Pediatric Nursing Specialists of Indiana

“Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient’s plan of care, for each patient’s medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This Condition is not met as evidenced by: Based on record review and interview, the Agency failed to ensure all Governing Body and Administrative staff were knowledgeable in the Federal and State regulations to ensure they met the requirements of a home health agency by employing and furnishing directly or indirectly services other than skilled nursing. The cumulative effect of this systemic problem resulted in the agency’s inability to ensure patients received services which could result in the agency not providing quality health care. Findings include: 1. During the entrance conference on 06-12-2024 at 5:10 PM, the Administrator indicated the agency provided skilled nursing services and had no other services provided directly or under contract. 2. A review of the agency document titled “Home Health Agency,” dated 06-13-2024 and signed by the Administrator, indicated the services provided were skilled nursing, provided by the agency. 3. During an interview on 06-13-2024 at 2:10 PM, the Administrator indicated the agency would have to recruit and hire a home health aide or physical therapist if their patients had new orders that required therapy. The Administrator further stated, “ We cannot accept a patient we cannot provide services to. Only skilled nursing.””

“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 91 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 06-13-2024 contained a section titled “Emergency Resource List” and directions stating, “ this may be duplicated for each county in your service area.” The binder contained 1 county serviced by the agency in the state but failed to include all 92 counties the agency serves. 3. During an interview on 06/13/2024 at 12:54 PM the Administrator reported they did not have information for all the counties they provide service in only for the county where their current patients reside and do not have any other contact information in the binder for other counties they could admit patients.”

“Skilled services furnished CFR(s): 484.105(f) Standard: Services furnished. Skilled nursing services and at least one other therapeutic service (physical therapy, speech-language pathology, or occupational therapy; medical social services; or home health aide services) are made available on a visiting basis, in a place of residence used as a patient’s home. An HHA must provide at least one of the services described in this subsection directly, but may provide the second service and additional services under arrangement with another agency or organization. This Standard is not met as evidenced by: Based on the record and interview, the agency failed to ensure skilled nursing services and at least one other service was provided by direct staff or under an arrangement in 1of 1 stand-alone home health agency. Findings Include: 1. During the entrance conference on 06-12-2024 at 5:10 PM, the Administrator indicated the agency provided skilled nursing services and had no services provided under contract. 2. A review of the agency document titled “Home Health Agency,” dated 06-13-2024 and signed by the Administrator, indicated services provided were skilled nursing provided by the agency. 3. During an interview on 06-13-2024 at 2:10 PM, the Administrator indicated the agency would have to recruit and hire a home health aide or physical therapist if their patients had new orders which required therapy. The Administrator further stated, “ We cannot accept a patient we cannot provide services to. Only skilled nursing.””

“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 failed to ensure the Emergency Preparedness program contained a Training and Testing plan or procedure, thereby failing to ensure the program’s effectiveness, 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 02-09-2024 failed to evidence a plan or procedure for testing and training the agency’s Emergency Preparedness Plan. 2. On 02-09-2024 at 1:15 PM, the person serving in the role of Administrator, Corporate Personnel 8, indicated there had been no been no exercises conducted by the agency in 2024, indicated was working on tornado tabletop exercise for this year, but this was not yet completed. Corporate Representative 8 conferred with Corporate Representative 6 then indicated there had been no exercises conducted in 2023 either. Indicated they were part of Healthcare Coalition in Ohio, but indicated that Corporate Representative 6 was part of a Healthcare Coalition here in Indiana and “does that in Indiana”.”

“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 failed to conduct Emergency drills/exercises, thereby failed to analyze and document an after- action response, analyze, and utilize the resulting outcomes to revise the agency’s Emergency Preparedness program, 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 02-08-2024 failed to evidence a plan or procedure for testing and training the agency’s Emergency Preparedness Plan. 2. On 02-09-2024 at 1:15 PM, the person serving in the role of Administrator, Corporate Personnel 8, indicated there had been no been no exercises conducted by the agency in 2024, indicated was working on tornado tabletop exercise for this year, but this was not yet completed. Corporate Representative 8 conferred with Corporate Representative 6 then indicated there had been no exercises conducted in 2023 either. Indicated they were part of Healthcare Coalition in Ohio, but indicated that Corporate Representative 6 was part of a Healthcare Coalition here in Indiana and “does that in Indiana”.”

