patient #3, 4). The findings include: *A clinical record for Patient #3 evidenced a comprehensive assessment completed by RN 5 on 4/15/2024, which indicated the patient’s supplies included tracheostomy (a tube inserted into a surgically hole in the neck to assist with breathing) and urinary catheter (a tube inserted into the bladder to drain urine). During an observation of care at the patient’s home on 4/25/2024, at 8:30 AM, the patient was not observed to have a tracheostomy or urinary catheter. On 4/26/2024, at 2:42 PM, Registered Nurse (RN) 5 indicated the patient did not have a tracheostomy or urinary catheter and she made an error in her clinical note. 1. During a home visit on 4/24/2024 at 1:50 PM, Patient #4 was observed using a motorized scooter and a walker to transfer. In a physical therapy evaluation note dated 4/5/2024, PT (Physical Therapist) 1 indicated the Patient had no DME (durable medical equipment) or assistive devices. The evaluation indicated the patient had a goal to improve ability to self-care, a decreased ability to perform ADL’s (activities of daily living), and impaired functional mobility. The note failed to evidence a functional assessment related to ADL’s or aerobic capacity / activity tolerance. During an interview on 4/24/2024 at 3:11 PM, the Administrator indicated PT 1 should have documented equipment in the home that the patient used in their assessment, and that PT 1 probably did not assess the Patient’s ADL’s because they did not think it applied to their care plan. When informed it was a patient goal, the Administrator offered nothing further.”

“Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This Element is not met as evidenced by: Based on record review and interview, the home health aide (HHA) failed to provide services as directed in the plan of care in 1 of 2 active clinical records reviewed with home health aide (HHA) services. (Patient #3) The findings include: A clinical record review for Patient #3 evidenced the “Multidisciplinary Care Plan” with an effective date of 3/12/2020, which indicated the HHA was to document bowel movements. Review of HHA visit notes completed by HHA 1 on 4/1/2024 - 4/3/2024, 4/5/2024, 4/8/2024-4/10/2024 - 4/12/2024, 4/15/2024 - 4/19/2024, 4/22/2024, and 4/23/2024 indicated the HHA marked “Done” for documenting bowel movements but failed to evidenced any documentation of bowel movements. On 4/25/2024, at 9:09 AM, HHA 1 indicated the patient had a bowel movement in the mornings before she arrived for her shift, and she did not document the bowel movement other than marking “done” on the visit note. On 4/29/2024, at 12:21 PM, the Administrator indicated the HHA was to document if the patient had a bowel movement.”

“In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This Element is not met as evidenced by: Based on observation, interview, and record review the agency failed to provide services in accordance with current clinical practice guidelines and accepted professional standards of practice in two of five active patient records with home visits (Patient #5, 6). Findings include: XX. During a home visit on 4/24/2024 at 11:20 AM, Patient #5 was wearing bilateral AFO’s (braces for the feet to lower legs). Observation of LPN (Licensed Practical Nurse) 1’s assessment of the Patient failed to evidence removal of the AFO’s for assessment of the patient’s skin. A review of the plan of care for certification period 3/9/2024 to 5/7/2024 evidenced Patient #5 was on skin breakdown prevention precautions. During an interview on 4/24/2024 at 11:47 AM, LPN 1 indicated she did not remove the AFO’s because the Patient did not like it. During an interview on 4/25/2024 at 12:25 PM, RN (Registered Nurse) 4 (case manager for Patient #5), indicated she saw the patient for re-certification assessments every 60 days, and had not removed the Patient’s AFO’s to assess the Patient’s skin. RN 4 indicated the Patient’s family member would tell them if there was a problem with the patient’s skin. During an interview on 4/29/2024 at 3:38 PM, the Administrator indicated the RN should have performed a full head-to-toe assessment, including removing the Patient’s AFO’s, at each recertification assessment. The agency policy titled “POLICY: CC-25.1 ASSESSMENT AND REASSESSMENT GUIDELINES”, last reviewed 1/28/23, indicates staff will adhere to appropriate assessment guidelines with the use of appropriate Standards of Practice. “Standards of Professional Nursing”, an agency training reference, indicates the registered nurse collects comprehensive data assessments in an ongoing process, prioritize data collected, and prioritize data collection based on immediate condition to implement a plan for the promotion and restoration of health. The agency policy titled “POLICY CC-40 PAIN MANAGEMENT”, revised 1/28/23, indicates patients experiencing pain will be assessed for appropriate interventions and management including the for the nature and intensity of pain. Clinical record of Patient #6 evidenced a comprehensive assessment completed by RN 3 on 3/5/24 which included Patient diagnoses of chronic obstructive pulmonary disease (lung disease) on home oxygen, congestive heart failure, lymphedema (swelling disorder), and neuropathy (nerve damage). During an observation of a recertification home visit with Patient #6 and RN 3 on 4/29/24 starting at 3:57 PM, RN failed to evidence a stethoscope in supplies which lead to no assessment of breath sounds, heart sounds, or bowel sounds. RN failed to evidence a thermometer which lead to no temperature measurement taken during comprehensive assessment. During wound dressing changes, RN commented on the foul odor (sign of bacterial infection) from wounds. During wound changes, Patient verbalized pain on multiple occasions. RN failed to assess Patient’s pain level during visit. RN failed to evidence assessment of pedal (foot) pulses (to assess perfusion of lower limbs). RN assessed the left radial (wrist) pulse for ten seconds. During an interview with RN 3 on 4/30/24 starting at 4:03 PM, she stated she forgot her stethoscope for the home visit. When asked how she assessed perfusion, she revealed Patient has good circulation and she checked a radial pulse. When asked how pain is assessed, she indicated that Patient would let her know when it hurts. During an interview with Patient #6 after a home visit on 4/29/24 starting at 6:30 PM, Pain assessment revealed 2-3 (out of 0-10 pain scale) pain at rest and moderate/strong pain measured at 6-7 during the dressing change.”

“Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the clinical record included all interventions and responses to those interventions in 1 of 1 active records receiving physical therapy services only (Patient #4). The findings include: A review of physical therapy visit notes for Patient #4 dated 4/11/2024, 4/15/2024, 4/17/2024, and 4/24/2024 failed to evidence how the Patient tolerated therapy. During an interview on 4/29/2024 at 3:11 PM, the Administrator indicated patient tolerance of therapy should be assessed and documented in the visit notes, but it was not.”

“Goals in the patient’s plans of care CFR(s): 484.110(a)(3) Goals in the patient’s plans of care and the patient’s progress toward achieving them; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patient’s clinical record included progress toward goals in 1 of 1 active records receiving physical therapy services only (Patient #4). The findings include: A review of physical therapy visit notes for Patient #4 dated 4/11/2024, 4/15/2024, 4/17/2024, and 4/24/2024 failed to evidence progress toward goals. During an interview on 4/29/2024 at 3:11 PM, the Administrator indicated patient progress toward goals should be measured and documented in the visit notes, but they were not.”