A Plus Home Health Care Incorporated

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure each patient received the home health services as ordered and written in the individualized plan of care that identifies patient-specific measurable outcomes and goals in 2 of 5 active clinical records reviewed (Patient #1, 4) and 2 of 2 closed clinical records reviewed (Patients #6, 7). Findings include: 1. The clinical record for Patient #1 included an initial POC dated 2/24/2025 to 4/24/2025 for SN visits once a week for two weeks then every other week for 4 weeks and PT services. The clinical record failed to evidence an SN visit was conducted the week of 3/12/2025 nor an attempt to reschedule the missed visit on 3/12/2025. During an interview on 3/17/2025 beginning at 10:00 AM, the Administrator relayed there were no attempts to reschedule the missed visit around Patient’s appointment. 2. The clinical record for Patient #4 included a POC dated 12/27/2024 to 2/24/2025 for SN visits once a week for 8 weeks and HHA visits twice a week for eight weeks and a subsequent POC dated 2/25/2025 to 4/25/2025 for SN visits once a week for nine weeks and HHA visits twice a week for 9 weeks. The clinical record included HHA missed visit documentation for 1/30/2025, 2/20/2025, and 2/25/2205 due to Patient not answering the door. The clinical record failed to evidence attempts to reschedule HHA visits. During an interview on 3/17/2025 beginning at 10:00 AM, the Administrator relayed the visits were missed because Patient did not answer the door and there were no attempts to do a wellness check nor reschedule the visits. 3. The closed clinical record for Patient #6 included a POC dated 1/2/2025 to 3/2/2025 for SN visits once a week for eight weeks. The clinical record included missed visit documentation on Monday, 1/13/2025 and Monday, 2/3/2025 due to ‘cancellation of care’. The clinical record failed to evidence attempts to reschedule care during the week of 1/13/2025 and 2/3/2025. During an interview on 3/17/2025 beginning at 10:00 AM, the Administrator relayed there were no attempts to reschedule Patient’s missed visits on 1/13/2025 and 2/3/2025. 4. The closed clinical record for Patient #7 included a POC dated 12/27/2024 to 2/24/2025 for SN services once a week for one week then every other week for four weeks. A SN visit was documented and dated 01/3/2025. The clinical record included a physician order dated 1/16/2025 to change the SN visit frequency to once a week for two weeks. The record evidenced SN visit were conducted weekly for 3 weeks, the SN visits were dated weekly and included the date of 01/30/2025. The clinical record failed to evidence an order nor physician communication for SN services the week of 1/30/2025. During an interview on 3/17/2025 beginning at 10:00 AM, the Administrator relayed there was not an order for a SN visit the week of 1/30/2025. 410 IAC 17-13-1(a)”

“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 observations and interviews, the agency failed to ensure accepted standards of practice to prevent the transmission of infections and diseases were followed in 1 of 3 active clinical records reviewed with home visits (Patient 1). Findings include: During a home visit observation for Patient #1 on 3/14/2025 beginning at 12:44 PM, PT 2 used a blood pressure cuff and a thermometer from a supply bag to assess Patient. After use, PT 2 used Radiance disinfectant wipes to disinfect the blood pressure cuff and thermometer and then returned the items to the supply bag within 5 seconds after wiping. The direction for use [DFU] on the disinfectant wipes indicated the product required 4 minutes of dry time to disinfect surfaces. PT 2 failed to follow the DFU of 4 to sanitize the supplies before returning to their home visit bag. During an interview on 3/17/2025 beginning at 10:00 AM, the Administrator did not know the required dry time of sanitation wipes, staff were not trained on the dry time of wipes, and indicated education would be provided to their staff. 410 IAC 17-12-1(m)”

