Home Health Angels LLC

“Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient’s medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This Condition is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the plan of care was updated at recertification and failed to ensure the patient received services as ordered (See G572); failed to ensure the POC included measures to address all safety concerns, frequency and duration of visits to be made, patient-specific interventions, and measurable outcomes and goals (See G574); failed to ensure all orders were recorded into the POC (See G576); failed to ensure services were provided only as ordered by a physician or allowed practitioner (See G580) failed to ensure the plan of care (POC) was reviewed with the physician at start of care (SOC) and/or recertification (See G588); failed to ensure the patient/caregiver was provided with written POC information including all treatments administered (See G618) and failed to provide the patient and/or caregiver with accurate clinical manager information (See G622). Findings include: The cumulative effect of these systemic problems had the potential to impact all 61 active patients which resulted in the agency being found out of compliance with the Condition of Participation 42 CFR 484.60 Care Planning, Coordination of Services and Quality of Care.”

“Home health aide services CFR(s): 484.80 Condition of participation: Home health aide services. All home health aide services must be provided by individuals who meet the personnel requirements specified in paragraph (a) of this section. This Condition is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the HHA was currently certified to provide home health services (See G754); failed to ensure the HHA provided services as ordered in the HHA POC (See G800) and failed to ensure the RN supervised the HHA every 14 days (See Tag G808). Findings include: The cumulative effect of these systemic problems had the potential to impact all 61 active patients which resulted in the agency being found out of compliance with the Condition of Participation 42 CFR 484.80 Home health aide services.”

“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 the Administrator was managing the day-to-day operations of the agency (see G948); failed to ensure a clinical manager was available during operating hours (See G950); failed to ensure the Clinical Manager was involved in daily activities of the agency (See G958); and failed to ensure the Clinical Manager was involved in the operations / oversight of the home health agency (See Findings below). Findings include: 1. The undated agency policy “Clinical Supervision” indicated the Director of Nursing/Nursing Supervisor shall be responsible for the quality of care provided and supervision of all staff providing therapeutic services. He/she will also be responsible for organizing and directing the Agency’s ongoing functions and nursing leaders shall coordinate the day-to-day operation of the organization and work with the Administrator. 2. The undated agency policy “Governing Body” indicated the duties and responsibilities of the Governing Body shall include adopting and periodically reviewing and approving administrative and personnel policies, patient care policies and procedures, bylaws as required, the annual operating budget and capital expenditure plan; overseeing the management and fiscal affairs of the agency, this shall include organizational operations; define the corporate structure and clearly indicate lines of authority. This policy indicated Heather Myers was appointed as the Administrator and Director of Nursing on 11/09/08. 3. Review of the home health agency organizational chart evidenced Admin 3 as the Clinical Manager of the agency. 4. Review of CMS provider details, last updated on 4/27/23, evidenced Admin 3 as the Clinical Manager of the agency. 5. Review of the Governing Body minutes, dated 12/15/23, failed to evidence Admin 3 was appointed as the Clinical Manager effective 4/07/23. 6. During an interview on 10/08/24 beginning at 8:23 AM, Admin 3 (who is listed as the Clinical Manager) relayed she was only available as a consultant. She also relayed she was unsure who the current clinical staff were at this time as she was not involved in the daily activities of the agency. She also relayed that she tried to check in with the agency at least once a year and has not provided any consulting services to the agency in over a year. Admin 3 stated Admin 2 was the Administrator and Clinical Manager of the home health agency. 7. During an interview on 10/09/24 beginning at 5:06 PM, Admin 1 (who is listed as the Administrator of the agency) relayed she was the only member of the Governing Body and Admin 2 was the current Administrator and Clinical Manager of the agency and Admin 2 was responsible for the day-to-day activities and overseeing patient care. 8. The cumulative effect of these problems resulted in the home health agency’s inability to ensure the provision of quality health care in a safe environment for the Condition of Participation 42 CFR 484.105 Organization and Administration of Services.”

“Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice’s ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This Standard is not met as evidenced by: Based on EP plan review and interview, the home health agency failed to ensure its EP plan included strategies for addressing emergency events identified by the risk assessment, which had the potential to affect all active patients and employees. Findings include: 1. The review of the agency’s Hazard and Vulnerability Assessment Tool, completed by Alternate Administrator on 1/04/24, indicated the agency identified the emergency events “Severe Thunderstorm … Snow Fall … Ice Storm … Temperature Extremes … Epidemic … Electrical Failure … HVAC Failure ….” as having a high probability of occurring. The emergency events “Drought … Earthquake … Transportation Failure … Fuel Shortage … Natural Gas Failure … Water Failure … Sewer Failure … Fire Alarm Failure … Communications Failure … Medical Gas Failure … Information Systems Failure … Flood, Internal … Supply Shortage … Structural Damage … Chemical Exposure … Internal Spill … Mass Casualty Incident … Hostage Situation … Civil Disturbance … Labor Action … Forensic Admission ….” were identified as having “moderate” or “low” probability of occurring. 2. The review of the agency’s EP plan failed to evidence the agency had identified and documented strategies for addressing the above emergency events identified by the risk assessment as having a probability of occurring. 3. During an interview with Alternate Administrator on 10/09/24 beginning at 5:50 PM, she reported she last reviewed the agency’s EP plan on 1/04/24, including updating the agency’s hazard and vulnerability risk assessment. Alternate Administrator reported the agency had not developed strategies for addressing emergency events identified by the risk assessment.”

“Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(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:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO’s Donation Service Area (DSA). This Standard is not met as evidenced by: Based on EP plan review and interview, the home health agency failed to ensure its EP communication plan included name and contact information for all staff, which had the potential to affect all agency staff and patients. Findings include: 1. The review of the agency’s EP binder evidenced a document titled “Associate List” dated 5/22/2020. The list failed to evidence contact information for COTA 1, RN 2, Office Assistant 4, and Speech Therapist 1. 2. During an interview with Alternate Administrator on 10/09/24 beginning at 5:50 PM, she reported she last reviewed the agency’s EP plan on 1/04/24, however she had not reviewed and updated the communication plan to include all active employees.”

“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 EP plan review and interview, the home health agency failed to ensure its EP communication plan included contact information for Federal, State, and local emergency preparedness staff, which had the potential to affect all agency staff and patients. Findings include: 1. The review of the agency’s EP binder evidenced a document titled “Indiana Public Health Preparedness District and District Healthcare Coalition Contacts,” dated 08/2017. The EP communication plan failed to evidence contact information for current Federal, State, and local emergency preparedness staff. 2. During an interview with Alternate Administrator on 10/09/24 beginning at 5:50 PM, she reported she last reviewed the agency’s EP plan on 1/04/24, however she had not reviewed and/or updated the communication plan to include current Federal, State, and local emergency preparedness staff.”

