Northwest Home Health Care Inc.

“Discharge or Transfer Summary Content CFR(s): 484.58(b)(1) Standard: Discharge or transfer summary content. The HHA must send all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure the discharge summary was sent to the physician within 5 business days of discharge per the agency’s policy in 1 of 1 closed record review of a patient discharged due to goals met. (Patient #6) The findings include: An undated policy titled “Discharge and Transfer” indicated the agency would send a discharge summary to the primary care practitioner within 5 business days of discharge from the agency. A clinical record review for Patient #6 evidenced a Discharge Summary which indicated the Patient discharged on 04/01/2025. The electronic health record’s (EHR) activity log indicated the discharge summary was not completed and signed by the CM until 04/08/2025. On 05/08/2025, at 1:25 PM, the CM indicated the Discharge Summary was not sent to the physician prior to the completion of the document on 04/08/2025, which was greater than 5 days from the date of discharge from the agency.”

“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’s governing body failed to approve the frequency and detail of the data collection for the Quality Assessment and Performance Improvement Program in 1 of 1 agency. Findings include: 1. An undated policy, titled, “Quality Assurance Performance Improvement Program,” indicated the Quality Assurance and Performance Improvement Program activities were communicated to the governing body. 2. A Governing Body Board Members Meeting Minutes, dated 06/27/2024, failed to include documentation of the governing body’s approval of frequency and detail of the data collection for the Quality Assessment and Performance Improvement Program. During an interview on 05/08/2025, beginning at 12:30 PM, the Administrator, Administrative Staff 1 indicated there was no documentation of the governing body’s approval of the performance improvement program frequency of data collection. 410 IAC 17 17-12-2(a)”

“Program activities CFR(s): 484.65(c) (1) The HHA’s performance improvement activities must— (i) Focus on high risk, high volume, or problem-prone areas; (ii) Consider incidence, prevalence, and severity of problems in those areas; and (iii) Lead to an immediate correction of any identified problem that directly or potentially threaten the health and safety of patients. This Standard is not met as evidenced by: Based on record review, and interview, the agency’s performance improvement activities failed to focus on high volume of hospital admissions to consider the severity of the problem that would lead to a correction of the identified problem in 1 of 1 agency. Findings include: An undated policy, titled, “Quality Assurance Performance Improvement Program,” indicated the agency would maintain an ongoing agency wide quality assessment and performance improvement program that would focus on high risk, high volume, and problem prone areas. The policy indicated the agency would take action aimed at performance improvement and after implementing the actions the agency would measure its success and track performance to ensure that improvements were sustained. The policy indicated the performance improvement activities would track adverse patient events, analyze their causes and trends, focus on high risk, high volume, or problem prone areas that would lead to an immediate correction of identified problems that potentially threaten the health and safety of patients, implement preventive actions and develop a plan of correction to prevent events from reoccurring. A Census Report, received on 05/06/2025, indicated the agency’s patient unduplicated census for the last 12 months of skilled patients was 98 with an active patient census of 25. A Hospital Admission Tracking Log, for 05/08/2024 to 05/06/2025, indicated 38 patient hospitalizations, 39% of patient census, hospital that included 8 hospital admissions for 01/01/2025 to 05/06/2025. A Quality Assessment and Performance Improvement Program review on 05/08/2025, failed to evidence the agency identified hospital admission high volume rate to analyze and implement improvement activities that would lead to corrective actions, and after implementing those actions would ensure the improvements were sustained. During an interview on 05/08/2025, beginning at 12:30 PM, the Administrator, Administrative Staff 1, indicated the agency did not implement an agency plan for the elevated hospitalization rate.”

“Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure the timely documentation of clinical notes in 1 of 3 active clinical records reviewed with PT services. (Patient #3) The findings include: A clinical record review for Patient #3 evidenced Home Health Discharge Orders upon discharge from Entity 2 dated 04/28/2025 which indicated home health services were to include PT. The clinical record review on 05/06/2025 failed to evidence any PT visit notes. On 05/06/2025, at 4:54 PM, the CM indicated PT completed an assessment on 05/01/2025 which was not yet documented. 410 IAC 17-15-1(b)”

“Written notice of patient’s rights CFR(s): 484.50(a)(1)(i) (i) Written notice of the patient’s rights and responsibilities under this rule, and the HHA’s transfer and discharge policies as set forth in paragraph (d) of this section. Written notice must be understandable to persons who have limited English proficiency and accessible to individuals with disabilities; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the written notice of Patient Rights were provided in a language the Patient/legal representative understood in 1 of 1 clinical record reviewed with Spanish as the primary language. (Patient #3) The findings include: A clinical record review for Patient #3 evidenced a comprehensive assess for the SOC dated 04/11/2025 completed by RN 4 which indicated the Patient’s preferred language was Spanish. The written notice of Patient Rights signed by the Patient on 04/11/2025 failed to be provided in Spanish. On 05/07/2025, at 4:20 PM, RN 4 indicated the Patient and Patient’s spouse spoke Spanish and the written notice of Patient Rights were not provide in Spanish. On 05/06/2025, at 4:27 PM, the CM indicated the Patient Rights should have been provided in Spanish and would look for them. No additional documentation or information was provided prior to survey exit on 05/08/2025.”

“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 agency failed to ensure medication interaction concerns identified during a patient’s medication review were reported to the physician in 5 of 5 active clinical records reviewed (Patient #1, 2, 3, 4, 5). Findings include: A review of the clinical record for Patient #1 evidenced a comprehensive assessment dated 04/07/2025 for the recertification period of 04/09/2025 through 06/07/2025 signed by RN 3 and indicated drug interactions were present but contained no information regarding what medications or interactions were found to have issues or how the Physician was notified and the Physician’s response. During an interview on 05/07/2025 at 2:15 PM the administrator reported drug regimen reviews were done in the office after the RN submitted the medication list to them and was not completed by the RN conducting the comprehensive assessment. 1. An undated policy, titled, “Physician Orders,” indicated when a nurse or therapist received a verbal order from a physician, the clinician would write the order to include the date, specific order and be signed by the title of the person that received the order, and all physician orders would be maintained in the clinical record. 2. An undated policy, titled, “Mediation Profile,” indicated at the time of admission the admitting professional would check all medications to identify possible adverse effects, significant side effects and report the identified problems to the physician. 3. A Comprehensive Assessment for Patient #2, dated 03/18/2025, indicated drug interactions were identified, and the physician and clinical manager were notified, and the physician was already aware of medication interactions and the risk but had determined that it was the best course of treatment for the patient and had taken appropriate precautions and was monitoring the patient for potential complications. The clinical record failed to evidence documentation the physician was notified of specific drug interactions. An Undated Medication Checker indicated 9 medication interactions were found between clonazepam (anti-anxiety medication) and midodrine (medication to treat low blood pressure), clonazepam and risperidone (antipsychotic medication), sertraline (antidepressant medication) and risperidone, sertraline and diclofenac (anti-inflammatory medication), risperidone and midodrine, diclofenac and fludrocortisone (steroid medication). The Medication Checker failed to indicate the physician was notified of the specific medication interactions. 4. A Comprehensive Assessment for Patient #4, dated 04/16/2025, indicated drug interactions were identified, and the physician and clinical manager were notified, and the physician was already aware of medication interactions and the risk but had determined that it was the best course of treatment for the patient and had taken appropriate precautions and was monitoring the patient for potential complications. An internet search of drugs.com indicated major drug interactions between buspirone (anti-anxiety medication), buspirone and tramadol (pain medication), aspirin and Eliquis (blood thinner), and buspirone and Imdur (blood vessel dilator). The clinical record failed to indicate documentation the physician was notified of specific drug interactions. 5. A Comprehensive Assessment for Patient #5, dated 03/24/2025, indicated drug interactions were identified, the physician and clinical manager were notified, and the physician was already aware of the medication interactions between Tradjenta (diabetic medication) and aspirin and the physician determined that that was the best course of treatment for the patient and had taken appropriate precautions and was monitoring the patient for potential complications. An internet search of drugs.com indicated major drug interactions between Tacrolimus (immunosuppression medication) and Venclexta (blood cancer medication). The clinical record failed to evidence documentation the physician was notified of the specific drug interactions. 6. During an interview on 05/08/2025, beginning at 12:15 PM, Registered Nurse [RN] 1 indicated the electronic medical record would populate medication interactions, she would notify the physician of the interactions by calling the physician’s office and would document if a message was left, and if a message was left, she would document the follow up response from the physician. 4 410 IAC 17-14-1(a)(1)(B) * A clinical record review for Patient #3 evidenced a comprehensive assessment for the SOC dated 04/11/2025 and a comprehensive assessment for the resumption of care dated 04/29/2024, both completed by RN 4, which indicated a medication review was completed and issues were identified. The comprehensive assessments indicated drug interactions were identified and failed to evidence which drugs interacted. The medication profile dated 04/11/2025 was signed by the CM, and the medication profile dated 04/29/2025 was signed by the Alternate CM. Neither medication profiles were signed by the RN conducting the comprehensive assessment at the time of the assessment. On 05/07/2025, at 3:19 PM, RN 4 indicated she was unaware of what the medication interactions were. On 05/07/2025, at 4:23 PM, the CM indicated either the CM or the Alternate CM reviewed the medications for interactions once the assessing RN submitted the comprehensive assessment.”

