Pediatric Nursing Specialists of Indiana

“Emergency Officials Contact Information CFR(s): 484.102(c)(2) §403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.542(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at §483.73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at §483.475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency. This Standard is not met as evidenced by: Based on record review and interview the agency failed to maintain a communication plan that included contact information for federal, state, local, and regional entities or other sources of assistance for 77 of the 92 counties served by the agency. Findings include: 1. A Policy titled “Emergency Preparedness Policy B-400” indicated but was not limited to “ The EDP [emergency disaster plan] will identify Resource links to the local community and be maintained as the Emergency Resources List.” 2. A review of the Agency’s Emergency Disaster Preparedness (EDP) binder received from the Agency on 06-10-2024 at 10:10 AM contained a section titled “Emergency Resource List” and directions stating, “ this may be duplicated for each county in your service area.” The binder contained 15 counties serviced by the agency in the state but failed to include all 92 counties the agency serves. 3. During an interview on 06/12/2024 at 1:22 PM the Alternate Administrator reported the agency offers care in all 92 counties in Indiana but had not completed all of the emergency resources in each county because they do not have patients in the other counties currently. When queried whether the agency is licensed to provide care to patients in all counties the Alternate Administrator reported they were and would have to update the information.”

“Discharge or Transfer Summary Content CFR(s): 484.58(b)(1) Standard: Discharge or transfer summary content. The HHA must send all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure continuity of care by providing pertinent information to another home health agency or facility of their patient to the alternate entity that would be responsible for providing ongoing care for 1 of 1 transfer discharged records reviewed (Patient: #6) and 1 of 1 transfer resumed active records reviewed. (Patient: #5) Findings Include: 1. A review of the revised October 2012 policy titled “Client Transfer” indicated but was not limited to, “ … Purpose: To assure continuity of care by providing pertinent information to another home health care agency or facility when a client is transferred … If a client is transferred to another health facility or home health agency, a copy of the summary shall be sent … ” 2. The clinical record for Patient #5 was reviewed on 06-10-2024 and indicated a start of care date of 01-09-2019. The record contained a plan of care for the recertification period of 05-15-2024 to 07-13-2024, indicating the principal diagnosis of Cerebral Palsy (a condition that affects muscle movement and coordination caused by damage to the developing brain) and other diagnoses of unspecified vision loss, postsurgical malabsorption, encounter for attention to gastrostomy (a surgical opening for a tube to be inserted into the stomach from the abdominal wall for nutrition and medications), developmental disorder of speech and language, and developmental disorder of motor function. Patient #5 had orders for Skilled Nursing hourly respite care for 36.50 hours. A review of the transfer document electronically signed by Registered Nurse (RN) 1, dated 05-21-2024, indicated Patient #5 was transferred to an inpatient facility but not discharged. A review of the agency documents titled “Case Communication Notes” from 05-21-2024 to 06-10-2024, failed to provide evidence of any communication between the agency and Entity 4, the facility to which Patient #5 was transferred. During an interview on 06-11-2024 at 1:50 PM, when queried regarding facilitating care when Patient #5 was transferred to Entity 4, RN 1 confirmed they did not communicate, send the plan of care, or transfer summary to Entity 4, the facility to which Patient #5 was transferred. 3. The clinical record for Patient #6 was reviewed on 06-11-2024 and indicated a start of care date of 01-19-2024. The record contained a plan of care for the recertification period of 03-19-2024 to 05-17-2024, indicating the principal diagnosis of Cerebral palsy (a condition that affects muscle movement and coordination caused by damage to the developing brain) and other diagnoses of Microcephaly (a condition which a baby’s head circumference is significantly smaller than average), Cortical blindness (loss of visual perception due to damage to certain areas of the brain), Lack of Expected Normal Physiological Development in Childhood (developmental delayed), Disorder of urea cycle metabolism (a disorder making it hard for the body to break down proteins), Unspecified Convulsions, and Gastro-esophageal Reflux Disorder (a digestive disorder that affects the ring of muscles between your esophagus and stomach which allows stomach contents to flow up into the esophagus). Patient #6 had orders for Skilled Nursing hourly respite care for 914 hours. A review of the agency documents titled “Case Communication Notes” from 05-15-2024 to 06-10-2024 contained a communication note dated 06-11-2021, electronically signed by RN 1. The communication note indicated the caregiver for Patient #6 notified RN 1 Patient #6 would receive services from Entity 1 due to a lack of nurse availability from Pediatric Nursing Specialist of Indiana. The communication notes failed to evidence RN 1 communication between the agency and Entity 1, the agency to which Patient #6 was transferred and discharged. During an interview on 06-11-2024 at 1:54 PM, RN 1 indicated Patient #6’s nurse retired, and the agency was unable to staff. RN 1 further stated, “ No, I do not have any communication with Entity 1. That is a coordination care barrier we need to work on.” 410 IAC 17-13-2(a)(b)(9)”