“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 the POC was updated at recertification for 4 of 4 active records reviewed with OT recertification (Patients #3, 4, 6, 7) and failed to ensure the patient received all PT and OT services as ordered in the plan of care for 1 of 1 discharged record reviewed where Patient received PT and OT services (Patient #9). Findings include: 3. Patient #3’s clinical record evidenced a recertification POC for the certification period 8/21/24 to 10/19/24. The POC included orders for an OT re-evaluation and treat per OT POC. The record evidenced an OT routine visit was completed on 8/24/24. The record failed to evidence an OT recertification POC was created and failed to include documentation of a verbal or written order for OT services to continue. During an interview on 10/09/24 beginning at 11:51 AM, OT 2 relayed they missed completing the recertification OT POC for Patient #3 and he did not collaborate with the physician after the 8/24/24 visit. 4. Patient #4’s clinical record evidenced a recertification POC for the certification period 8/24/24 to 10/22/24. The POC included orders for an OT re-evaluation and treat per OT POC. The record evidenced an OT routine visit was completed on 8/17/24. The record failed to evidence an OT recertification POC was created and failed to include documentation of a verbal or written order for OT services to continue. During an interview on 10/09/24 beginning at 11:51 AM, OT 2 relayed they missed completing the recertification OT POC for Patient #4 and he did not collaborate with the physician after the 8/17/24 visit. 5. Patient #6’s clinical record evidenced a recertification POC for the certification period 9/14/24 to 11/12/24. The POC failed to include OT orders. The record evidenced an OT Routine visit was completed on 9/07/24. The record failed to evidence an OT recertification POC was created and failed to include documentation of a verbal or written order for OT services to continue. During an interview on 10/09/24 beginning at 11:51 AM, OT 2 relayed they missed completing the recertification OT POC for Patient #6 and he did not collaborate with the physician after the 9/07/24 visit. 6. Patient #7’s clinical record evidenced a recertification POC for the certification period 9/14/24 to 11/12/24. The POC included orders for HHA visits 3 times a week for 8 weeks and an OT re-evaluation and treat per OT POC. The record failed to evidence HHA visits were completed the week of 9/08/24. The record evidenced an OT Routine visit was completed on 8/31/24. The record failed to evidence an OT recertification POC was created and failed to include documentation of a verbal or written order for OT services to continue. During an interview on 10/09/24 beginning at 10:12 AM, RN 1 was unaware that Patient #7 did not receive HHA visits during the week of 9/08/24. During an interview on 10/09/24 beginning at 11:51 AM, OT 2 relayed they missed completing the recertification OT POC for Patient #6 and he did not collaborate with the physician after the 8/31/24 visit. 410 IAC 17-13-1(a) Findings include: 1. Agency Policy “Plan of Care” indicated all patients should have a written, individualized plan of care which was “periodically reviewed” by the ordering provider at least every 60 days. The revised plan of care should “reflect current information from the patient’s updated comprehensive assessment and contain information concerning the patient’s progress toward the measurable outcomes and goals ….” Services were to be provided as ordered by the physician. 2. Patient #9’s clinical record indicated Patient was referred for physical therapy and occupational therapy services. On 5/25/24, OT 2 conducted an OT resumption of care re-evaluation. The therapist wrote an order for 2 OT visits per week for 4 weeks, effective 5/26/24. The record indicated only 1 OT visits was conducted the week of 5/26/24 – 6/02/24. On 5/29/24, PT 2 conducted a PT resumption of care re-evaluation. The therapist wrote an order for 1 PT visit per week for 4 weeks, effective 6/02/24. The record failed to evidence Patient received a PT visit the week of 6/24/24 – 6/30/24. On 7/06/24, PT 2 conducted a PT re-evaluation of Patient. PT 2 documented Patient was going to have a cardiac stent placed on 7/08/24, and “Patient needs continued PT to work on [his/her] strength and stability to improve [his/her] balance. Patient also needs monitored after the stent placement and will be re-evaluated next week for continued PT services.” The therapist wrote an order for Patient to be re-evaluated for PT services effective 7/07/24. The record failed to evidence a PT re-evaluation of Patient was completed and failed to evidence Patient received further PT services. On 7/27/24, OT 2 conducted an OT re-evaluation of Patient. The therapist wrote an order for 1 OT visit per week for 4 weeks, effective 7/28/24. The record failed to evidence Patient received an OT visit the week of 7/28/24 – 8/03/24. On 8/24/24, OT 2 conducted an OT re-evaluation of Patient. The therapist wrote an order for 1 OT visit per week for 3 weeks, effective 8/25/24. The record failed to evidence Patient received an OT visit the week of 8/25/24 – 8/31/24. On 9/07/24, OT 2 conducted an OT re-evaluation of Patient. This was the first OT visit completed since Patient’s previous OT re-evaluation on 8/24/24. OT 2 wrote an order for Patient to be discharged from OT services due to Patient meeting goals. During an interview with PT 2 on 10/09/24 beginning at 10:39 AM, he reported if an ordered visit was not conducted, he would contact Patient’s ordering provider and document the reason for the missed visit in the record. During a follow-up interview with PT 2 on 10/09/24 beginning at 11:45 AM, he reported he did not obtain a new order for Patient’s PT services to resume after his/her cardiac stent was placed. PT 2 could not recall the reason a new order was not obtained, or the reason Patient’s PT services failed to continue. During an interview with OT 2 on 10/09/24 beginning at 11:52 PM, he reported if an ordered visit was not conducted, he would notify Patient’s nurse and send a written order to the provider. When queried on the reason for Patient’s missed visits, OT 2 stated Certified Occupational Therapy Assistant (COTA) 1 was responsible for conducting these visits. During an interview with COTA 1 on 10/09/24 beginning at 12:20 PM, she reported if a patient’s visit was unable to be conducted, she would send a missed visit order to the patient’s provider. COTA 1 reported Patient’s OT visits would occasionally be missed due to Patient not being available. The therapy assistant reported she would document her attempts to schedule Patient’s visits in the record, however the record failed to evidence these attempts and failed to evidence Patient’s physician was notified of the missed visits. During an interview with Patient #9 on 10/09/24 beginning at 10:58 AM, he/she reported they were hoping his/her therapy services would not be stopped, as he/she would have liked to continue working on their endurance and balance.”

“Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to measure, document improvement actions and track quality indicators for 1 of 1 agency. Findings include: 1. The agency policy “Quality Assurance Performance Improvement-QAPI”, last revised 11/2018, indicated the program will be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. The HHA will measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care. 2. The agency’s QAPI binder, weekly whiteboard meeting notes and Governing Body minutes from the last 12 months were reviewed. The QAPI binder failed to include any data for measuring, improving or tracking quality indicators. 3. During an interview on 10/09/24 beginning at 12:40 PM, the Alternate Administrator relayed the agency does not keep QAPI meeting minutes and they were unsure if the agency was tracking any quality indicators. 4. During an interview on 10/09/24 beginning at 5:06 PM, the Administrator relayed the agency is always looking at QAPI items, however, the agency does not keep any meeting minutes of this. 410 IAC 17-12-2(a)”

“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 Governing Body approved the frequency and detail of the data collection of the QAPI program for 1 of 1 agency. Findings include: 1. The agency policy “Quality Assurance Performance Improvement-QAPI”, last revised 11/2018, indicated the program will be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. The HHA will measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care. 2. The agency’s QAPI binder, weekly whiteboard meeting notes and Governing Body minutes from the last 12 months were reviewed. The QAPI binder failed to include meeting minutes and failed to evidence documentation of the frequency and detail of the data collection approved by the Governing Body. During an interview on 10/09/24 beginning at 12:40 PM, the Alternate Administrator relayed the agency does not keep QAPI meeting minutes and therefore the governing body has not approved the QAPI program. During an interview on 10/09/24 beginning at 5:06 PM, the Administrator relayed the agency does not keep any QAPI meeting minutes and therefore, the governing body has not approved any QAPI information. 410 IAC 17-12-2(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 observation, record review, and interview, the agency failed to ensure employees followed standards of practice for hand hygiene and bag technique to reduce the spread of infections for 2 of 3 home visit observations (Patients #2 and 3). Findings include: 1. The undated agency policy “Handwashing/Hand Hygiene” indicated hand hygiene should be performed between tasks on the same patient, after removing gloves and after touching objects that are potentially contaminated. 2. The undated agency policy “Infection Control” indicated the home health agency will follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. Standard precautions included hand hygiene and use of personal protective equipment. 3. The undated policy “Healthcare Bag Technique for Home Health Care Clinicians” indicated staff is to wash their hands if you need to re-enter the home care bag for additional supplies during patient care. To never reach into the bag with gloved hands, to remove gloves and clean hands first, utilize the antiseptic wipes or alcohol pads to clean your equipment, lay them in your clean area, to dry, prior to returning them to the bag, then wash your hands, and repack and close the healthcare bag. 4. During a home visit observation conducted with Patient #2 and COTA 1 on 10/04/24 beginning at 8:50 AM, COTA 1 was observed wearing gloves while performing an assessment and therapy exercises during the entire session with Patient #2. COTA 1 was also observed to cleanse the vitals equipment and return cleaned items to their equipment bag immediately without allowing to air dry, while wearing the same gloves. COTA 1 failed to change gloves or perform hand hygiene during the visit. During an interview on 10/07/24 beginning at 3:48 PM, COTA 1 relayed hand hygiene should have been performed before, during and after the patient session and gloves should have been changed in between patients and if soiled. 5. During a home visit observation conducted with Patient #3 and RN 1 on 10/07/24 beginning at 1:03 PM, RN 1 used the vitals equipment to obtain vital signs on Patient #3 and then sat the items on a paper towel on the table. RN 1 was observed cleaning the vitals equipment with a bleach wipe. RN 1 then sat the clean vitals equipment back on the dirty towel to air dry. During an interview on 10/07/24 beginning at 1:57 PM, RN 1 relayed the clean vitals equipment should have been placed on a clean barrier to air dry. During an interview on 10/07/24 beginning at 2:08 PM, the Alternate Administrator relayed all cleaned vitals equipment should have been placed on a clean barrier to air dry. 410 IAC 17-12-1(m)”