“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 agency failed to ensure the comprehensive assessment was completed within 48 hours of return home from the hospital in 1 of 1 active clinical record reviewed with a hospitalization. (Patient #3) The findings include: A clinical record review for Patient #3 evidenced a Physician Order dated 04/29/2025 which indicated the agency resumed home care services after the Patient returned home from the hospital. The clinical record failed to evidence a revised comprehensive assessment following the resumption of care at time of review on 05/06/2025. On 05/06/2025, at 3:59 PM, the CM indicated the nurse had not yet completed the comprehensive assessment.”

“Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA’s internal policies. (4) When services are provided on the basis of a physician or allowed practitioner’s verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA’s policies, must document the orders in the patient’s clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA’s internal policies. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure verbal orders were written and sent to the physician for signature in 1 of 1 active clinical records reviewed with a hospitalization. (Patient #3) The findings include: A clinical record review for Patient #3 evidenced Home Health Discharge Orders upon discharge from Entity 2 dated 04/28/2025 which indicated home health services were to include SN, PT, and OT and included the medications to continue at home. The POC for the resumption of care for certification period 04/11/2025-06/09/2025 signed and dated by RN 4 on 04/29/2025 was not yet signed by the physician. On 05/07/2025, at 4:20 PM, the CM indicated she spoke to the nurse practitioner for the physician responsible for the POC to receive the resumption order for home health. The CM indicated she did not document the verbal order received and indicated the POC upon resumption dated 04/29/2025 was not sent to the physician for signature until 05/06/2025 and was not yet returned signed. 410 IAC 17-14-1(a)(H)”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on record review and interview, the agency failed to notify the physician of a medication discrepancy in 1 of 1 active clinical record reviewed with a hospitalization. (Patient #3) The findings include: A clinical record review for Patient #3 evidenced Home Health Discharge Orders upon discharge from Entity 2 dated 04/28/2025 which indicated the medications to continue at home included cyanocobalamin (vitamin B12) 2,000 micrograms (mcg) daily and docusate sodium (stool softener) 100 milligrams (mg) twice daily for 10 days. The POC for the resumption of care for certification period 04/11/2025-06/09/2025 signed and dated by RN 4 on 04/29/2025 failed to evidence the docusate sodium to stop after 10 days and indicated 5,000 mcg of vitamin B12 was to be taken daily. The clinical record failed to evidence the agency notified the physician of the discrepancy of the medication orders with docusate sodium and vitamin B12. On 05/07/2025, at 4:20 PM, RN 4 indicated she left a message for the physician but did not hear back from the physician or physician’s representative regarding the resumption orders. On 05/08/2025, beginning at 4:23 PM, the CM indicated she spoke to the physician regarding the resumption orders but did not see the discrepancies with docusate sodium and vitamin B 12, so she did not notify the physician of the medication discrepancies. 410 IAC 17-13-1(a)(2)”

“Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This Element is not met as evidenced by: Based on record review, and interview, the agency failed to integrate services to assure the identification of patient needs that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines in 1 of 1 active clinical records reviewed with a home health aide (Patient #2). Findings include: 1. An undated policy titled, “Coordination of Patient Services,” indicated the primary nurse would be responsible for the coordination of services to assigned patients for the ongoing evaluation of the patient’s needs, and efficient communication with all care providers would be maintained to ensure prompt transmission of significant information that could require action. 2. A Plan of Care, for certification period 03/19/2025 to 05/17/2025, for Patient #2, with a start of care date of 11/19/2024, indicated Patient received developmental disability assistance care from Entity 1, a home care provider, 5 hours per day 2 days per week. The Plan of Care indicated the agency would provide home health aide services 2 times per week. A Professional Services Order from Entity 1, dated 08/12/2022, indicated Patient #2 was to receive home health aide services 5 hours per day 5 days per week from Entity 1. The clinical record review failed to evidence further documentation of coordination of care or delineation of care with Entity 1 after 08/12/2022. During an interview on 05/08/2025, beginning at 1:00 PM, the Administrator, Administrative Staff 1, indicated the last communication with Entity 1 was in 2022, and indicated Patient was discharged and readmitted to the agency after a hospitalization on 11/19/2024. The Administrator indicated she did not know what care Entity 1 provided to Patient, Patient’s family member told the agency that Entity 1 did not do bathing for Patient, and the agency was to complete Patient bathing. During a follow up interview on 05/08/2025, beginning at 2:00 PM, the Administrator indicated she had contacted Entity 1 and Patient received services 35 hours per week from Entity 1. 410 IAC 17-12-2(g)”

“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 agency failed to ensure the home health aide provided services that were ordered by the physician and included in the plan of care in 1 of 1 active clinical records reviewed with a home health aide (Patient #2). Findings include: 1. An undated policy, titled, “Home Health Aide Services,” indicated a home health aide worked under the direction of a physician and registered nurse, and the assignment would be made in accordance with a plan of care established by the patient’s physician. 2. A Home Health Aide Plan of Care, for certification period 03/19/2025 to 05/17/2025, for Patient #2 indicated the home health aide should complete shaving Patient at every visit and the home health aide should report a refusal of care. Home Health Aide Visit Notes, for 03/25/2025, 03/28/2025, 04/01/2025, 04/04/2025, 04/08/2025, 04/11/2025, 04/15/2025, 04/18/2025, 04/29/2025, and 05/02/2025 indicated Patient refused to be shaved. The Home Health Aide Visit Notes failed to evidence documentation of Patient’s refusal to be shaved being reported. Home Health Aide Visit Notes, for 04/11/2025 and 04/25/2025, indicated activities completed with Patient included dangling on the side of the bed. The Home Health Aide Plan of Care, for certification period 03/19/2025 to 05/17/2025, failed to evidence activity to dangle on the side of the bed was to be completed. The Home Health Aide Plan of Care, for certification period 03/19/2025 to 05/17/2025, indicated catheter care and emptying of the drainage bag would be completed at every visit. Home Health Aide Visit Notes, for 04/04/2025 and 04/25/2025, indicated catheter care and emptying of the drainage were not completed due to not applicable and failed to evidence documentation of the reason catheter care and emptying of the drainage bag were not completed or that the task assigned was not completed was reported. The Home Health Aide Plan of Care, for certification period 03/19/2025 to 05/17/2025, indicated the home health aide would assist with transfer at every visit. A Home Health Aide Visit Note, dated 04/04/2025, indicated Patient refused assist with transfer and failed to evidence documentation the refusal was reported. A Home Health Aide Visit Note, dated 04/25/2025, indicated not applicable to assist with transfer and failed to evidence documentation of the reason transfer assistance was not provided or that the refusal was reported. During an interview on 05/08/2025, beginning at 1:00 PM, the Administrator, Administrative Staff 1, indicated if a patient refused care the home health aide should report to the nurse and the nurse should follow up with the patient. The Administrator indicated a registered nurse [RN] would instruct the home health aide on the plan of care to identify the care that would provided to the patient by the home health aide. During an interview on 05/08/2025, beginning at 12:15 PM, RN 3 indicated the home health aide should report to the nurse if a patient refused care that was ordered on the aide plan of care. RN 3 indicated a nurse would follow up with a patient if the patient refused home health aide care, and if a home health aide was performing range of motion on a patient and it was not on the plan of care the nurse should update the plan of care to include range of motion if there were no contraindications for the patient.”