“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 contact and facilitate the safe transfer of their patient to the alternate entity that would be responsible for providing ongoing care for 1 of 1 transfer discharged inactive records reviewed. (Patient: #6) Findings Include: 1. A review of a revised January 2028 policy titled “Client Discharge Process” indicated but was not limited to, “ … To assure collaboration with the physician/nurse practitioner, client, family, and other … The agency must arrange a safe and appropriated transfer to other care entities when the needs of the patients … exceed the agencies capabilities … ” 2. A review of the revised October 2012 policy titled “Client Transfer” indicated but was not limited to, “ … Purpose: To assure continuity of care by providing pertinent information to another home health care agency or facility when a client is transferred … If a client is transferred to another health facility or home health agency, a copy of the summary shall be sent … ” 3. The clinical record for Patient #6 was reviewed on 06-11-2024 and indicated a start of care date of 01-19-2024. The record contained a plan of care for the recertification period of 03-19-2024 to 05-17-2024, indicating the principal diagnosis of Cerebral Palsy (a condition that affects muscle movement and coordination caused by damage to the developing brain) and other diagnoses of Microcephaly (a condition which a baby’s head circumference is significantly smaller than average), Cortical blindness (loss of visual perception due to damage to certain areas of the brain), Lack of Expected Normal Physiological Development in Childhood (developmental delayed), Disorder of urea cycle metabolism (a disorder making it hard for the body to break down proteins), Unspecified Convulsions, and Gastro-esophageal Reflux Disorder (a digestive disorder that affects the ring of muscles between your esophagus and stomach which allows stomach contents to flow up into the esophagus). Patient #6 had orders for Skilled Nursing hourly respite care for 914 hours. A review of the agency documents titled “Case Communication Notes” from 05-15-2024 to 06-10-2024, contained a communication note dated 06-11-2024, electronically signed by RN 1. The communication note indicated the caregiver for Patient #6 notified RN 1 that Patient #6 would receive services from Entity 1 due to a lack of nurse availability from Pediatric Nursing Specialist of Indiana. The communication notes failed to evidence RN 1 communication between the agency and Entity 1, the agency to which Patient #6 was discharged. During an interview on 06-11-2024 at 1:54 PM, RN 1 indicated Patient #6’s nurse retired, and the agency was unable to staff. RN 1 further stated, “ No, I do not have any communication with Entity 1. That is a coordination care barrier we need to work on.””

“EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, “Organizations” under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This Standard is not met as evidenced by: Based on record review and interview the agency’s Emergency Preparedness program failed to evidence a testing and training plan or procedure, thereby failing to ensure the effectiveness of the agency’s program, in 1 of 1 Emergency Preparedness program reviewed. Findings include: 1. Review of an agency document dated 02-08-2019, titled ‘EMERGENCY PREPAREDNESS POLICY’ failed to evidence a testing and training component as part of the agency’s program. Review of the agency’s Emergency Preparedness binder on 02-05-2024 failed to evidence a plan or procedure for testing and training the agency’s Emergency Preparedness Plan. 2. On 02-05-2024 at 2:28 PM, Corporate Representative 6 indicated was a member of a local healthcare coalition and as a representative of the home health agency, had taken part in a large-scale radiation disaster drill at the local county fairgrounds in the summer of 2023 and more recently took part in that same organization’s tabletop ‘surge’ exercise and offered these documents for review. Corporate Representative 6 indicated there were no after-action reports completed as a result of having participated in these drills/exercises, further indicated knew the after-action reports were required in order to evidence the agency’s response to each drill/exercise and how the agency intended to modify their Emergency plan as a result, if need be. On 02-12-2024 at 12:24 PM, Corporate Representative 6 indicated was the only individual to take part in the drills/exercises and indicated the agency needed to include their staff, including the new Registered Nurse (RN) Case Manager, Corporate Representative 9 in such training and testing. Corporate Representative 7 indicated the agency certainly needed to revisit this.”

“EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: Based on record review and interview the agency, after participating in Emergency drills/exercises, failed to analyze and document their response by completing after-action reports, and failed to revise the agency’s Emergency Preparedness program based on the outcome, in 1 of 1 Emergency Preparedness programs reviewed. Findings include: 1. Review of an agency document dated 02-08-2019, titled ‘EMERGENCY PREPAREDNESS POLICY’ failed to evidence a testing and training plan or procedure as part of the agency’s program. Review of the agency’s Emergency Preparedness binder on 02-05-2024 failed to evidence a plan or procedure for testing and training the agency’s Emergency Preparedness Plan. 2. On 02-05-2024 at 2:28 PM, Corporate Representative 6 indicated was a member of a local healthcare coalition and as a representative of the home health agency, had taken part in a large-scale radiation disaster drill at the local county fairgrounds in the summer of 2023 and more recently took part in that same organization’s tabletop ‘surge’ exercise and offered these documents for review. When queried, Corporate Representative 6 indicated there were no after-action reports completed as a result of having participated in these drills/exercises and further indicated knew the after-action reports were required in order to evidence the agency’s response to each drill/exercise and how the agency intended to modify their Emergency plan as a result of their analysis, if need be. On 02-12-2024 at 12:24 PM, when queried, Corporate Representative 7 indicated the agency’s Emergency Preparedness Policy provided was the most updated version but would check to be certain there was not a more current version and indicated the agency certainly needed to revisit this. On 02-12-2024 at 12:24 PM, Corporate Representative 6 indicated she was the only individual to take part in the drills/exercises and indicated the agency needed to include their staff, including their new Registered Nurse )RN) Case Manager Corporate Representative 9 in such training and testing.”

“Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA’s governing body. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure the frequency and detail of the data collected in the development of the Qaulity Assurance Performance Improvement(QAPI) program was approved by the agency’s governing body in 1 of 1 agency. Findings include: 1. A review of a policy titled “QAPI COMMITTEE” revised in January 2018, indicated under “SPECIAL INSTRUCTIONS … 3. Frequency and detail of data collection developed by QAPI committee and approved by governing body … “ 2. A review of the agency’s QAPI on 2/8/24 revealed an undated document “tracking items” listed were: monitor organizational chart to keep it up to date- administrator, monitor for governing body meetings-administrator, continue to monitor missed visits-administrator, monitor the patients for discharge-administrator, monitor for emergency preparedness documents to be sent to homes-quality, monitor for medication profiles to be sent at recertifications-quality, monitor for in-person visits-administration, monitor for complete and accurate information on the plan of care and patient-specific interventions-quality, monitor for all visits, supervisory and recertifications are completed in person. 3. A review of Governing Body Minutes dated 01/29/2024 revealed, ” … QAPI is being reviewed weekly and there are no concerns ... “ No other documents were provided to evidence other meetings which might identify governing body approval of the frequency and detail of data collection. 4. On 02/05/2024 at 2:20 PM during an interview, the person serving in the role of Administrator, Corporate Personnel 6 indicated the undated document identified as tracking items were Performance Improvement indicators that were identified at the last survey, which were discussed at the board meetings, but was unsure if they were approved by the governing body. On 02/12/2024 at 11:40 AM, the person serving in the role of Administrator, Corporate Personnel 6 indicated the Monday morning meetings were their Board Meetings. 410 IAC 17-12-2(a)”

“Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA’s services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to initiate Performance Improvements Projects (PIPS) for identified elements, define why elements of a PIP were determined to be a priority and measure the progress for each PIP for the Quality Assessment and Performance Improvement Program (QAPI). Findings include: 1. An agency policy number B-260, titled “QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT,” dated Jan 2005 with the last revision date of Jan 2018 revealed, “ … OBJECTIVES OF THE PROGRAM … to identify deviations from agency and professional standards and pursue improvement opportunities by assessment, planning and evaluation. To identify, address, track and resolve problems in client care services … To meet state and federal regulatory requirements. To support the organization’s process improvement through data collection and outcome measurement … To reduce factors that contribute to unanticipated outcomes … SPECIAL INSTRUCTIONS 1. … Additional actives for performance improvement will be prioritized by the agency’s governing body … 2. Data will be collected … 4. … to measure process and outcome. 5. Data will be assessed to: a. Identify current level of performance b. Evaluate the stability of the process c. Identify areas to be improved d. Identify strategies to stabilize or improve processes e. Evaluate whether outcomes were achieved … “ 2. A review of the agency’s Quality Assessment and Performance Improvement for 2023 revealed an undated handwritten document of PIPS which included but not limited to the following, “ … Continue to monitor missed visits- Admin, Monitor for pt that need discharged- Admin, Monitor for EDP’s to be sent to homes- Quality, monitor for med profiles to be sent at recertifications-Quality, Monitor for In-person visits-Admin … “ 3. On 02/05/2024 at 1:26 PM the person serving in the role of Administrator, Corporate Personnel 6 indicated they identified the undated handwritten list of PIPS since the past survey but hadn’t documented why they were conducting the PIPS and the plan of action they need to put in place.”

“Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency’s overall management and operation, the provision of all home health services, fiscal operations, review of the agency’s budget and its operational plans, and its quality assessment and performance improvement program. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to have a Governing Body assume full legal authority and responsibility for the agency’s overall management and operation, including its quality assessment and performance improvement program. Findings include: 1. A review of a policy titled “Governing Body” last reviewed in January 2018, indicated the duties and responsibilities of the Governing Body were not limited to Appointing a qualified Administrator under state and federal regulations, and agency mission; ensuring an ongoing Quality Assessment and Performance Improvement (QAPI) program for quality improvement and patient safety is defined, implemented, and maintained; reviewing policy and procedures; adopt and periodically review and approve the administrative and personnel policies and procedures. 2. A review of the agency’s policy titled “Quality Assessment Performance Improvement” revised in January 2018, stated “Special Instructions: 1. The governing body appoints a committee that must include clinical administrator, representative of all disciplines/ services provided ... 3. Frequency and detail of data collection developed by QAPI committee and approved by governing body ... 13. The QAPI Committee meeting minutes will be maintained in writing and signed by the Administrator ... “ 3. A review of the Governing Body Minutes dated 1/29/2024 indicated the Administrator (Corporate Trainer), LPN 3 (presumed Alternate Administrator), and Clinical Manager (Corporate Clinical Administrator) were on the Governing Body, as well as Corporate Representatives 1, 2, 14, 15, 16, 17, and 18. The state agency failed to be notified of board member changes. 4. A review of the Governing Body meeting minutes dated 03/10/2023, 11/20/2023, 11/30/23, 12/04/23, and 12/11/23, failed to evidence that the Governing Body ensured the Quality Assessment and Performance Improvement (QAPI) addressed the program and the agency’s complexity of its organization and services it provides, including services provided under contract or arrangement, indicators related to improved outcomes, emergency care services, hospital admissions and readmissions, and any action that addresses the home health agency’s performance. A review of the meeting minutes dated 1/29/24 indicated the “QAPI is being reviewed weekly and there are no concerns.” During an interview on 02/05/24 at 1:10 PM, when asked if the frequency and detail of data collection were approved by the agency’s Governing Body, LPN 3 indicated she was unsure if the Governing Body approved it. When asked how the Governing Body was involved, the Clinical Supervisor indicated there were weekly Monday meetings where the “checklist” was reported and there was collaboration. No documentation of these weekly meetings was provided by the date of exit. During an interview with the Administrator, LPN 3, and Clinical Manager on 2/8/24 at 11:40 AM, when asked to explain the QAPI program, how it operated from auditing to Performance Improvement Plans (PIPs), who is responsible, and who is on the committee, they indicated the administrators or designee completes chart and human resource audits. If a trend is found in a particular office, it gets documented, creates a correction plan, and submits this to the Governing Body. When asked how often they have QAPI, they indicated there is a grid, and is done monthly, and then quarterly it would be discussed with all of the Administrators and Governing Body together. If a problem comes up in an agency, it would be brought up on a Monday meeting, regularly quarterly, then as needed. They indicated the committee consists of all Administrators, including the Ohio Administrators. No other documents were provided to evidence meetings were held monthly by the date of exit. During an interview on 2/12/24 at 9:38 AM, when asked to verify who was the QAPI and Governing Body Members, the Clinical Manager indicated LPN 3 was the only person who resided in Indiana and remaining “members” were from Ohio. A review of the “Quality Program Administrator” job description, updated on 10/16/2023, the qualifications included but were not limited to graduating from an accredited nursing program with a current license as a Registered Nurse in the state(s) of practice. This document was signed by the Alternate Administrator on 10/16/23. A review of LPN 3’s personnel file failed to evidence any documentation she held a Registered Nurse license. 410 IAC: 17-12-1(b) 410 IAC 17-12-2(a)”

