Deaconess Home Health, LLC

“Retrieval of records CFR(s): 484.110(e) Standard: Retrieval of clinical records. A patient’s clinical record (whether hard copy or electronic form) must be made available to a patient, free of charge, upon request at the next home visit, or within 4 business days (whichever comes first). This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure patient’s clinical records were made available to a patient within 4 business days of request for 1 of 1 active patient on the medical record request log (Patient #12). Findings include: Review of the agency’s Medical Record Daily Activity Log 2026 showed Patient #12’s Power of Attorney (POA) emailed Entity 1’s Medical Records Department on 02/26/2026 to request two years of medical records. The log showed the Medical Records Clerk documented that on 03/19/2026 the Administrator called for an update because the POA was inquiring about the status of the request. The log showed the records were pulled on 03/06/2026 but had not yet been released. The log further showed the Administrator emailed the clerk on 03/26/2026 to follow up on another inquiry from the POA. The clerk documented the records had been released to the POA on 03/19/2026. During an interview on 04/14/2026 at 10:55 AM, the Administrator stated the corporate medical records department did not notify the agency or follow up on medical record requests. She stated requestors sometimes contacted the agency when they had not received their records. She stated the corporate medical records department was responsible for sending records to patients, and she did not track requests before forwarding them to the corporate department. She stated the corporate medical records department was expected to follow the agency’s policy for record request completion and that she should be involved to ensure deadlines were met. During an interview on 04/15/2026 at 4:04 PM, the Administrator stated the request began on 02/26/2026 and the POA received the records on 03/19/2026. She stated Entity 1’s medical records department handled all home health record requests and the agency did not independently track or monitor them. She stated patients and their representatives received contact information to initiate medical record requests. She stated Entity 1 used a third‑party vendor to maintain medical records and the agency’s policy required records to be provided within 30 days of the request. 410 IAC 17-12-3(b)(3)”

“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 provide the name and contact information for the agency’s Clinical Manager for 9 of 9 home visits conducted (Patients #1, #2, #3, #4, #5, #7, #8, #9, and #25). Findings include: 3. During a home visit with Patient #2 on 04/15/2026 at 11:58 AM, a review of the patient’s folder provided by the agency failed to evidence the agency informed the patient of the name and contact information for the clinical manager. During the home visit interview, Patient #2 expressed no knowledge of a clinical manager or their name. 4. During a home visit with Patient #3 on 04/16/2026 at 10:56 AM, a review of the patient’s folder provided by the agency failed to evidence the agency informed the patient of the name and contact information for the clinical manager. During the home visit interview, Patient #3 expressed no knowledge of a clinical manager or their name. 5. During a home visit with Patient #4 on 04/16/2026 at 12:28 PM, a review of the patient’s folder provided by the agency failed to evidence the agency informed the patient of the name and contact information for the clinical manager. During the home visit interview, Patient #4 and spouse expressed no knowledge of a clinical manager or their name. 6. During a home visit with Patient #5 on 04/17/2026 at 11:33 AM, a review of the patient’s folder provided by the agency failed to evidence the agency informed the patient of the name and contact information for the clinical manager. During the home visit interview, Patient #5 expressed no knowledge of a clinical manager or their name. 7. During a home visit with Patient #7 on 04/15/2026 at 1:34 PM, a review of the patient’s folder provided by the agency failed to evidence the agency informed the patient of the name and contact information for the clinical manager. During the home visit interview, Patient #7 expressed no knowledge of a clinical manager or their name. 8. During a home visit with Patient #8 on 04/20/2026 at 8:35 AM, there was no admission folder provided by the agency that evidenced the agency informed the patient of the name and contact information for the clinical manager. During the home visit interview, Patient #8 expressed no knowledge of a clinical manager or their name. 9. During an interview with Patient #9 on 04/17/2026 at 8:30 AM, a review of the patient’s folder provided by the agency failed to evidence the agency informed the patient of the name and contact information for the clinical manager. During the home visit interview, Patient #9 and patient’s representatives expressed no knowledge of a clinical manager or their name. 1. Review of the agency’s admission packet evidenced a welcome letter provided by the agency to patients. The document specified patients should contact the agency with anything about their care they would like to discuss. The document specified management staff of the agency as the Director of Clinical Services (the title of the identified Administrator); the document failed to specify who the agency Administrator was and name/contact information for the Administrator. The packet failed to evidence the CM’s name and contact information. 2. During a home visit with Patient #1 on 04/15/2026 at 10:00 AM, a review of the patient’s folder provided by the agency failed to evidence the agency informed the patient of the name and contact information for the clinical manager. During the home visit interview, Patient #1 expressed no knowledge of the clinical manager or their name. 10. During a home visit with Patient #25 on 04/20/2026 at 9:30 AM, a review of the patient’s folder provided by the agency failed to evidence the agency informed the patient of the name and contact information for the clinical manager. During the home visit interview, Patient #25 expressed no knowledge of the clinical manager or their name. 11. During an interview on 04/15/2026 at 11:00 AM, RN 1 indicated he/she thought the Administrator was the Clinical Manager and didn’t realize she was also the Administrator of the home health. He/She indicated not being familiar with the name of the Clinical Manager for the home health agency.”

“5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient’s immediate needs, but no later than 5 calendar days after the start of care. This Element is not met as evidenced by: Based on record review and interviews, the agency failed to have a signed POC or a verbal POC order from the primary physician before providing services and treatments to patients for 2 of 3 closed record reviews. (Patients #1, #5) Findings include: 1. A 03/25/2024 policy titled “Plan of Care and Physician and Allowed Practitioner Orders” states that staff must keep unsigned POCs in the EMR until they receive a signed POC from a physician or allowed practitioner. The policy allows staff to implement the POC with a verbal order until they receive the signed POC. 2. A review of Patient #1’s record for the certification period from 02/06/2025 to 04/06/2025 evidenced that the agency provided care without obtaining either a detailed verbal order or a physician-signed Plan of Care (POC) for visits on 02/10/2025, 02/13/2025, 02/14/2025, 02/17/2025, 02/21/2025, 02/24/2025, and 02/26/2025. The agency failed to secure these orders before delivering care. 3. A review of Patient #5’s record for the certification period from 11/20/2024 to 01/18/2025 indicated that the agency provided care without a detailed verbal order or a physician-signed Plan of Care (POC) for the visits on 11/27/2025 and 12/03/2025. The agency failed to secure orders before providing care. 4. During an interview on 07/17/2025 at 11:32 AM, the Administrator stated that she did not know staff needed to obtain a signed POC or a detailed verbal order before providing direct care and treatment.”