“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 agency failed to ensure the Clinical Manager was involved in daily activities of the agency for 1 of 1 home health agency surveyed. Findings include: 1. During the entrance conference on 10/03/24 beginning at 9:58 AM, the Alternate Administrator listed Admin 3 as the Clinical Manager of the home health agency. Review of CMS provider details, last updated on 4/27/23, evidenced Admin 3 as the Clinical Manager of the agency. Review of the home health agency organizational chart evidenced Admin 3 as the Clinical Manager of the agency. 2. During an interview on 10/08/24 beginning at 8:23 AM, Admin 3 (who is listed as the Clinical Manager) relayed she was only available as a consultant, and she thought Admin 2 was the Clinical Manager of the agency. She also relayed she was unsure who the current clinical staff were at this time as she was not involved in the daily activities of the agency. 4. During an interview on 10/09/24 beginning at 5:06 PM, Admin 1 (who is listed as the Administrator of the agency) relayed Admin 2 was the current Clinical Manager of the agency and was responsible for the day-to-day activities. 410 IAC 17-12-1(d)”

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on record review and interview, the home health agency failed to conduct an initial assessment to determine the patient’s immediate care and support needs within 48 hours of referral for 5 of 9 records reviewed (Patients #1, 5, 6, 7, 8, 9). Findings include: 2. Patient #1’s clinical record evidenced a referral was received on 9/09/24 and RN 1 conducted a start of care visit on 9/12/24. The record failed to evidence the reason for delay in conducting an initial assessment. During an interview on 10/07/24 beginning at 12:35 PM, RN 1 was unsure of the delay in SOC. During an interview on 10/08/24 beginning at 2:45 PM, the Alternate Administrator relayed she was unsure of the delay in SOC and verified the clinical record was missing documentation of the delay. 3. Patient #5’s clinical record evidenced a referral was received on 5/03/24 and RN 1 conducted a start of care visit on 5/06/24. The record failed to evidence the reason for delay in conducting an initial assessment. During an interview on 10/07/24 beginning at 12:55 PM, RN 1 was unsure of the delay in SOC. During an interview on 10/08/24 beginning at 2:45 PM, the Alternate Administrator relayed she was unsure of the delay in SOC and verified the clinical record was missing documentation of the delay. 4. Patient #6’s clinical record evidenced a referral was received on 2/16/24 and RN 1 conducted a start of care visit on 3/18/24. The record failed to evidence the reason for delay in conducting an initial assessment. During an interview on 10/09/24 beginning at 9:50 AM, the Alternate Administrator relayed the home health agency was waiting on insurance authorization and verified the clinical record for Patient #6 did not include documentation that the patient or the assisted living facility was notified of the delay. During an interview on 10/09/24 beginning at 10:12 AM, RN 1 was unsure of the delay in SOC and relayed the delay should have been documented in the clinical record for Patient #6. 5. Patient #7’s clinical record evidenced a referral was received on 2/13/24 and RN 1 conducted a start of care visit on 3/18/24. The record failed to evidence the reason for delay in conducting an initial assessment. During an interview on 10/08/24 beginning at 3:24 PM, the Alternate Administrator relayed the home health agency was waiting on insurance authorization and verified the clinical record for Patient #7 did not include documentation that the patient or the assisted living facility was notified of the delay. During an interview on 10/09/24 beginning at 10:12 AM, RN 1 was unsure of the delay in SOC and relayed the delay should have been documented in the clinical record for Patient #7. 410 IAC 17-14-1(a)(1)(A) Findings include: 1. Agency policy “Initial Patient Assessment” indicated a Registered Nurse (RN) should an initial assessment visit within 48 hours of referral or within 48 hours of the patient’s return home. 6. Patient #8’s clinical record evidenced a referral was received on 7/08/24 and RN 2 conducted a start of care visit on 7/12/24. The record failed to evidence the reason for delay in conducting an initial assessment. During an interview with Alternate Administrator on 10/08/24 beginning at 1:08 PM, she reported RN 2 was currently on leave from the 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 interview, the home health agency failed to conduct a comprehensive assessment which included an evaluation for all referred services within 5 days of the start of care for 2 of 3 records reviewed with SOC in the last 3 months (Patient #1 and 8). Findings include: 2. Patient #1’s clinical record evidenced a referral was received for PT, OT and SN services on 9/09/24. RN 1 conducted a SOC visit on 9/12/24 and created a POC which failed to include the OT evaluate and treat order. The record evidenced an OT Evaluation was completed on 9/27/24, fifteen days after SOC, by OT 2. The record failed to evidence an order for the OT Evaluation. During an interview on 10/07/24 beginning at 12:35 PM, RN 1 relayed they didn’t order the OT Evaluation at the SOC to allow Patient #1 time to improve from COVID-19 symptoms and she verified the clinical record failed to evidence documentation that the physician was notified of the delay in OT services. During an interview on 10/07/24 beginning at 3:13 PM, OT 2 relayed they were unsure why the initial OT Evaluation was not ordered at SOC on 9/12/24. 1. Agency policy titled “Comprehensive Patient Assessment” indicated all patients were to have a comprehensive assessment completed within 5 calendar days of the start of care. 3. Patient #8’s clinical record evidenced a referral was received on 7/08/24 for PT services on 7/08/24 and Patient’s start of care date was 7/12/24. RN 2 conducted a start of care visit on 7/12/24 and created a plan of care which indicated PT was to evaluate and treat Patient. The record indicated on 7/22/24, Patient had not yet had a PT referral. Alternate Administrator obtained a second order for PT to evaluate and treat Patient. The record indicated on 7/23/24, Patient was discharged on 7/23/24 due to “expired at home.” The record failed to evidence a PT evaluation had been conducted prior to Patient’s discharge. During an interview with PT 1 on 10/09/24 beginning at 11:45 AM, he reported he had attempted multiple times to contact Patient, however Patient did not answer or return the calls. PT 1 reported on 7/23/24, he went to Patient’s home to attempt to conduct the PT evaluation, and found the coroner and police were at Patient’s home, as Patient was deceased. The record failed to evidence PT’ 1’s reported attempts to contact Patient nor attempted visit.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure an accurate review of all medications for 2 of 2 active records reviewed who reside in an Assisted Living Facility (ALF) (Patient #6 and 7). Findings include: 1. The undated agency policy “Medication Profile” indicated the medication profile shall be reviewed by a RN every sixty (60) days and updated whenever there is a change or discontinuation in medication. 2. Patient #6’s clinical record evidenced a start of care (SOC) on 3/18/24 and included a POC and medication profile for the certification period 9/14/24 to 11/12/24. Clinical records were obtained from Entity G during the survey. Comparison of Entity G’s current medication orders list and the home health agency’s POC medication profile evidenced the following discrepancies: a) Ipratropium-Albuterol Inhalation Solution (used to treat COPD) 0.5-2.5 (3mg/3 milliliter (ml)) daily at bedtime was listed on Entity G’s current medication list. The medication was not listed on the home health agency’s medication profile. b) Ipratropium-Albuterol Inhalation Solution (used to treat shortness of breath/wheezing) 0.5-2.5 (3mg/3ml) every 6 hours as needed was listed on Entity G’s current medication list. The medication was not listed on the home health agency’s medication profile. c) Acetaminophen with Codeine Phosphate (used to treat pain) 300-30 milligram (mg) three times a day as needed was listed on the home health agency medication profile. The medication was not listed on Entity G’s current medication list. During an interview on 10/09/24 beginning at 10:12 AM, RN 1 relayed they reconcile medications for Patient #6 during every recertification visit. 3. Patient #7’s clinical record evidenced a start of care (SOC) on 3/18/24 and included a POC and medication profile for the certification period 9/14/24 to 11/12/24. Clinical records were obtained from Entity G during the survey. Comparison of Entity G’s current medication orders list and the home health agency’s POC medication profile evidenced the following discrepancies: a) Calcium carbonate (used to treat indigestion) 500 mg tablet was listed on Entity G’s current medication list as 2 tablets every 8 hours as needed. The home health agency’s medication profile listed the medication as a 600 mg tablet with dosing of 2 tablets daily as needed. b) Cholecalciferol (used to treat Vitamin D deficiency) 50 microgram (mcg) 2000 units was listed on Entity G’s current medication list as 50 mcg daily (2000 units). The home health agency’s medication profile listed the medication as 5000 units daily. During an interview on 10/09/24 beginning at 10:12 AM, RN 1 relayed they reconcile medications for Patient #7 during every recertification visit. 4. During the entrance conference on 10/03/24 beginning at 9:58 AM, the Alternate Administrator relayed medications should be reconciled during every visit. 410 IAC 17-14-1(a)(1)(B)”

“Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This Element is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the therapy evaluation was completed within 5 days of the recertification for 4 of 4 active records reviewed with a therapy recertification (Patient #3, 4, 6 and 7). Findings include: 1. Patient #3’s clinical record evidenced a SOC on 4/23/24 and a recertification period of 8/21/24 to 10/19/24. OT and PT Evaluations were completed on 8/24/24 by OT 2 and PT 1, three days after the recertification period began. The record failed to include the OT and PT recertification evaluations were performed within 5 days of the 8/21/24 recertification date. During an interview on 10/07/24 beginning at 2:04 PM, PT 1 relayed the PT evaluation should have been done within 5 days of the recertification and he was unsure why the evaluation was late. During an interview on 10/07/24 beginning at 3:13 PM, OT 2 relayed OT recertification should be done every 60 days, and he was unsure if it was completed within that timeframe. 2. Patient #4’s clinical record evidenced a SOC on 5/02/23 and a recertification period of 8/24/24 to 10/22/24. An OT Evaluation was completed on 8/17/24 by OT 2, seven days before recertification period began. The record failed to include an OT recertification evaluation was performed within 5 days of the 8/24/24 recertification date. During an interview on 10/07/24 beginning at 3:13 PM, OT 2 relayed OT recertification should be done every 60 days, and he was unsure why it was not completed within that timeframe. 3. Patient #6’s clinical record evidenced a SOC on 3/18/24 and a recertification period of 9/14/24 to 11/12/24. An OT Evaluation was completed on 9/07/24 by OT 2, seven days before recertification period began and a PT Evaluation was completed on 9/14/24 by PT 1, the first day of the recertification period. The record failed to include OT and PT recertification evaluations were performed within 5 days of the 9/14/24 recertification date. During an interview on 10/09/24 beginning at 10:36 AM, PT 1 relayed he was unsure why the evaluation was late. During an interview on 10/09/24 beginning at 11:51 AM, OT 2 relayed he the OT evaluation was done early because he usually only works on Saturday. 4. Patient #7’s clinical record evidenced a SOC on 3/18/24 and a recertification period of 9/14/24 to 11/12/24. An OT Evaluation was completed on 8/31/24 by OT 2, fourteen days before the recertification period. The record failed to include the OT recertification evaluation was performed within 5 days of the 9/14/24 recertification date. During an interview on 10/09/24 beginning at 11:51 AM, OT 2 relayed he completes the reevaluation visits when he is available, usually on Saturdays. 410 IAC 17-14-1(a)(1)(B)”

“Within 48 hours of the patient’s return CFR(s): 484.55(d)(2) Within 48 hours of the patient’s return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This Element is not met as evidenced by: Based on record review and interview, the home health agency failed to conduct a ROC re-evaluation for all services within 48 hours from a patient’s return home after hospitalization for 1 of 2 records reviewed of a patient who was hospitalized (Patient #9). Findings include: 1. Agency policy “Comprehensive Patient Assessment” indicated when a client was admitted to an inpatient facility for more than 24 hours, a resumption of care assessment would be completed within 48 hours of the patient’s discharge home. 2. Patient #9’s clinical record evidenced a start of care date of 5/16/24. PT 2 and OT 2 conducted initial evaluations on 5/18/24 and documented Patient was to receive further therapy services. The record indicated Patient was hospitalized after admission to the home health agency. RN 1 conducted a nursing ROC visit on 5/23/24. The visit note indicated Patient was discharged from the hospital on 5/21/24. The record evidenced OT 2 conducted an OT ROC visit on 5/25/24, which was 4 days after Patient’s hospital discharge. PT 2 conducted a PT ROC visit on 5/29/24, which was 8 days after Patient’s hospital discharge. The record failed to evidence a reason the PT and OT ROC visits were delayed. 3. During an interview with PT 2 on 10/09/24 beginning at 10:39 AM, he reported if a patient was hospitalized, a ROC visit should be completed within 24-48 hours of their hospital discharge, unless the therapist was unavailable, or the patient requested a delayed visit. The therapist reported the reason for a delayed visit should be entered in the medical record PT 2 could not recall the reason Patient’s ROC visit was delayed. 4. During an interview with OT 2 on 10/09/24 beginning at 11:52 PM, he reported if a patient was hospitalized, a ROC visit should be completed within 3 days of their hospital discharge. OT 2 could not recall the reason Patient’s ROC visit was delayed.”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on observation, record review, and interview, the home health agency failed to ensure the POC included measures to address all safety concerns, frequency and duration of visits to be made, patient-specific interventions, and measurable outcomes and goals, for 9 of 9 full records reviewed (Patients #1, 2, 3, 4, 5, 6, 7, 8, 9) and 1 of 4 focused records reviewed (Patient #4). Findings include: 2. Patient #1’s clinical record included a SOC assessment completed on 9/12/24 by RN 1. The assessment indicated the Patient was a risk for falls and the medication profile evidenced the patient was taking an anticoagulant. The POC for Patient #1 for the certification period of 9/12/24 to 11/10/24, created by RN 1, failed to evidence safety measures to address patient’s risk for falls and anticoagulant precautions and failed to include interventions for SN goals. During an interview on 10/07/24 beginning at 12:35 PM, RN 1 relayed the POC for Patient #1 should have included fall safety measures and bleeding precautions and she verified the POC failed to include interventions for nursing goals. 3. Patient #2’s clinical record included a SOC assessment completed on 9/25/24 by RN 1. The assessment indicated the Patient was a risk for falls and the medication profile evidenced the patient was taking an anticoagulant. The POC for Patient #2 for the certification period of 9/25/24 to 11/23/24, created by RN 1, failed to evidence safety measures to address patient’s risk for falls and anticoagulant precautions and failed to include interventions for SN goals. During an interview on 10/07/24 beginning at 12:42 PM, RN 1 relayed the POC for Patient #2 should have included fall safety measures and bleeding precautions and she verified the POC failed to include interventions for nursing goals. 4. Patient #3’s clinical record included a recertification assessment completed on 8/16/24 by RN 1. The assessment indicated the Patient was a risk for falls and the medication profile evidenced the patient was taking an anticoagulant. The recertification POC for Patient #3 for the certification period of 8/21/24 to 10/19/24, created by RN 1, failed to evidence safety measures to address patient’s risk for falls and anticoagulant precautions and failed to include interventions for SN goals. During an interview on 10/07/24 beginning at 12:47 PM, RN 1 relayed the POC for Patient #3 should have included fall safety measures and bleeding precautions and she verified the POC failed to include interventions for nursing goals. 5. Patient #4’s clinical record included a recertification assessment completed on 8/22/24 by RN 1. The assessment indicated the Patient was a risk for falls and the medication profile evidenced the patient was taking an anticoagulant. The recertification POC for Patient #4 for the certification period of 8/24/24 to 10/22/24, created by RN 1, failed to evidence safety measures to address patient’s risk for falls and anticoagulant precautions and failed to include interventions for SN goals. During an interview on 10/07/24 beginning at 12:51 PM, RN 1 relayed the POC for Patient #4 should have included fall safety measures and bleeding precautions and she verified the POC failed to include interventions for nursing goals. 6. Patient #5’s clinical record evidenced an admission diagnosis of Type 2 Diabetes Mellitus and included a ROC assessment completed on 9/02/24 by RN 1. The ROC assessment indicated the Patient was a risk for falls and the medication profile evidenced the patient was taking diabetic medications. The recertification POC for Patient #5 for the certification period of 9/03/24 to 11/01/24, created by RN 1, failed to evidence safety measures to address patient’s risk for falls and diabetic precautions and failed to include interventions for SN goals. During an interview on 10/07/24 beginning at 12:55 PM, RN 1 relayed the POC for Patient #5 should have included fall safety measures and diabetic precautions and she verified the POC failed to include interventions for nursing goals. 7. Patient #6’s clinical record included a recertification assessment completed on 9/09/24 by RN 1. The assessment indicated the Patient was a risk for falls. The recertification POC for Patient #6 for the certification period of 9/14/24 to 11/12/24, created by RN 1, failed to evidence safety measures to address patient’s risk for falls and failed to include interventions for SN goals. During an interview on 10/09/24 beginning at 10:12 AM, RN 1 relayed the POC for Patient #6 should have included fall safety measures and she verified the POC failed to include interventions for nursing goals. 8. Patient #7’s clinical record included a recertification assessment completed on 9/09/24 by RN 1. The assessment indicated the Patient was a risk for falls. The recertification POC for Patient #7 for the certification period of 9/14/24 to 11/12/24, created by RN 1, failed to include all DME ordered for the patient, failed to evidence safety measures to address patient’s risk for falls and failed to include interventions for SN goals. During an interview on 10/09/24 beginning at 10:12 AM, RN 1 relayed the POC for Patient #7 should have included fall safety measures and she verified the POC failed to include all DME ordered for the patient and failed to include interventions for nursing goals. 410 IAC 17-13-1(a)(1)(C) 1. Agency policy “Plan of Care” indicated each patient should have an individualized, written plan of care which must include “… the frequency and duration of visits to be made … all medications and treatments … safety measures to protect against injury … patient-specific interventions … measurable outcomes and goals ….” 9. Patient #8’s clinical record included a start of care assessment completed on 7/12/24 by RN 2. The assessment indicated Patient was a risk for falls. Patient’s plan of care for the initial certification period of 7/12/24 – 9/09/24, created by RN 2, failed to evidence safety measures to address patient’s risk for falls. During an interview with Alternate Administrator on 10/08/24 beginning at 1:08 PM, she reported RN 2 was currently on leave from the agency. 10. Patient #9’s clinical record included a recertification visit conducted on 7/10/24 by RN 1. The assessment indicated Patient was at risk for falls. Patient’s plan of care for the recertification period of 7/15/24 – 9/12/24, created by RN 1, failed to evidence safety measures to address Patient’s risk for falls. The POC indicated Patient’s medications included Clopidogrel (a blood thinner used to decrease a patient’s risk of heart attack and/or stroke). The POC failed to evidence safety measures to address Patient’s increased risk for bleeding with use of this medication. The POC indicated the nursing goals included Patient’s pain would be “controlled” throughout the certification period. The POC failed to evidence an individualized, measurable goal for Patient’s pain. During an interview with RN 1 on 10/09/24 beginning at 10:12 AM, she reported she was unaware the plan of care should include safety measures to address a patient’s risk for falls and/or bleeding. When queried how she would measure the goal “[Patient’s] pain will be controlled,” she reported she would ask a patient if their pain was controlled, what their pain “numbers” were, and if pharmacological interventions were “controlling” pain.”