“Clinical manager CFR(s): 484.105(c) Standard: Clinical manager. One or more qualified individuals must provide oversight of all patient care services and personnel. Oversight must include the following-- This Standard is not met as evidenced by: Based on record review and interview, the Clinical Manager and the Alternate Clinical Manager failed to ensure one was available upon surveyors’ arrival, failed to ensure they were able to travel within a reasonable distance to the office/and or field, failed to ensure they had a set schedule of when they will be at this location on a frequent and consistent basis to be responsible for the referrals, patient and personnel assignments, coordination of care, patient needs continually assessed, and the plan of care for this agency. Findings Include: Upon arrival at this home health agency on 1/31/24 at 9:30 AM, the door was found to be locked with a note to knock on the door. LPN (Licensed Practical Nurse) 3 was observed walking downstairs to allow surveyors in. No other person was observed in the office with LPN 3. During the entrance conference on 1/31/24 starting at 9:30 AM, the Administrator indicated a message was left with the Alternate Clinical Supervisor (Corporate Trainer), and the Clinical Manager (Corporate Clinical Administrator) was on a visit and would be in around noon. The Administrator indicated both the Clinical Manager/ Alternate Administrator and Alternate Clinical Supervisor were located in Ohio. The Clinical Manager arrived at the Indy location and met with the surveyors at approximately 12 noon. A review of the State Agency notes in the National Database revealed the Alternate Clinical Manager and Clinical Manager assumed their roles effective 10/12/23. On 01/31/24 at 12:45 PM, the Clinical Manager indicated she comes to the office when needed, sometimes monthly to every other month, and works remotely in Ohio. The Clinical Manager indicated she would get in her car and drive to Indiana if there were an emergency. When asked who manages faxes, physician orders, and referrals, the Clinical Manager indicated LPN 3 (presumed Alternate Administrator) manages them and uploads everything into the patient record. A review of the Clinical Manager’s personnel file revealed the Clinical Manager resided approximately 2 hours from this office per Google Maps. This provider’s service area adds additional travel time as it goes as far northeast as Wayne County, as far west as Parke County, and as far southeast as Clay County, all would require an approximate 3-hour drive. Should there be an emergency at this location, the Clinical Manager would not be able to arrive within a reasonable amount of time. On 2/1/24 at 4:00 PM, the Clinical Manager indicated the Alternate Clinical Manager was only at the office when needed and had not been back since 11/15/23. On 2/02/24 at 4:00 PM, the Alternate Clinical Manager indicated she had not been back to the office since she was here for the other surveys a few months ago and indicated she could return when called to do so. A review of the Alternate Clinical Manager’s personnel file revealed the Administrator resides approximately 4 hours away from this office per Google Maps. This provider’s service area adds additional travel time as it goes as far southeast as Bartholomew County which is approximately a 3.5-hour drive, as far west as Parke County, which is approximately 4.45 -hour drive, and as far southwest as Clay County, which is approximately a 4.5-hour drive. Should there be an emergency at this location, the Clinical Manager would not be able to arrive within a reasonable amount of time. On 2/8/24 at 11:40 AM, the Clinical Manager, the Alternate Clinical Manager, and LPN 3 were interviewed. It was reported LPN 3 was responsible for making the patient and personnel assignments, coordinated care, and referrals. When asked who ensures a patient’s needs were continually assessed, The Clinical Manager and the Alternate Clinical Manager reported LPN 3 and the RN Case Manager were responsible. The Clinical Manager and the Alternate Clinical Manager indicated the RN Case Manager creates the plan of care and LPN 3 sends it to the physician for signature. When asked how they oversee these tasks, both reported they communicate with the case managers, the “quality department”, which is LPN 3, would review it and bring it to their attention, or she takes it directly to the case manager. Both indicated LPN 3 uploads the information to the patient record. A review of the job description for the Quality Administrator which LPN 3 holds indicated the employee must hold a Registered Nurse license. A review of the organizational chart revealed that Corporate Representative 6 also held the following positions: Quality Director and Quality Nurse; Intake Director, Intake Nurse, and Intake Specialist; and Recruiting Director and Recruiter for this agency.”