“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 collection in the development of the QAPI program was approved by the agency’s governing body. The Governing Body failed to demonstrate and maintain documentary evidence of its involvement with QAPI. Findings include: 1 Review of an agency document dated January 2018 titled ‘GOVERNING BODY B-100’ stated, “... The duties and responsibilities of the Governing body shall include: ... 2. To ensure an ongoing QAPI (Quality, Assessment and Performance Improvement) program for quality improvements and patient safety is defined, implemented and maintained. 3. Oversees QAPI Program guiding the organization in the formulation and review of policies and procedures and ensure the highest quality of quality of patient care focusing on indicators related to improved outcomes ...” Review of an agency document dated January 2018 titled ‘QAPI COMMITTEE B-160’ stated, “... 1. The governing body appoints a committee that must include clinical administrator, representative of all disciplines/services provided. The objectives of the QAPI committee include: ... 3. Frequency and detail of data collections developed by QAPI committee and approved by governing body ... 6. The committee [sic]with perform improvement projects. The number and scope of improvement projects conducted annually must reflect scope, complexity and past performance of agency’s service and operations. 7 . The QAPI committee [sic]with document the improvement project undertaken, the reason for conducting these projects and the measurable progress achieved on these projects ... 13. The QAPI committee meeting minutes will be maintained in writing ...” Review of an agency document titled ‘Governing Body Meeting Minutes 1/29/2024 BU 61’ stated, “.... QAPI is being reviewed weekly and there are no concerns ...” and failed to evidence what specifically had been reviewed, by whom, and how it was decided that there were no concerns. 2. On 02-09-2024 at 1:15 PM, when queried as to how the Governing Body was involved with QAPI, Corporate Representative 8 indicated the Governing Body made sure the agency was monitoring what was on the new performance improvement “PI grid” (i.e. infections, hospitalizations, rehospitalization, etc.) and indicated the Governing Body wanted to be advised of anything adverse happening to clients. Indicated met with the Governing Body to discuss these items every Monday morning, quarterly, and/or as needed if an emergency. On 02-12-2024 at 10:25 AM, documentation of the agency’s QAPI meetings had been requested, Corporate Representative 6 submitted copies of the agency’s ‘Governing Body Meeting minutes’ and indicated the documents were one and the same/all inclusive.”

“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 ensure Performance Improvements Projects (PIPS) were documented, reason for conducting, and measurable progress with each project in 1 of 1 agency. Findings include: Review of an agency document dated January 2018, titled ‘QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT - B260’ stated, “… 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 … “ Review of the agency’s QAPI binder evidenced an undated, untitled yellow sheet of paper which contained handwritten entries in black ink. Reading from left to right, the first column stated, “Governing Body Meetings, Emergency Meeting 10/12/23, 10/16/23 meeting, ongoing monthly November (check-marked), Dec (check-marked), Jan (no mark). The second column stated, “Tracking and Telehealth Visits, week ending 10/21/23, ongoing tracking, follow up - continue to, monitor weekly, Follow up Jan 2024. The third column stated, “New hire & current staff job descriptions, all management staff job desc. updated”, no dates were provided. A fourth column to the lower right of the page stated, “Track, IDH notified of changes if needed, Updated on 10/13/23 - Admin & case manager Changes.” The document failed to evidence these items had been brought before the Governing Body for review and approval, the reason, whether an acceptable action plan for each of the items had been developed, failed to name who would be responsible for ensuring an action plan was carried out, details of what specific actions or steps had been taken or needed to be taken toward resolution, a proposed outcome, whether the proposed outcome was measurable, proposed date of the resolution, whether each concern had been resolved and the date of its resolution. 2. On 02-09-2024 at 1:15 PM, when queried about the entries on the yellow sheet of paper and whether these detailed the agency’s latest Performance Improvement Plans (PIPs), Corporate Representative 8 indicated these were not the agency’s PIPs only items being monitored or tracked as a result of the agency’s last survey. Informed she performed an audit, approximately 02-06-2024 during the survey, and had audited the agency’s HR files and clinical records, had identified a PIP at that time related to items missing in the personnel files, and made this PIP to be due 03-07-2024. This concern was not listed on the yellow sheet. When queried as to the last time such an audit had been performed, Corporate Representative 8 indicated could ‘look remotely’ from Ohio but had not performed such an audit since just after the Covid public health emergency had ended in 2023. Indicated there was a total of only two patients receiving services. Indicated further the agency had recently started to utilize an electronic performance improvement grid, the ‘PI grid’, in January of this year, where the agency could enter all their data for tracking (i.e. infections, hospitalizations, re-hospitalizations, etc.), indicated they would need to feed three months’ worth of data into the system before it would be valuable to analyze data, and they had not reached that point yet.”