“All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This Element is not met as evidenced by: Based on record review and interviews, the agency failed to ensure all patient care orders were recorded in the POC in 3 of 3 active clinical records reviewed with PT services (Patients #1, 3, 5) and 1 of 1 closed clinical record with PT services (Patient #7). Findings include: 1. The clinical record for Patient #1 included an initial POC dated 2/24/2025 to 4/24/2025 for SN visits and one PT evaluation. A PT evaluation was documented on 2/26/2025 that included PT frequency ordered as twice a week for 3 weeks, interventions, goals, and was signed by the physician on 3/7/2025. The clinical record failed to evidence a POC that included PT orders, frequencies, interventions and goals on the POC nor an addendum to the initial POC. 2. The clinical record for Patient #3 included an initial POC dated 2/26/2025 to 4/26/2025 for SN, HHA, and one PT evaluation visit. The clinical record included a PT evaluation documented on 2/27/2025 that indicated PT frequency ordered as once a week for one week then twice a week for three weeks. The PT evaluation included interventions, goals, and was signed by the physician on 3/12/2025. The clinical record failed to evidence the POC included the PT orders, frequencies, interventions and goals on nor an addendum to the initial POC. 3. The clinical record for Patient #5 included a POC dated 1/19/2025 to 3/19/2025 for SN services and one PT evaluation visit. The clinical record included a PT evaluation documented on 1/20/2025 that indicated PT frequency ordered as twice a week for three weeks, included interventions and goals, and was signed by the physician on 2/3/2025. The clinical record failed evidence the POC included PT orders, frequencies, interventions, and goals nor on an addendum to the initial POC. 4. The closed clinical record for Patient #7 included a POC dated 12/27/2024 to 2/24/2025 for SN, HHA, and a PT evaluation visit. The record included a PT evaluation that was documented on 01/03/2025 that indicated PT frequency order once a week for one week then twice a week for three weeks, included interventions and goals, and was signed by the physician on 01/21/2025. The clinical record failed to evidence the POC included the PT orders, frequencies, interventions and goals nor an addendum to the initial POC. During an interview on 2/14/2025 beginning at 10:00 AM, a clinical record review interview was conducted with the Administrator for Patients #1, 3, 5, and 7. The administrator relayed the PT evaluation documentation was the PT POC and orders. She revealed PT orders were not included in the POC nor was there an addendum to the POC.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on record review and interviews, the agency failed to ensure services and treatments were administered only as ordered by a physician in 3 of 3 active clinical records reviewed with PT services (Patient #1, 3, 5) and 1 of 1 closed clinical records reviewed with PT services (Patient #7). Findings include: 1.The clinical record for Patient #1 included an initial POC dated 2/24/2025 to 4/24/2025 for SN visits and one PT evaluation. A PT evaluation was documented on 2/26/2025 that included PT frequency ordered as twice a week for 3 weeks, interventions, goals, and was signed by the physician on 3/7/2025. PT visits were documented on 2/28/2025 and 3/5/2025. The clinical record failed to evidence a verbal nor written order was received for the PT therapy provided on 2/28/2025 and 3/5/2025, prior to the PT evaluation being signed by the attending on 3/7/2025. 2. The clinical record for Patient #3 included an initial POC dated 2/26/2025 to 4/26/2025 for SN, HHA, and one PT evaluation visit. The clinical record included a PT evaluation documented on 2/27/2025 that indicated PT frequency ordered as once a week for one week then twice a week for three weeks. The PT evaluation included intervention and goals and was signed by the physician on 3/12/2025. PT visits were documented on 2/28/2025, 3/4/2025, and 3/6/2025. The clinical record failed to evidence a verbal nor written order was received for the PT therapy provided on 2/28/2025, 3/4/2025, and 3/6/2025, prior to the PT evaluation was signed on 3/10/2025. 3. The clinical record for Patient #5 included a POC dated 1/19/2025 to 3/19/2025 for SN services and one PT evaluation visit. The clinical record included a PT evaluation documented on 1/20/2025 that indicated PT frequency ordered as twice a week for three weeks, included intervention and goals, and was signed by the physician on 2/3/2025. PT visits were documented on 1/22/2025, 1/27/2025, and 1/29/2025. The clinical record failed to evidence a verbal nor written order was received for the PT therapy provided on 1/22/2025, 1/27/2025, and 1/29/2025, prior to the PT evaluation was signed on 2/3/2025. 4. The closed clinical record for Patient #7 included a POC dated 12/27/2024 to 2/24/2025 for SN, HHA, and a PT evaluation visit. The record included a PT evaluation that was documented on 1/3/2025 that indicated PT frequency order once a week for one week then twice a week for three weeks, included interventions and goals, and was signed by the physician on 1/21/2025. PT visits were documented on 01/6/2026, 01/8/2025, 01/13/2025, 01/17/2025, and 01/20/2025. The clinical record failed to evidence a verbal nor written order was received for the PT therapy provided on 01/6/2026, 01/8/2025, 01/13/2025, 01/17/2025, and 01/20/2025, visits prior to the PT evaluation was signed on 01/21/2025. During an interview on 3/17/2025 beginning at 10:00 AM, interviews were conducted with the Administrator regarding the chart review of Patients #1, 3, 5, and 7. The Administrator relayed the PT evaluations included the PT POC orders and there were no verbal orders, nor written ordered received, for the PT therapy provided, prior to the physician signing patients PT evaluation. 410 IAC 17-13-1(a)”

“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 the contents of the clinical record included a completed transfer summary that was sent to the primary care provider within 2 business days if the patient was admitted into a health care facility in 1 of 1 active clinical record reviewed with a hospitalization in the current care period (Patient #4) and 2 out of 2 closed clinical records reviewed (Patient #6, 7). Findings include: 1.The clinical record for Patient #4 included a POC dated 2/25/2025 to 4/25/2025 for SN visits once a week for nine weeks and HHA visits twice a week for 9 weeks. The clinical record included a physician order dated 3/4/2025 that indicated Patient was admitted into a hospital on 3/3/2025 due to a fall. The clinical record failed to evidence a transfer summary sent to the physician within 2 business days of the notification of the Patient’s hospitalization. 2. The closed clinical record for Patient #6 included a POC dated 1/2/2025 to 3/2/2025 for SN visits once a week for eight weeks. The clinical record included documentation that Patient was admitted into a hospital for respiratory problems dated 2/27/2025. The clinical record failed to evidence a transfer summary sent to the physician within 2 business days of the notification of the Patient’s hospitalization. 3. The closed clinical record for Patient #7 included a POC dated 12/27/2024 to 2/24/2025 for SN, HHA, and PT services. The clinical record included documentation that Patient was admitted to a hospital on 2/22/2025 due to fainting and weakness. The clinical record failed to evidence a transfer summary sent to the physician within 2 business days of the notification of the Patient’s hospitalization. During an interview on 3/17/2025 beginning at 10:00 AM, the records for Patient 4, Patient 6, and Patient 7 were reviewed with the Administrator. The Administrator revealed the agency did not send transfer summaries for these patients that were transferred for emergent care and hospitalized. 410 IAC 17-15-1(a)(7)”