“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 identify correct durable medical equipment in the individualized plan of care in 1 of 3 home visits conducted. (Patient # 7) Findings include: 1. An agency policy number C-580IN, titled “PLAN OF CARE”, with the last revised date of 06/10/2021 revealed, “ … 2. The Plan of Care shall be completed in full to include: … m. Medical supplies and equipment required n. Any safety measures to protect against injury … “ 2. A review of the clinical record of Patient #7 on 02/04/2024 evidenced a home health certification and plan of care (POC) for the certification period of 12/29/2023 to 02/26/2024 which revealed the following diagnoses but not limited to, Aicardi Syndrome (the structure that connects the two sides of the brain [called the corpus callosum] is partly or completely missing) and unspecified convulsions (sudden, violent, irregular movement of a limb or the body, caused by involuntary contraction of muscles and associated especially with brain disorders). The POC revealed the patient was to have a hospital bed, an electric air mattress, and side rails. Further review of the clinical record of Patient #7 evidenced a Recertification dated 12/27/2023 and signed by the person serving in the role of Registered Nurse, Corporate Personnel 9 indicated Patient #7 was dependent with all activities of daily living, bed mobility, and transfers, with a helper performing an activity or the assistance of 2 or more helpers and the Medical Equipment indicated the patient had a hospital bed and electric mattress. 3. On 02/05/2024, during a home visit at 10 AM to observe the person serving in the role of LPN, Corporate Personnel 13 providing skilled nursing services for Patient #7, upon entering the patient’s bedroom, this writer observed Patient #7 lying in a device that had padded sides and cradled Patient #7 which was on a king-size bed with a regular mattress. Corporate Personnel 13 completed peri care, and bath, and Patient #7 was given morning medications via MicKey G-Button (A button-type feeding tube that allows children to receive nutrition, fluids, and medicine directly into the stomach), site clean and appeared to be dry. Person E (a family member) entered the bedroom and announced they had to leave so Corporate Personnel 13 needed to hurry up and finish dressing Patient #7 so Person E could transfer Patient #7 to their wheelchair. Person E assisted with putting socks on Patient #7 while Corporate Personnel 13 was putting Patient #7 shirt on. Person E then lifted Patient #7 off the bed, placed them in their wheelchair, put the armrests down, and exited the room. 4. During an interview on 02/05/2024 at 2:46 PM, Corporate Personnel 13 indicated they had cared for Patient #7 for 8-9 years at Person E’s residence every other weekend and Monday. Corporate Personnel 13 indicated there was never a hospital bed, side rails, or air mattress in Person E’s home. Person E uses the device the patient had been lying in on the bed. Corporate Personnel 13 further indicated there was a side rail Person E had previously used but doesn’t know what had happened to it. During an interview on 02/05/2024 at 1:05 PM, the person serving in the role of Administrator, Corporate Personnel 6 indicated they would have to check into the medical equipment at Person E’s residence for Patient #7. 410 IAC 17-13-1(a)(1)(D)(i-xiii)”

“Improvements are sustained CFR(s): 484.65(c)(3) The HHA must take actions aimed at performance improvement, and, after implementing those actions, the HHA must measure its success and track performance to ensure that improvements are sustained. This Element is not met as evidenced by: Based on record review and interview the agency failed to establish a system to measure and track performance elements related high risk, high volume and problem prone areas to ensure improvements were sustained. Findings include: 1. A review of a policy titled “QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT” revised in January 2018, indicated, “ … 4. Data will be systematically collected to measure process and outcome. 5. Data will be assessed to: a. Identify current level of performance b. Evaluate the stability of the processes c. Identify areas to be improved D. Identify strategies to stabilize or improve processes e. Evaluate whether outcomes were achieved f. Compare results with self, other standards, and best practices, using statistical techniques … “ 2. A review of the agency’s Quality Assessment Performance Improvement (QAPI) failed to evidence a system to measure and track performance related to identified performance elements and to ensure improvements were sustained. 3. On 02/05/2024 at 1:24 the person serving in the role of Administrator, Corporate Personnel 6 indicated every quarter trends were identified, and actions were put in place to address identified problems. They further indicated they have a Performance Improvement form to start using, but hadn’t utilized it yet. 410 IAC 17-12-2(a)”