“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 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 was 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 the 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. The Organization Chart indicated the Alternate Administrator holds other positions within the agency, such as Quality Director/ Quality Nurse; Intake Director, Intake Nurse and Intake Specialist; and Recruiting Director / Recruiter. 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 schedule of when they would 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. LPN 3 indicated she had called the Administrator/ Alternate Clinical Manager (Corporate Trainer) and the Clinical Manager (Corporate Clinical Administrator), but both of whom reside in Ohio, were not available for the entrance conference. The entrance conference was held with LPN 3 (presumed Alternate Administrator). 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 that 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 that 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 that LPN 3 (presumed Alternate Administrator) manages them and uploads everything into the patient record. A review of the Clinical Manager’s personnel file revealed that the Clinical Manager resided approximately 2 hours from this office. This provider’s service area adds additional travel time as it goes as far north as St. Joseph County (Central Indiana/ Michigan state line) which is approximately a 4.5-hour drive and as far as Porter County (Northwest Indiana/ Michigan state line). 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 Administrator’s personnel file revealed the Administrator resides approximately 4 hours away from this office. This provider’s service area adds additional time for it goes as far north as St. Joseph County (Central Indiana/ Michigan state line) which is an approximately a 4-hour drive and as far as Porter County (Northwest Indiana/Michigan state line) which is approximately 4.5 hours away per Google Maps. Should there be an emergency at this location, the Administrator 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 that LPN 3 was responsible for making the patient and personnel assignments, coordinated care, and referrals. When asked who ensures a patient’s needs are 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.”