“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 interview, the home health agency failed to ensure all orders were recorded into the POC for 1 of 1 active wound clinic patient (Patient #5). Findings include: 1. Patient #5’s clinical record included updated wound care treatment orders received from Entity M dated 10/01/24. The clinical record failed to include the updated wound care orders effective 10/01/24. 2. During an interview on 10/09/24 beginning at 9:50 AM, the Alternate Administrator relayed all outside orders are sent to the RN who should be updating the POC immediately. 3. During an interview on 10/09/24 beginning at 10:12 AM, RN 1 relayed she updates orders as soon as she received them and after looking through her inbox, she relayed she had not received the updated 10/01/24 orders from the home health agency fax.”

“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 interview, the home health agency failed to ensure services were provided only as ordered by a physician or allowed practitioner for 6 of 7 active patient records reviewed (Patient #1, 3, 4, 5, 6 and 7). Findings include: 1. The undated agency policy “Physician Orders” indicated all medications, treatments and services provided to patient must be ordered by a physician and when the nurse or therapist receives a verbal order from the physician, he/she shall write the order as given and then read the order back to the physician verifying that the person receiving the order heard it correctly and interpreted the order correctly. 2. Patient #1’s clinical record included a POC for certification period 9/12/24 to 11/10/24 with orders for SN visit frequencies of 1 visit every week effective 9/15/24 and a PT visit frequency of 1 visit for Eval and treat effective 9/12/24. The record evidenced SN visits were performed on 9/16/24 and 9/23/24 and PT visits were performed on 9/18/24, 9/24/24 and 9/26/24. The clinical record for Patient #1 failed to include a verbal or signed written order for the SN and PT frequencies was obtained prior to the above visits performed. During an interview on 10/07/24 beginning at 12:35 PM, RN 1 relayed they thought they spoke with the physician during the SOC and she faxed the POC to the physician for signature. The clinical record for Patient #1 failed to include documentation of collaboration with the physician for SOC orders. During an interview on 10/07/24 beginning at 2:04 PM, PT 1 verified the clinical record for Patient #1 did not include any documentation with the physician and they did not create a verbal order for the PT POC and frequencies. 3. Patient #3’s clinical record included a recertification POC for certification period 8/21/24 to 10/19/24 with orders for an OT visit for Eval and treat. The record evidenced an OT evaluation visit was completed on 8/24/24 and OT visit was performed on 8/28/24. The clinical record for Patient #3 failed to include a verbal or signed written order for the OT frequencies was obtained prior to the above visits performed. During an interview on 10/07/24 beginning at 3:13 PM, OT 2 relayed he there were no changes in Patient #3’s needs and he faxed the OT frequency order to the physician for signature. 4. Patient #4’s clinical record included a recertification period of 8/24/24 to 10/22/24 with orders for SN visit 1 time a week for 8 weeks and PT and OT visit frequencies of 1 visit for Eval and treat. The record evidenced SN visits were performed on 8/28/24, 9/05/24, 9/12/24 and 9/18/24. PT visits were performed on 8/29/14, 9/04/24 and 9/11/24 and OT visits were performed on 8/29/14, 9/05/24, 9/14/24 and 9/19/24. The clinical record for Patient #4 failed to include a verbal or signed written order for the SN, PT and OT frequencies was obtained prior to the above visits performed. During an interview on 10/07/24 beginning at 12:51 PM, RN 1 relayed the POC for Patient #4 was faxed to physician for signature and a verbal order was not received. During an interview on 10/07/24 beginning at 2:04 PM, PT 1 verified the clinical record for Patient #4 did not include any documentation with the physician and they did not create a verbal order for the PT POC and frequencies. PT 2 relayed the PT recertification orders were faxed to the physician. During an interview on 10/07/24 beginning at 3:13 PM, OT 2 relayed he faxed the OT frequency order to the physician for signature. 5. Patient #5’s clinical record evidenced a ROC on 9/02/24 and a recertification period of 9/03/24 to 11/01/24 with orders for SN visits 2 times a week for 1 week and them 3 times a week for 8 weeks. The record evidenced a SN visit was performed on 9/03/24. The clinical record for Patient #5 failed to include a verbal or signed written order for the SN frequencies was obtained prior to the above visit performed. During an interview on 10/07/24 beginning at 12:55 PM, RN 1 relayed she was unsure if she collaborated with the physician for Patient #5’s ROC orders and the clinical record did not include any documentation. 6. Patient #6’s clinical record evidenced a recertification POC for 9/14/24 to 11/12/24 with orders for SN visit frequencies of 1 visit every month; PT visit frequency of 1 visit for Eval and treat per PT POC and OT visit frequency of 1 visit for Eval and treat per OT POC. The record evidenced an OT was performed on 9/15/24 and HHA visits were performed on 9/17/24, 9/18/24, 9/19/24, 9/24/24, 9/25/24, 9/26/24, 10/01/24, 10/02/24 and 10/03/24 without orders. The clinical record for Patient #6 failed to include a verbal or signed written order for the POC frequencies was obtained prior to the above visits performed and failed to include documentation with the physician regarding the OT frequency orders. During an interview on 10/09/24 beginning at 10:12 AM, RN 1 relayed they did not collaborate with the physician for Patient #6’s recertification POC and the POC was just faxed to the physician for signature. She was unsure why the HHA frequencies were not on the POC. During an interview on 10/09/24 beginning at 11:51 AM, OT 2 relayed he did not collaborate with the physician for the recertification, and he faxed the OT frequency order to the physician for signature. 7. Patient #7’s clinical record evidenced a recertification period of 9/14/24 to 11/12/24 with orders for SN visit frequencies of 1 visit every month; OT visit frequency of 1 visit for Eval and treat per OT POC and HHA visit 3 times a week for 7 weeks. The record evidenced an OT visit was performed on 9/21/24 and HHA visits were performed on 9/17/24, 9/18/24 and 9/19/24. The clinical record for Patient #7 failed to include a verbal or signed written order for the POC frequencies was obtained prior to the above visits performed and failed to include documentation with the physician regarding the OT frequency orders. During an interview on 10/09/24 beginning at 10:12 AM, RN 1 relayed they did not collaborate with the physician for Patient #7’s recertification POC and the POC was just faxed to the physician for signature. During an interview on 10/09/24 beginning at 11:51 AM, OT 2 relayed he did not collaborate with the physician for the recertification, and he faxed the OT frequency order to the physician for signature. 410 IAC 17-13-1(a)”

