Interim Healthcare of Indianapolis

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure infection control practices were followed to prevent transmission of infection in the use of hand hygiene and gloving during 1 of 1 home visits (Patient: #3) observed with Peripherally Inserted Central Cather (PICC) (a thin, soft flexible tube used for administering medication treatments) care being provided. Findings include: 1. A review of a of dated 12/19/2022, Interim HealthCare policy titled “Engineering Control and Worl Practices” indicated but wasn’t limited to, “ … Employees wash their hands: d) Immediately before applying gloves …. E) Immediately after removal of gloves … ” 2. A review of an undated agency procedure titled “Peripherally inserted Central Catheter Use” indicated but was not limited to, “ … Performing a PICC dressing change … Perform hand hygiene. Put on gloves … Remove existing dressing … Remove and discard your gloves. Perform hand hygiene. Put on sterile gloves … ” 3. During a home visit at Patient #3’s residence on 04/01/2025 at 9:05 AM, RN 1 was observed performing a PICC dressing change. RN 1 removed the PICC dressing from Patient #3’s right upper arm and discarded the dressing and gloves into the trash receptacle. Afterward, RN 1 donned the sterile gloves and cleansed the PICC site with Chloraprep swabsticks (a swabstick with a sterile skin antiseptic solution). RN 1 failed to perform hand hygiene after discarding the old PICC dressing and before donning the sterile gloves. During an interview on 04/01/2025 at 9:25 AM, when queried regarding the agency policy for hand hygiene and gloving during a PICC dressing change, RN 1 indicated when gloves were removed or prior to gloving. When questioned regarding hand hygiene after removing the old PICC dressing RN 1 stated,” No, I did not perform hand hygiene after discarding the dressing and before donning sterile gloves. I didn’t even have it on the table when I set up my barriers.” 410 IAC 17-12-1(m)”

“HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator’s name, business address, and business phone number in order to receive complaints. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patient received the name and contact information for the Administrator to be able to file a complaint for 1 of 1 (Patient: #1) home visits for patients receiving physical therapy. Findings Include: 1. A review of a dated 04/02/2021, Interim HealthCare policy titled “Contents of the Patient/Client Record” indicated but wasn’t limited to, “ … Contents of An In-Home Presentation Pocket Folder … The following paper forms … are found in the in home presentation Pocket folder … Patient information letter …Name and contact information of the clinical manager … ” 2. During a home visit on 04/01/2025 at 11:46 AM, at Patient #1’s residence, Person 4, the family member/caregiver for Patient #1, provided the agency pocket folder for review. Upon examining the folder, noted it did not include the name or contact information of the agency’s Administrator. When I asked Patient #1 and Person 4 if they knew who the Administrator was and how to contact them in case, they had complaints or concerns, they indicated they were unaware. PT 1 reviewed the agency pocket folder and confirmed the agency pocket folder lacked the Administrator’s name and contact details. PT 1 confirmed Patient #1’s SOC date of 02/24/2025.”

“State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patient received the Indiana state toll-free home health hotline contact information to be able to file a complaint to 1 of 1 (Patient: #1) home visits for patients receiving physical therapy. Findings Include: 1. A review of a dated 04/02/2021, Interim HealthCare policy titled “Contents of the Patient/Client Record” indicated but wasn’t limited to, “ … Contents of An In-Home Presentation Pocket Folder … The following paper forms … are found in the in home presentation Pocket folder … Patient information letter …Name and contact information of the clinical manager … Patient Rights and Responsibilities … ” 2. During a home visit at Patient #1’s residence on April 1, 2025, at 11:46 AM, Person 4, the family member/caregiver for Patient #1, provided the patient’s agency’s pocket folder for review. A review of the agency pocket folder noted the Indiana state toll-free hotline phone number and information missing. When asked Patient #1 and the caregiver how they knew to contact the Indiana state hotline for complaints, they indicated they did not know. PT 1 reviewed the agency pocket folder and confirmed that the folder did not include the sticker on the front that should provide the hotline information and number for the Indiana state toll-free complaint hotline. PT 1 further confirmed Patient #1’s SOC date of 02/24/2025. 410 IAC 17-12-3(b)(2)(B)”

“Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient’s needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure patient clinical records included information about the services the patient received from other agencies and failed to ensure they coordinated care delivery to meet the patient’s needs for 2 of 2 (Patients #2 and 4), active patient records reviewed of patients receiving outside personal care services. Findings include: 1. A review of a dated 04/02/2021, Interim HealthCare policy titled “Coordination of Care/Services” indicated but wasn’t limited to, “ …Interim Healthcare maintains regular communication with the patient/client and with others providing patient/client care/services …. Interim HealthCare coordinates care delivery to meet the patient’s needs … ” 2. During a home visit on 04/01/2025 at 10:12 AM, Person 1, caregiver/family member for Patient #2, repositioned Patient #2 for RN 2. Person 2 indicated they provided 23 hours a day for Patient #2 through Entity 2, a personal care agency. Person 2 further specified their care schedule, providing attendant care from 1:00 AM to 8:00 PM, and HHA care from 8:00 PM to 12:00 PM. A review of the clinical record for Patient #2 SOC 03/30/2024, contained a ROC dated 03/18/2025, which failed to evidence the patient was receiving services from Entity 2. A review of a recertification comprehensive assessment dated 03/12/2025, failed to evidence the patient was receiving services from Entity 2. A review of the plan of care for the recertification period 03/15/2025 to 05/13/2025, failed to evidence Patient #2 was receiving services from Entity 2. A review of the care coordination notes dated 03/30/2024 to 04/01/2025, failed to evidence the patient was receiving services from Entity 2. During an interview on 04/02/2025 at 2:15 PM, when queried regarding the process and location of the documentation for coordinating care with other services Patient #2 had been receiving with Entity 2, RN 2 indicated they were aware of Entity 2, they did not contact the other agency, and the process should have been to document coordination of care between the two agencies in the care coordination notes. 3. A review of the clinical record for Patient #4 SOC 09/01/2023, contained a recertification comprehensive assessment dated 02/19/2024, failed to evidence Patient #4 was receiving services from Entity 3. A review of the plan of care for the recertification period 02/22/2025 to 04/22/2025, failed to evidence Patient #4 was receiving services from Entity 3. A review of the care coordination notes dated 01/01/2025 to 04/01/2025, failed to evidence the patient was receiving services from Entity 3. A review of dated 04/02/2025, document titled “Census Activity Report” provided by Entity 3, a personal care agency, listed Patient #4 SOC date 09/01/2023, receiving waiver services. During an interview on 04/01/2025 at 1:10 PM, Patient #4 confirmed they received attendant care services from Entity 3 and had been for years. During an interview on 04/02/2025 at 9:37 AM, RN 3 indicated they were unaware they needed to coordinate care between agencies if the agency was the personal care agency affiliated with the home care agency. RN 3 indicated they needed to start doing that. During an interview on 04/02/2025 at 3:01 PM, the CM indicated they could not provide care coordination notes for Patient #4 regarding care coordinated between the agency and Entity 3, until they added it today. 410 IAC 17-14-1(a)(1)(F)”

“Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patient had been provided a medication schedule to 1 of 1 (Patient: #1) home visits for patients receiving physical therapy. Findings Include: 1. A review of a dated 04/02/2021, Interim HealthCare policy titled “Contents of the Patient/Client Record” indicated but wasn’t limited to, “ … Contents of An In-Home Presentation Pocket Folder … The following paper forms … are found in the in home presentation Pocket folder … Written information to the patient that includes: Patient medication schedule/instructions … ” 2. During a home visit on 04/01/2025 at 11:46 AM, at Patient #1’s residence, Person 4, the caregiver/family member for Patient #1, provided the agency pocket folder for review. The agency pocket folder contained a document titled “Medication Profile” which was blank. When queried regarding a medication list being provided, the patient and Person 4, regarding a medication list, indicated they had only received the medication list from Entity 5, the skilled nursing facility Patient #1 had stayed before returning home. During an interview on 04/01/2025 at 12: PM, when queried regarding Patient #1’s medication profile being blank, PT 1 indicated they had not completed a medication profile/schedule for Patient #1, and thought the agency would mail the plan of care from the office later. A review of the clinical record for Patient #1, SOC 02/24/2025, contained an initial comprehensive assessment dated 02/24/2025, and electronically signed by PT 1. The comprehensive assessment contained a section titled “Clinical Visit Summary.” The clinical visit summary revealed PT 1 reviewed the agency admission book, medication actions, and side effects with Patient #1 and the caregiver. During an interview on 04/02/2025 at 2:00 PM, the CM confirmed a medication list should be provided to the patients.”

“Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patient received the name and contact information for the CM to 1 of 1 (Patient: #1) home visits for patients receiving physical therapy. Findings Include: 1. A review of a dated 04/02/2021, Interim HealthCare policy titled “Contents of the Patient/Client Record” indicated but wasn’t limited to, “ … Contents of An In-Home Presentation Pocket Folder … The following paper forms … are found in the in home presentation Pocket folder … Patient information letter …Name and contact information of the clinical manager … ” 2. During a home visit on 04/01/2025 at 11:46 AM, at Patient #1’s residence, Patient #1’s family member/caregiver, Person 4 provided the agency pocket folder for review. A review of the agency pocket folder failed to contain the name and contact information for the agency’s CM. When queried if Patient #1 and Person 4 knew who the CM was and how to contact them, they indicated they were not aware. PT 1 confirmed the agency pocket folder provided had not contained the CM name and contact information. PT #1 further confirmed Patient #1’s SOC date of 02/24/2025.”