“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 to ensure improvements were sustained. Findings include: 1. Review of agency document dated January 2018, titled ‘QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT’ stated, “… 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 … “ Review of the agency’s QAPI binder evidenced an undated, untitled yellow sheet of paper which contained handwritten entries in black ink. Reading from left to right, the first column stated, “Governing Body Meetings, Emergency Meeting 10/12/23, 10/16/23 meeting, ongoing monthly November (check-marked), Dec (check-marked), Jan (no mark). The second column stated, “Tracking and Telehealth Visits, week ending 10/21/23, ongoing tracking, follow up - continue to, monitor weekly, Follow up Jan 2024. The third column stated, “New hire & current staff job descriptions, all management staff job desc. updated”, no dates were provided. A fourth column to the lower right of the page stated, “Track, IDH notified of changes if needed, Updated on 10/13/23 - Admin & case manager Changes.” The document failed to evidence these items had been brought before the Governing Body for review and approval, the reason, whether an acceptable action plan for each of the items had been developed, failed to name who would be responsible for ensuring an action plan was carried out, details of what specific actions or steps had been taken or needed to be taken toward resolution, a proposed outcome, whether the proposed outcome was measurable, proposed date of the resolution, whether each concern had been resolved and the date of its resolution. Review of the agency’s Quality Assessment Performance Improvement (QAPI) program failed to evidence a system to measure and track performance to ensure improvements were sustained Review of an agency document titled ‘Governing Body Meeting Minutes 1/29/2024 BU 61’ stated, “.... QAPI is being reviewed weekly and there are no concerns ...” and failed to evidence what specifically had been reviewed, by whom, and how it was decided that there were no concerns. 2. On 02-09-2024 at 1:15 PM, when queried about the entries on the yellow sheet of paper and whether these detailed the agency’s latest Performance Improvement Plans (PIPs), Corporate Representative 8 indicated these were not the agency’s PIPs, but were only items being monitored or tracked as a result of the agency’s last survey. Informed she had audited the agency’s files earlier in the week, approximately 02-06-2024, and had audited the agency’s HR files and clinical records, had identified a PIP at that time related to items missing in the personnel files, and made this PIP to be due 03-07-2024. This concern was not listed on the yellow sheet. When queried as to the last time such an audit had been performed, Corporate Representative 8 indicated could ‘look remotely’ from Ohio but had not performed such an audit since just after the Covid public health emergency had ended in 2023. Indicated there were only a total of two patients receiving services. Indicated further the agency had recently started to utilize an electronic performance improvement grid, the ‘PI grid’, in January of this year, where the agency could enter all their data for tracking (i.e. infections, hospitalizations, re-hospitalizations, etc.), indicated they would need to feed three months’ worth of data into the system before it would be valuable to analyze data, and they had not reached that point yet.”

“Administrator appointed by governing body CFR(s): 484.105(b)(1)(i) (i) Be appointed by and report to the governing body; This Element is not met as evidenced by: Based on record review and interview, the Governing Body failed to ensure they appointed an appropriate Administrator for this agency. Findings include: 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 Administrator/ Alternate Clinical Manager had been appointed by the Governing body. A review of the Administrator’s personnel file failed to evidence orientation to this home health agency. During an interview on 2/8/24 at 11:40 AM, when asked what kind of training they receive at this office, the Administrator indicated she already knew what needed to be done from working in Ohio. The Administrator indicated she has been with the company since 2003 and in 2020, was designated the “Corporate Trainer”, taking the same knowledge and applying it to this location. When asked about the appointment by the Governing Body, the Administrator indicated she was the secretary of the Governing and thought there was documentation indicating she had been appointed.”

“Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This Element is not met as evidenced by: Based on observation, record review, and interview, the Administrator failed to ensure they had a schedule of when they would be at this location on a frequent and consistent basis and failed to ensure they were available, able to respond to emergencies within a reasonable amount of time, and responsible for the day-to-day operations of the home health 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. LPN 3 indicated she had called the Administrator (Corporate Trainer) and the Clinical Manager(Corporate Clinical Administrator), but both of whom reside in Ohio were not available for the entrance conference. The entrance conference was held with LPN 3 (presumed Alternate Administrator). The Clinical Manager arrived at the Indy location and met with the surveyors approximately after 12:00 PM. A review of the State Agency notes in the National Database revealed the Administrator/ Alternate Clinical Manager and the Clinical Manager assumed their role effective 10/12/23. On 2/1/24 at 4:00 PM, the Alternate Administrator and Clinical Manager indicated the Administrator 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 Administrator 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, the Administrator and LPN 3 communicate often via phone. A review of the Administrator’s personnel file revealed the Administrator resides approximately 4 hours away from this office. This provider’s service area requires additional travel time as it goes as far north as St. Joseph County (Central Indiana/ Michigan state line) which is an approximate 4-hour drive and as far as Porter County (Northwest Indiana/Michigan state line) which is approximately 4.5 hours away per Google Maps. Should there be an emergency at this location, the Administrator would not be able to arrive within a reasonable amount of time. On 2/8/24 at 11:40 AM, the Clinical Manager, the Administrator/ 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.”