“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 have a qualified Administrator and an agency-appointed Governing Body to ensure a qualified Alternate Administrator and/or Clinical Manager was appointed to assume the same responsibilities and obligations as the Administrator during their absence from this agency. Findings include: Upon entering the agency on 1/31/23 at 9:15 AM, the door was locked and a note on the window indicated to knock. Upon entering, it was noted only LPN 3 was working in the office. During the entrance conference on 1/31/24 starting at 9:30 AM, the Administrator indicated a message was left with the Alternate Clinical Supervisor (Corporate Trainer), and the Clinical Manager (Corporate Clinical Administrator) was on a visit and would be in around noon. The Administrator indicated both the Clinical Manager/ Alternate Administrator and Alternate Clinical Supervisor were located in Ohio. A review of the State Agency notes in the National Database revealed that the Alternate Administrator/ Clinical Manager assumed their role on October 12, 2023. A review of the personnel file evidenced a job description titled Alternate program Administrator dated 10/16/23. A review of the Governing Body minutes dated March 10, 2023, November 20, 2023, November 30, 2023, December 4, 2024, December 11, 2023, and January 8, 2024, failed to evidence an Alternate Administrator/ Clinical Manager had been appointed by an agency appointed Governing body. On 01/31/24 at 12:45 PM, the Clinical Manager indicated she comes to the office when needed, sometimes monthly to every other month, and works remotely in Ohio. The Clinical Manager indicated she would get in her car and drive to Indiana if there were an emergency. When asked who manages faxes, physician orders, and referrals, the Clinical Manager indicated LPN 3 (presumed Alternate Administrator) manages them and uploads everything into the patient record. During an interview on 2/8/24 at 11:40 AM, when asked how one gets appointed to their positions, the Alternate Administrator/ Clinical Manager indicated they have discussions during the Governing Body meetings. When asked if there were Governing Body meeting minutes around October 2023 that would include the appointment of the Alternate Administrator/ Clinical Manager, the Alternate Clinical Manager indicated she was the secretary of the Governing Body, she knows it was discussed and should have been there. No other documents were provided by the exit date of 2/12/24, that would indicate an Alternate Administrator/ Clinical Manager was appointed. 410 IAC 17-12-1(d)(1)(2)(3)(4)”

“Primary HHA is responsible for patient care CFR(s): 484.105(e)(3) The primary HHA is responsible for patient care, and must conduct and provide, either directly or under arrangements, all services rendered to patients. This Element is not met as evidenced by: Based on record review and interview, the agency, which holds a Medicare Provider Enrollment agreement, failed to ensure 15 patients receiving care and services were provided by clinicians who were directly employed by this agency and failed to ensure 2 of 2 service contracts under arrangement were able to provide therapy services that cover the entire state of Indiana. Findings include: 2. A review of an agency document titled ‘ANCILLARY SERVICES AGREEMENT’ indicated a contract was created between the agency and Entity F, a therapy company, to provide physical and occupational therapy services to home health patients. Page 2 stated, “This agreement is entered into on the 11th day of January, 2024, by and between Home Care Network/ Pediatric Nursing Specialists (herein referred as “Agency”) whose principal place of business is located [the Corporate office in Ohio’s address was given] (Corporate Office) ...” The contract was signed by Corporate Representative 2, Director of Operations on 01-12-2024. The contract failed to specify which of the three Indiana agencies the agreement had been made with and failed to evidence the services would be pediatric-specific. A review of an agency document titled ’[Entity D, a Therapy company] Contract/ Partnership Agreement’ indicated a contract was created between the corporation, Home Care Network, Inc., and Entity D, to provide physical, occupational, and speech therapy services, as well as social work services “for Indiana and Ohio”. The therapy company listed an Ohio address. The corporation, Home Care Network, Inc., also listed an Ohio address. The contract was signed by Corporate Representative 2, the Director of Operations, on 01-12-2024. The contract failed to specify which of the three Indiana agencies the agreement had been made with and failed to evidence the services would be pediatric-specific. On 01-01-2024 at 9:30 AM during the entrance conference, Corporate Representative 6 indicated the agency had recently secured contracts with two therapy companies but was not yet providing therapy services to patients. On 01-31-2024 at 12:35 PM, Corporate Representative 6, indicated she had conferred with Corporate Representative 2 that the newly obtained therapy contracts were not individualized to each of the three Indiana agencies, but with Indiana as a whole. On 01-31-2024 at 12:51 PM, Corporate Representative 7, indicated that the two newly contracted Therapy companies, Entities D and F, were chosen to ensure coverage of the entire state. On 01-31-2024 at 2:51 PM, Person E With Entity D, a Physical Therapy company, indicated was based in Ohio, stated “We don’t service Indiana” and further indicated they had no therapists who were dually licensed in both Ohio and Indiana to provide