The Care Team Home Health

“Information to the state survey agency CFR(s): 484.100(a) Standard: The HHA also must disclose the following information to the state survey agency at the time of the HHA’s initial request for certification, for each survey, and at the time of any change in ownership or management: This Standard is not met as evidenced by: Based on record review and interview the agency failed to ensure the Indiana Department of Health was notified when changes were made to key administrative roles, in 1 of 1 Home Health provider surveyed. Findings include: 1. Review of an agency document dated 2021, and titled ‘1.3 - DISCLOSURE OF OWNERSHIP AND MANAGEMENT’ stated, “... Responsibility of Agency: The agency, and it’s staff, must operate and furnish services in compliance with all applicable federal, state, and local laws and regulations related to the health and safety of patients ... Reportable Changes in Authority, Ownership, or Management: The Administrator or designee will inform all appropriate Federal and accrediting organization personnel, in writing and within 30 days, regarding any of the following changes: ... 3. Changes in authority, ownership, or management ... Relocation and other Changes ... Except in an emergency, the agency will notify the department in writing ... and obtain approval if required for staff changes for ... Administrator and Clinical Manager. If an Administrator and Clinical Manager resigns or is forced to discontinue suddenly, the agency will have 30 days to find a replacement ...” 2. An agency document dated 10-06-2023, titled ‘The Care Team Home Health and Hospice Governing Board Meeting Minutes Ad Hoc Meeting 10-06-2023’ stated, “... Appointments of Site Leadership: 1. The Governing Board hereby appoints the following Leadership roles in 1st Care Home Health Services Administrator; Alternate Administrator, Supervising Nurse, Alternate Supervising Nurse as of October 22nd, 2023 ...” The document evidenced Administrative staff 1 was named Administrator, Administrative staff 2 was named Alternate Administrator and also Clinical Manager, and Administrative staff 3 was named as Alternate Clinical Manager. This information was not consistent with the information currently on file with IDOH. 3. On 01-08-2024 at 09:30 AM, during the Entrance Conference, Administrator 1 indicated that the agency had recently made changes to the role of Administrator and there was documentation to this effect which had been sent to the Indiana Department of Health (IDOH) notifying of the changes. This information was requested of the agency. On 01-08-2024 at 01:39 PM, the Administrator indicated she had been informed that IDOH had not yet been notified of the agency’s recent administrative personnel changes. When queried as to what became of the former Administrator, Administrator 1 indicated the former Administrator was no longer with the agency as of December of 2023. On 01-10-2024 at 12:40 PM, via a video/teleconference, when queried as to whether information regarding management changes had been reported to the IDOH and who was responsible for ensuring this was done, the Chief Compliance Officer (CCO) indicated they were working on this and the administrative changes had not yet been sent to the Indiana Department of Health (IDOH) due to requiring more recent Criminal Background checks which had not yet been returned, as is required, and this had delayed sending the info to IDOH. Indicated would contact IDOH in the interim to inform them of the recent changes and reason for the delay.”

“Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency’s overall management and operation, the provision of all home health services, fiscal operations, review of the agency’s budget and its operational plans, and its quality assessment and performance improvement program. This Standard is not met as evidenced by: Based on record review and interview the Governing Body failed to ensure there was an organizational chart clearly defining the lines of authority for the delegation of responsibility down to the patient care level in 1 of 1 Home Health Agency and failed to ensure Governing Body meetings and minutes were individualized to the agency in 1 of 1 Governing Body. Findings include: 1. An agency’s policy titled ‘1.8 CHAIN OF COMMAND / ORGANIZATIONAL CHART’ dated 2021 indicated, “ ... 1. The organizational chart must be current and show the relationship for each job function down to the patient care/service level. 2. The services furnished by the HHA, administrative control, and lines of authority for the delegation of responsibility down to the patient care level are clearly defined in writing ... “ An agency’s policy titled ‘1.7 ADMINISTRATOR RESPONSIBILITIES’ dated 2021 revealed, “ ... maintain a current organizational chart to show lines of authority to the client level ... “ 2. A review of the organizational chart on 01-08-2024 failed to identify who the administrator was and did not include patients but did identify Administrative Staff 2 as the Branch Director, and Administrative Staff 3 as the Clinical Manager. 3. A review of an agency document dated 10/06/2023 at 9:00 AM, titled, “The Care Team Home Health and Hospice Governing Board Meeting Minutes Ad Hoc Meeting” indicated this meeting was intended for Entities G, H, I, J, K, L, M, N, O, P, and Q, along with 1st Care Home Health Services. 4. On 01/10/2024 at 12:25, the Administrator indicated they had approached the Governing Body indicating they should hold separate Governing Body Meetings, but they were told this was how they were going to conduct their Governing Body Meetings. 5. On 01-08-2024 at 9:40 AM, Administrator 1 indicated Administrative Staff 2 was the Alternate Administrator and Clinical Supervisor, and Administrative Staff 3 was the Alternate Clinical supervisor.”