“Ensures qualified pre-designated person CFR(s): 484.105(b)(2) When the administrator is not available, a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator. The pre-designated person may be the clinical manager as described in paragraph (c) of this section. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure 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: A review of the “Alternate Program Administrator” job description, updated on 5/11/2018, November 2022, and October 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 of practice or holds an undergraduate degree; Baccalaureate degree in nursing or related field experience preferred. This document was signed by the LPN 3 on 10/16/23. A review of the personnel file for LPN 3 failed to evidence she had an undergraduate degree. A review of the Governing Body meeting minutes dated 3/10/23 indicated LPN 3 would assume the responsibilities as the Alternate Administrator of the Home Care Network, Inc BU (Business Unit) 61 however, the state agency was made aware of this change in June of 2022. A review of the State Agency notes in the National Database revealed LPN 3 assumed the position of Alternate Administrator on 6/01/2022. Further review of the documents evidenced the State Agency received, LPN 3’s resume that indicated she held an Associate’s degree in Nursing (ASN) since May 2001. A review of the same resume sent to the State Agency for Entity B, a sister agency, indicated LPN 3 graduated in May 2001 as a Practical Nurse. During the entrance conference on 1/31/24 starting at 9:30 AM, when asked if she held an undergraduate degree, LPN 3 stated she did not due to not finishing school. On 2/8/24 at 10:20 AM, LPN 3 was shown a resume provided to the state agency that was for a sister agency, Entity B, and a resume that was provided for this entity. Both resumes were the similar with the exception of the undergrad education. The resume for Entity B indicated LPN 3 graduated as a practical nurse in May of 2001 and the resume for this entity indicated that LPN 3 graduated with an ASN in May of 2001. After review, LPN 3 indicated the resume for this entity indicating she held an ASN was not accurate and she did not create it. LPN 3 indicated this was the first time she had seen this document. When asked who would be sending documents to the state, she indicated Corporate Representative 5 would be doing so. On 2/8/24 at 10:45 AM, LPN 3 indicated she remembered what happened, how she was recently married and dealing with a personal issue, another employee was helping her, and she failed to review and verify what the other employee had done to her resume. The State Agency approved LPN 3 in 2022 based on the fact the resume indicated she held an Associate’s degree. 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 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 E, 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 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 G, a Therapy company] Contract/Partnership Agreement’ indicated a contract was created between the corporation, Home Care Network, Inc., and Entity G, 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 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. 3. 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 and 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 the two newly contracted Therapy companies, Entities E and G, were chosen to ensure coverage of the entire state. On 01-31-2024 at 2:51 PM, Person F With Entity E, 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 H with Entity G, 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 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 E and G, Corporate Representative 1 indicated Corporate Representative 6, Corporate Representative 7, and Corporate Representative 2 had done so. When informed Entity E indicated they did not service Indiana, and Entity G 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 2 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, hired date of 11/27/23, contained an I-9 tax form that identified the employer as Home Care Network/Pediatric Nursing in Jackson Ohio. The form was signed by the Corporate Human Resource Representative. 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, 11, and 12 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.”

“Skilled services furnished CFR(s): 484.105(f) Standard: Services furnished. Skilled nursing services and at least one other therapeutic service (physical therapy, speech-language pathology, or occupational therapy; medical social services; or home health aide services) are made available on a visiting basis, in a place of residence used as a patient’s home. An HHA must provide at least one of the services described in this subsection directly, but may provide the second service and additional services under arrangement with another agency or organization. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure skilled nursing services and one other direct or contracted therapeutic service was provided in 1 of 1 home health agency. (Entity A) Findings include: 1. A review of an agency document titled, “Home Health Agency Survey Report” signed and dated 11-13-2023 by the Alternate Administrator, revealed the agency provided only skilled nursing with the home health agency’s staff. 2. During the entrance interview on 11-13-2023 at 9:45 AM, the Alternate Administrator indicated they provide only skilled nursing services.”