“HH aide supervision elements CFR(s): 484.80(h)(4)(i-vi) Home health aide supervision must ensure that aides furnish care in a safe and effective manner, including, but not limited to, the following elements: (i) Following the patient’s plan of care for completion of tasks assigned to a home health aide by the registered nurse or other appropriate skilled professional; (ii) Maintaining an open communication process with the patient, representative (if any), caregivers, and family; (iii) Demonstrating competency with assigned tasks; (iv) Complying with infection prevention and control policies and procedures; (v) Reporting changes in the patient’s condition; and (vi) Honoring patient rights. This Element is not met as evidenced by: Based on record review, and interview, the agency failed to ensure the home health aide supervision by a registered nurse [RN] included that the home health aide was following the patient’s plan of care for completion of tasks in 1 of 1 active clinical records reviewed with a home health aide (Patient #2). Findings include: 1. An undated policy, titled, “Home Health Aide Supervision,” indicated supervisory visits were made to patients by the RN to assure that the home health aide services are being provided in accordance with the plan of care. The policy indicated the RN would assess the home health aide’s provision of services as outlined in the assignment sheet to determine if changes are required. 2. A Home Health Aide Plan of Care, for certification period 03/19/2025 to 05/17/2025, for Patient #2 indicated the home health aide should completed shaving Patient at every visit and the home health aide should report a refusal of care. Home Health Aide Visit Notes, for 03/25/2025, 03/28/2025, 04/01/2025, 04/04/2025, 04/08/2025, 04/11/2025, 04/15/2025, 04/18/2025, 04/29/2025, and 05/02/2025 indicated Patient refused to be shaved. The Home Health Aide Visit Notes failed to evidence documentation of Patient’s refusal to be shaved being reported. Home Health Aide Visit Notes, for 04/11/2025 and 04/25/2025, indicated activities completed with Patient included dangling on the side of the bed. The Home Health Aide Plan of Care, for certification period 03/19/2025 to 05/17/2025, failed to evidence activity to dangle on the side of the bed was to be completed. The Home Health Aide Plan of Care, for certification period 03/19/2025 to 05/17/2025, indicated catheter care and emptying of the drainage bag would be completed at every visit. Home Health Aide Visit Notes, for 04/04/2025 and 04/25/2025, indicated catheter care and emptying of the drainage were not completed due to not applicable and failed to evidence documentation of the reason catheter care and emptying of the drainage bag were not completed or that the task assigned was not completed was reported. The Home Health Aide Plan of Care, for certification period 03/19/2025 to 05/17/2025, indicated the home health aide would assist with transfer at every visit. A Home Health Aide Visit Note, dated 04/04/2025, indicated Patient refused assist with transfer and failed to evidence documentation the refusal was reported. A Home Health Aide Visit Note, dated 04/25/2025, indicated not applicable to assist with transfer and failed to evidence documentation of the reason transfer assistance was not provided or that the refusal was reported. Home Health Aide Supervisory Visits Notes, dated 03/25/2025, 04/01/2025, 04/08/2025, 04/15/2025, 04/29/2025 and 05/06/2025 indicated the home health aide followed the patient’s plan of care for the completion of tasks assigned. The Supervisory Visits failed to evidence documentation of Patient’s refusal to be shaved, catheter care and drainage bag being emptied were not completed, and patient dangling on the side of the bed was completed when the plan of care did not include the assignment. During an interview on 05/08/2025, beginning at 12:15 PM, RN 3 indicated completion of the home health aide supervisory visits were completed by communication with the patient and family to see if they were satisfied with the aide’s care, ensure the aide’s plan of care was being followed, and the RN would follow up with the patient and the aide if care was not being completed as assigned in the aide plan of care. 410 IAC 17-14-1(n)”