“Treatments and therapy services CFR(s): 484.60(e)(3) Any treatments to be administered by HHA personnel and personnel acting on behalf of the HHA, including therapy services. This Element is not met as evidenced by: Based on observation, record review, and interview, the home health agency failed to ensure the patient/caregiver was provided with written POC information including all treatments administered by the agency for 3 of 3 home visits observed (Patient #1, 2, and 3). Findings include: 1. Patient #1’s clinical record evidenced a SOC on 9/12/24. During a home visit observation with Patient #1 on 10/03/24 beginning at 3:27 PM, the home health agency’s folder was reviewed and failed to evidence the home health agency had provided Patient #1 a copy of the current POC and treatment orders. 2. Patient #2’s clinical record evidenced a SOC on 9/25/24. During a home visit observation with Patient #2 on 10/04/24 beginning at 8:50 AM, the home health agency’s folder was reviewed and failed to evidence the home health agency had provided Patient #2 a copy of the current POC and treatment orders. 3. Patient #3’s clinical record evidenced a SOC on 4/23/24. During a home visit observation with Patient #3 on 10/04/24 beginning at 1:03 PM, the home health agency’s folder was reviewed and failed to evidence the home health agency had provided Patient #3 a copy of the current recertification POC and treatment orders. 4. During an interview on 10/08/24 beginning at 1:49 PM, the Alternate Administrator relayed the patient should be given a copy of the POC at the next visit after the POC has been created.”

“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 observation, document review and interview, the home health agency failed to provide the patient and/or caregiver with accurate clinical manager information for 3 of 3 active patients with home visit observations (Patient #1, 2 and 3). Findings include: 1. During a home visit observation with Patient #1 on 10/03/24 beginning at 3:27 PM, the home health agency’s folder was reviewed and failed to evidence the correct name and contact information of the clinical manager. 2. During a home visit observation with Patient #2 on 10/04/24 beginning at 8:50 AM, the home health agency’s folder was reviewed and failed to evidence the correct name and contact information of the clinical manager. 3. During a home visit observation with Patient #3 on 10/04/24 beginning at 1:03 PM, the home health agency’s folder was reviewed and failed to evidence the correct name and contact information of the clinical manager. 4. During an interview on 10/08/24 beginning at 8:23 AM, the Clinical Manager (person who was identified during the entrance conference as the Clinical Manager) relayed that she was just a consultant for the home health agency. She stated she was not the Clinical Manager and was not involved in the daily operations of the agency. 5. During an interview on 10/08/24 beginning at 1:49 PM, the Alternate Administrator verified the clinical manager listed in the home folder was inaccurate and indicated the agency folder in the patient’s home should be corrected to include the current clinical manager’s name and contact information.”

“Development and evaluation of plan of care CFR(s): 484.75(b)(2) Development and evaluation of the plan of care in partnership with the patient, representative (if any), and caregiver(s); This Element is not met as evidenced by: Based on observation, record review and interview, the OT failed to ensure a recertification OT POC was created for 4 of 4 patients who received OT services with a recertification period (Patient #3, 4, 6 and 7). Findings include: 1. The undated agency policy “Plan of Care” indicated each patient must receive home health services that are written in an individualized plan of care which is established, periodically reviewed, and signed by a doctor and all patient care orders, including verbal orders, must be recorded in the plan of care. The plan of care must be reviewed and revised by the physician who is responsible for the home health plan of care and the HHA as frequently as the patient’s condition or needs require, but no less frequently than once every 60 days. 2. Patient #3’s clinical record evidenced a SOC on 4/23/24 and included a recertification POC for the certification period 8/21/24 to 10/19/24. The POC included orders for an OT re-evaluation and treat per OT POC. The record evidenced OT Routine visits were completed on 8/10/24 and 8/24/24. The record failed to evidence an OT recertification POC was created and failed to include documentation of a verbal or written order for OT services to continue. During an interview on 10/09/24 beginning at 11:51 AM, OT 2 relayed they missed completing the recertification OT POC for Patient #3. 3. Patient #4’s clinical record evidenced a SOC on 5/02/23 and included a recertification POC for the certification period 8/24/24 to 10/22/24. The POC included orders for an OT re-evaluation and treat per OT POC. The record evidenced an OT Routine visit was completed on 8/17/24. The record failed to evidence an OT recertification POC was created and failed to include documentation of a verbal or written order for OT services to continue. During an interview on 10/09/24 beginning at 11:51 AM, OT 2 relayed they missed completing the recertification OT POC for Patient #4. 4. Patient #6’s clinical record evidenced a SOC on 3/18/24 and included a recertification POC for the certification period 9/14/24 to 11/12/24. The record evidenced an OT Routine visit was completed on 9/07/24. The record failed to evidence an OT recertification POC was created and failed to include documentation of a verbal or written order for OT services to continue. During an interview on 10/09/24 beginning at 11:51 AM, OT 2 relayed they missed completing the recertification OT POC for Patient #6. 5. Patient #7’s clinical record evidenced a SOC on 3/18/24 and included a recertification POC for the certification period 9/14/24 to 11/12/24. The record evidenced an OT Routine visit was completed on 8/31/24. The record failed to evidence an OT recertification POC was created and failed to include documentation of a verbal or written order for OT services to continue. During an interview on 10/09/24 beginning at 11:51 AM, OT 2 relayed they missed completing the recertification OT POC for Patient #6. 410 IAC 17-14-1(b)”

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure all OT visit note documentation was completed accurately for 4 of 4 active patient records reviewed who have received OT services for at least 30 days (Patient’s #3, 4, 6 and 7). Findings include: 1. Patient #3’s clinical record included documentation of OT Supervisory visits completed on 8/11/24 and 8/25/24. OT 2 failed to complete the OT Supervisory visits during the OT visits on 8/10/24 and 8/24/24 and the clinical record failed to include documentation of the date discrepancies. 2. Patient #4’s clinical record included documentation of an OT Supervisory visit completed on 8/18/24. OT 2 failed to complete the OT Supervisory visit during the OT visit on 8/17/24 and the clinical record failed to include documentation of the date discrepancy. 3. Patient #6’s clinical record included documentation of an OT Supervisory visit completed on 8/25/24. OT 2 failed to complete the OT Supervisory visit during the OT visit on 8/24/24 and the clinical record failed to include documentation of the date discrepancy. 4. Patient #7’s clinical record included documentation of an OT Supervisory visit completed on 9/02/24. OT 2 failed to complete the OT Supervisory visit during the OT visit on 8/31/24 and the clinical record failed to include documentation of the date discrepancy. 5. During an interview on 10/07/24 beginning at 3:13 PM, OT 2 relayed he had forgot to document the OT Supervisory visits during the OT visits and he was unable to backdate the supervisory visit notes to reflect the actual visit date. 410 IAC 17-14-1(c)(5)”

“Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This Element is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the PT POC was reviewed with the attending physician and/or a verbal or written order was obtained prior to visits being performed for 5 of 5 active patient records reviewed who received PT services (Patient #1, 2, 3, 4 and 6) and failed to ensure the OT collaborated with the attending physician and/or a verbal or written order was obtained prior to visits being performed for 6 of 6 active patient records reviewed who received OT services (Patient #1, 2, 3, 4, 6 and 7). Findings include: 1. The undated agency policy “Plan of Care” indicated each patient must receive home health services that are written in an individualized plan of care which is established, periodically reviewed, and signed by a doctor and all patient care orders, including verbal orders, must be recorded in the plan of care. The plan of care must be reviewed and revised by the physician who is responsible for the home health plan of care and the HHA as frequently as the patient’s condition or needs require, but no less frequently than once every 60 days. 2. Patient #1’s clinical record evidenced a SOC on 9/12/24. A PT Evaluation was completed on 9/18/24 by PT 1 and an OT Evaluation was completed on 9/27/24 by OT 2. The record failed to include documentation with the physician and failed to include documentation of a verbal or written order for the PT and OT POC’s and frequency orders. During an interview on 10/07/24 beginning at 2:04 PM, PT 1 verified the clinical record for Patient #1 did not include any documentation with the physician and they did not create a verbal order for the PT POC and frequencies. During an interview on 10/07/24 beginning at 3:13 PM, OT 2 relayed he only collaborated with the physician if there were questions, and he faxed the OT POC to the physician for signature. 3. Patient #2’s clinical record evidenced a SOC on 9/25/24. An OT Evaluation was completed on 9/26/24 by OT 2 and a PT Evaluation was completed on 9/27/24 by PT 1. The record failed to include documentation with the physician and failed to include documentation of a verbal or written order for the OT and PT POC’s and frequency orders. During an interview on 10/07/24 beginning at 2:04 PM, PT 1 verified the clinical record for Patient #2 did not include any documentation with the physician and they did not create a verbal order for the PT POC and frequencies. PT 2 relayed they faxed the PT POC to the physician a couple days after the evaluation visit. During an interview on 10/07/24 beginning at 3:13 PM, OT 2 relayed he only collaborated with the physician if there were questions, and he faxed the OT POC to the physician for signature. 4. Patient #3’s clinical record evidenced a SOC on 4/23/24 and a recertification period of 8/21/24 to 10/19/24. OT and PT Evaluations were completed on 8/24/24 by OT 2 and PT 1. The record failed to include documentation with the physician and failed to include documentation of a verbal or written order for the OT and PT POC’s and frequency orders. During an interview on 10/07/24 beginning at 2:04 PM, PT 1 verified the clinical record for Patient #3 did not include any documentation with the physician and they did not create a verbal order for the PT POC and frequencies. PT 2 relayed the PT recertification orders were faxed to the physician. During an interview on 10/07/24 beginning at 3:13 PM, OT 2 relayed he there were no changes in Patient #3’s needs and he faxed the OT frequency order to the physician for signature. 5. Patient #4’s clinical record evidenced a SOC on 5/02/23 and a recertification period of 8/24/24 to 10/22/24. An OT Evaluation was completed on 8/17/24 by OT 2 and a PT Evaluation was completed on 8/21/24 by PT 1. The record failed to include documentation with the physician and failed to include documentation of a verbal or written order for the OT and PT POC’s and frequency orders. During an interview on 10/07/24 beginning at 2:04 PM, PT 1 verified the clinical record for Patient #4 did not include any documentation with the physician and they did not create a verbal order for the PT POC and frequencies. PT 2 relayed the PT recertification orders were faxed to the physician. During an interview on 10/07/24 beginning at 3:13 PM, OT 2 relayed he faxed the OT frequency order to the physician for signature. 6. Patient #6’s clinical record evidenced a SOC on 3/18/24 and a recertification period of 9/14/24 to 11/12/24. An OT Evaluation was completed on 9/07/24 by OT 2 and a PT Evaluation was completed on 9/14/24 by PT 1. The record failed to include documentation with the physician and failed to include documentation of a verbal or written order for the OT and PT POC’s and frequency orders. During an interview on 10/09/24 beginning at 10:36 AM, PT 1 relayed he thought he collaborated with the physician, however, the clinical record for Patient #6 did not include any documentation with the physician. PT 2 relayed the PT recertification orders were faxed to the physician. During an interview on 10/09/24 beginning at 11:51 AM, OT 2 relayed he did not collaborate with the physician for the recertification, and he faxed the OT frequency order to the physician for signature. 7. Patient #7’s clinical record evidenced a SOC on 3/18/24 and a recertification period of 9/14/24 to 11/12/24. An OT Evaluation was completed on 8/31/24 by OT 2. The record failed to include documentation with the physician and failed to include documentation of a verbal or written order for the OT frequency orders. During an interview on 10/09/24 beginning at 11:51 AM, OT 2 relayed he did not collaborate with the physician for the recertification, and he faxed the OT frequency order to the physician for signature. 410 IAC 17-14-1(a)(1)(G)”

“A qualified HH aide successfully completed: CFR(s): 484.80(a)(1)(i-iv) A qualified home health aide is a person who has successfully completed: (i) A training and competency evaluation program as specified in paragraphs (b) and (c) respectively of this section; or (ii) A competency evaluation program that meets the requirements of paragraph (c) of this section; or (iii) A nurse aide training and competency evaluation program approved by the state as meeting the requirements of §483.151 through §483.154 of this chapter, and is currently listed in good standing on the state nurse aide registry; or (iv) The requirements of a state licensure program that meets the provisions of paragraphs (b) and (c) of this section. This Element is not met as evidenced by: Based on personnel file review, policy review, and interview, the home health agency failed to ensure the HHA was currently certified to provide home health services for 1 of 1 HHA personnel file reviewed (HHA 1), which had the potential to affect 12 of 12 patients who received services during the time frame the aide was not certified (Patients #6, 7, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20). Findings include: 1. Agency policy “Competency Evaluation of Home Care Staff” indicated employees should be “licensed, registered, or certified as required by law, policy, or standards of practice.” 2. A list of current agency employees indicated HHA 1 was the only current HHA employed by the agency. 3. HHA 1’s personnel file indicated a hire date of 4/02/19. She was trained by the agency and issued a HHA certification by the State of Indiana on 6/04/19. The expiration date for the aide’s certification was 6/04/23. The file failed to evidence an active certification for HHA 1. 4. Review of the State of Indiana’s license and certification verification website, www.mylicense.IN.gov, on 10/09/24 evidenced the employee’s home health aide certification had expired on 6/04/23. The website failed to evidence HHA 1’s certification was renewed until 10/08/24. 5. A list of patients who received home health aide services from HHA 1 between 6/05/23 – 10/07/24 evidenced 12 patients received HHA services from the aide while she was not certified. These included Patients #6, 7, 11, 12, 13, 14, 15, 16, 17, 18, 19, and 20. 6. During an interview with HHA 1 on 10/09/24 beginning at 4:39 PM, she reported she was unaware her home health aide certification had expired on 6/04/23. 7. During an interview with Alternate Administrator on 10/09/24 beginning at 4:45 PM, she reported staff were responsible for ensuring their license and/or certification was kept up to date. 410 IAC 17-14-1(l)(1)(B)”

“Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This Element is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the HHA provided services as ordered in the HHA POC for 5 of 5 patient records reviewed who have received HHA services for at least 2 weeks (Patient #6, 7, 11, 12 and 13). Findings include: 1. The undated policy “Home Health Aide Care Plan” indicated the HHA cannot be responsible for performing any procedure that is not assigned to him/her in writing or that is beyond his/her ability. 2. Patient #6’s clinical record for certification period 9/14/24 to 11/12/24 included a HHA care plan which indicated Patient #6 was to receive HHA visits 3 times a week. The aide care plan indicated the patient was to receive a shower/bath every visit. The HHA visit notes for 9/18/24, 9/25/24 and 10/02/24 failed to include Patient #6 receiving a shower/bath during the HHA visits. HHA 1 failed to document the reason for not bathing Patient # during the HHA visits. The HHA visit note for 10/03/24 indicated HHA 1 trimmed Patient #6’s hair. HHA 1 failed to document the reason for not bathing Patient #6 during the HHA visits and failed to follow the HHA care plan. During an interview on 10/09/24 beginning at 9:38 AM, HHA 1 relayed they are not a licensed beautician and shouldn’t have trimmed Patient #6’s hair and she relayed she only gives Patient #6 a shower on her assigned assisted living facility (ALF) shower days. During an interview on 10/09/24 beginning at 9:50 AM, the Alternate Administrator relayed the HHA should be documenting if a shower has not been given on the aide visit note and the HHA should not be cutting a patient’s hair when she is not licensed. 3. Patient #7’s clinical record for certification period 9/14/24 to 11/12/24 included a HHA care plan which indicated Patient #7 was to receive HHA visits 3 times a week. The aide care plan indicated the patient was to receive a shower/bath every visit. The HHA visit notes for 9/17/24, 9/18/24, 9/19/24, 9/24/24, 9/25/24, 9/26/24, 10/01/24, 10/02/24 and 10/03/24 failed to include Patient #7 receiving a shower/bath during the HHA visits. HHA 1 failed to document the reason for not bathing Patient #7 during the HHA visits. During an interview on 10/09/24 beginning at 9:38 AM, HHA 1 relayed Patient #7 prefers to bathe in the evening and the ALF staff give the patient the shower. 4. Patient #11’s clinical record for certification period 8/28/24 to 10/26/24 included a HHA care plan which indicated Patient #11 was to receive HHA visits 2 times a week. The HHA visit notes for 8/12/24, 8/16/24, 8/19/24, 8/23/24, 8/26/24, 8/30/24, 9/02/24, 9/06/24, 9/09/24, 9/16/24, 9/20/24, 9/23/24, 9/30/24 and 10/04/24 indicated HHA 1 took Patient #11 to the gym, park and shopping. HHA 1 failed to follow the aide care plan and HHA scope of practice. During an interview on 10/09/24 beginning at 9:38 AM, HHA 1 relayed Patient #11’s parents allow her to transport the patient to activities and to get snacks. During an interview on 10/09/24 beginning at 9:50 AM, the Alternate Administrator relayed they were unsure if transporting a patient was an allowable HHA activity. 5. Patient #12’s clinical record for certification period 8/16/24 to 10/14/24 included a HHA care plan which indicated Patient #12 was to receive HHA visits 3 times a week. The aide care plan indicated the patient was to receive a shower 1 time a week and partial bath the other visits of the week. The HHA visit notes for 8/13/24, 8/14/24, 8/15/24, 8/20/24, 8/21/24, 8/22/24, 8/27/24, 8/28/24, 8/29/24, 9/03/24, 9/04/24, 9/05/24, 9/10/24, 9/11/24, 9/12/24, 9/17/24, 9/18/24, 9/19/24, 9/24/24, 9/25/24, 9/26/24, 10/01/24, 10/02/24 and 10/03/24 failed to include Patient #12 receiving a shower/partial bath during the HHA visits. HHA 1 failed to document the reason for not bathing Patient #12 during the HHA visits. During an interview on 10/09/24 beginning at 9:38 AM, HHA 1 relayed Patient #12 prefers to bathe in the evening and the ALF staff give the patient the shower. 6. Patient #13’s clinical record for certification period 9/10/24 to 11/08/24 included a POC and aide care plan which indicated Patient #13 was to receive HHA visits 3 times a week. HHA visits were performed on 9/10/24, 9/11/24, 9/12/24, 9/17/24, 9/18/24, 9/19/24, 9/24/24, 9/25/24, 9/26/24, 10/01/24, 10/02/24 and 10/05/24. The POC for certification period 9/10/24 to 11/08/24 failed to include orders for HHA visits. During an interview on 10/09/24 beginning at 9:50 AM, the Alternate Administrator relayed the HHA frequencies should have been listed on the POC. During an interview on 10/09/24 beginning at 10:12 AM, RN 1 relayed the HHA frequencies should be on the POC and she was unsure why they were missing. 7. During an interview on 10/09/24 beginning at 9:50 AM, the Alternate Administrator relayed the HHA should be documenting if the HHA is offering the shower and the reason it was not given.”

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This Element is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the RN supervised the HHA every 14 days for 2 of 2 active clinical records reviewed of patients receiving skilled services and HHA services (Patient #6 and 7). Findings include: 1. The undated agency policy “Home Health Aide Supervision” indicated when skilled services are being provided to a patient, a RN/Therapist must make a supervisory visit to the patient’s residence at least every fourteen (14) days to assess relationships and determine whether goals are being met. 2. Patient #6’s clinical record included a POC for the certification period 9/14/24 to 11/12/24 and included orders for SN, PT, OT and HHA services. The record evidenced the RN performed HHA supervisory visits on 7/11/24 and 9/09/24. The clinical record failed to evidence RN 1 performed HHA supervisory visits every 14 days. During an interview on 10/09/24 beginning at 10:12 AM, RN 1 relayed HHA supervisory visits should be done every 30 days. When queued, she stated she did not perform HHA supervisory visits for Patient #6 every 14 days. 3. Patient #7’s clinical record included a POC for the certification period 9/14/24 to 11/12/24 and included orders for SN, OT and HHA services. The record evidenced the RN performed HHA supervisory visits on 7/11/24 and 9/09/24. The clinical record failed to evidence RN 1 performed HHA supervisory visits every 14 days. During an interview on 10/09/24 beginning at 10:12 AM, RN 1 relayed HHA supervisory visits should be done every 30 days. When queued, she stated she did not perform HHA supervisory visits for Patient #7 every 14 days. 4. During an interview on 10/09/24 beginning at 9:50 AM, the Alternate Administrator relayed supervisory visits should be done every 30 days. 410 IAC 17-14-1(h)”

“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 record review and interview, the agency failed to ensure the Administrator was responsible for the day-to-day operations of the agency for 1 of 1 agency. Findings include: 1. During the entrance conference on 10/03/24 beginning at 9:58 AM, the Alternate Administrator listed Admin 1 as the Administrator of the home health agency. Review of the form CMS 1572, completed by the Alternate Administrator on 10/04/24 evidenced Admin 1 listed as the Administrator. The home health agency failed to have an Administrator that was responsible for the day-to-day operations of the agency. 2. During an interview on 10/04/24 beginning at 3:48 PM, COTA 1 relayed Admin 1 was the Administrator of the agency. 3. During an interview on 10/08/24 beginning at 8:23 AM, Admin 3 (who is listed as the Clinical Manager) relayed she thought Admin 2 was the Administrator of the agency. 4. During an interview on 10/09/24 beginning at 5:06 PM, Admin 1 (who is listed as the Administrator of the agency) relayed Admin 2 was the current Administrator of the agency. 410 IAC 17-12-1(c)(1)”

“Ensure clinical manager is available CFR(s): 484.105(b)(1)(iii) (iii) Ensure that a clinical manager as described in paragraph (c) of this section is available during all operating hours; This Element is not met as evidenced by: Based on record review and interview the Administrator failed to ensure a clinical manager was available during operating hours for 1 of 1 home health agency surveyed. Findings include: 1. During the entrance conference on 10/03/24 beginning at 9:58 AM, the Alternate Administrator listed Admin 3 as the Clinical Manager of the home health agency. Review of CMS provider details, last updated on 4/27/23, evidenced Admin 3 as the Clinical Manager of the agency. Review of the home health agency organizational chart evidenced Admin 3 as the Clinical Manager of the agency. 2. During an interview on 10/07/24 beginning at 12:58 PM, RN 1 relayed they were unsure when the Clinical Manager (Admin 3) was available. 3. During an interview on 10/08/24 beginning at 8:23 AM, Admin 3 (who is listed as the Clinical Manager) relayed she was only available as a consultant, and she thought Admin 2 was the Clinical Manager of the agency. 4. During an interview on 10/09/24 beginning at 5:06 PM, Admin 1 (who is listed as the Administrator of the agency) relayed Admin 2 was the current Clinical Manager of the agency. 410 IAC 17-12-1(d)”

“Contact info for primary care practitioner CFR(s): 484.110(a)(5) Contact information for 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; and This Element is not met as evidenced by: Based upon record review and interview, the home health agency failed to ensure the accuracy of the correct attending physician for 2 of 11 records reviewed (Patient #5 and 11). Findings include: 1. Patient #5’s clinical record included a POC for the certification period of 9/03/24 to 11/01/24 which indicated the patient’s attending physician was Physician L. Physician L’s name was marked through on the POC and Physician P signed the POC. During an interview on 10/07/24 beginning at 12:55 PM, RN 1 relayed she was unsure why the POC had Physician L listed as the attending physician. 2. Patient #11’s clinical record included a POC for the certification period of 8/28/24 to 10/26/24 which indicated the patient’s attending physician was Physician L. Physician L’s name was marked through on the POC and the POC was signed by another practitioner (unable to read). During an interview on 10/07/24 beginning at 12:55 PM, RN 1 relayed she was unsure why the POC had Physician L listed as the attending physician. She relayed the POC was faxed to Physician P for approval. 3. A telephone call was placed to Physician P’s office on 10/07/24 at 11:55 AM to attempt to verify the attending physician for Patient #5 and 11 with no return call received. 4. During an interview on 10/08/24 beginning at 12:12 PM, the Alternate Administrator was unsure why the electronic medical record (EMR) system was pulling Physician L’s name to the POC’s. She relayed she would contact the EMR system to inquire about this. 410 IAC 17-15-1(a)(2)”