therapy services. On 01-31-2024 at 3:06 PM, Person G with Entity F, a Physical Therapy company, indicated the company did not service the entire state of Indiana. Indicated further, for example, the company would be unable to staff anyone in Evansville, IN if a patient needed to be serviced the following day. On 01-31-2024 at 4:08 PM, Corporate Representative 1, the Chief Operating Officer, indicated when vetting out therapy agencies to contract with, they attempted to ensure such agencies could service pediatric patients. When queried as to who had vetted Entities D and F, Corporate Representative 1 indicated Corporate Representatives 2, 6, and 7 had done so. When informed Entity D indicated they did not service Indiana, and Entity F indicated they could not service the whole of Indiana, Corporate Representative 1 indicated having had this same kind of problem “wherever we go”, indicating further such companies were also short-staffed. 410 IAC 17-12-2(e) 1. During the entrance conference on 1/31/24 from 9:30 AM to 10:27 AM, when asked if other Registered Nurses (RN) were working in the field besides management, Corporate Representative 6 indicated there were none, other than Corporate Representative 9, who was fairly new, and the field staff was mostly Licensed Practical Nurses (LPN). When asked if Corporate Representative 10 was an employee of this agency, Corporate Representative 6 indicated she was not but was an employee of the sister agency, Entity C, which is located at this same address. A review of the employee list indicated that 2 Registered Nurses were working in the office and 15 Registered Nurses were working in the field. On 1/31/24 at 12:31 PM, the employee list was reviewed with Corporate Representative 6 and she confirmed there were other Registered Nurses in the field and she misunderstood the question. When asked if Corporate Representative 10 was an employee of this agency again, Corporate Representative 7 stated “Yes”. The agency failed to have a personnel file for Corporate Representative 10. A review of the personnel file for Corporate Representative 6 contained an I-9 tax form dated 2020 that failed to identify the employer (provider). No other tax forms were noted in the file. A review of the personnel file for Corporate Representative 7 contained an I-9 tax form dated 2021 which indicated the employer business is in Centerville, Ohio. No other tax forms were noted in the file. A review of the personnel file for Corporate Representative 8 contained an I-9 tax form dated 2020 which indicated the employer’s business is in Perrysburg, Ohio. No other tax forms were noted in the file. A review of the personnel file for Corporate Representative 9, an RN Case Manager, contained an I-9 tax form that failed to identify the employer. Corporate Representative 10 failed to have a personnel file for this agency. On 01/31/2024 at 2:00 PM, Corporate Representatives 6 and 7 were asked for the W-2s for this agency and were also asked if they were paid by this agency, at which Corporate Representative 7 indicated that all W-2s come from the corporation in Ohio and no W-2s come from the agency. On 2/9/24 at 12:38 PM, Corporate Representative 5 provided 2023 W-2s. A review of Corporate Representatives 9, 10, and 13 indicated the employer’s name and address was that of the Home Care Network, Inc. in Dayton Ohio. Corporate Representative 5 confirmed at 1:44 PM that the Employer ID number was directly tied to the Home Care Network and not directly connected to the agency in Indiana and all Indiana W-2s are affiliated with the Home Care Network in Dayton Ohio, and not the agency in Indiana.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure a discharge summary was written and sent to the primary care physician who is responsible for the patient’s care after discharge within 5 business days of the patient’s discharge for 1 of 2 discharged record reviews. (Patient #1) Findings include: 1. An agency policy number CI-500, titled “CLIENT DISCHARGE PROCESS,” dated Jan 2007 with the last revision date of Jan 2018 revealed, “ … 2. A discharge OASIS assessment will be completed when appropriate. 3. 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 service to the patient after discharge from the home health agency within 5 business days of the patient’s discharge … “ 2. A review of the clinical record of Patient #1 on 02/01/2024 revealed a home health certification and plan of care for the certification period of 11/10/2023 to 01/08/2024 and a transfer to an inpatient facility form dated 01/04/2024, which indicated the patient was not discharged from the agency. 3. A review of the agency’s discharged patients from 11/05/2023 to 02/01/2023 evidenced Patient #1 was discharged on 01/08/2024. 4. During an interview on 02/05/2024 at 1:55 PM with the person serving in the role of Administrator, Corporate Personnel 6 indicated since the patient was admitted to the hospital and the length of stay surpassed the 5-day window period for the re-certification, Patient #1 was an automatic discharge, and a discharge summary was not necessary. The agency failed to provide all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility and/or health care practitioner to ensure the safe and effective transition of care within 5 days of discharge. 410 IAC17-15-1(A)(6)”