One Home Health, LLC

“Establishment of the Emergency Program (EP) CFR(s): 484.102 §403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.542, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must establish and maintain a [comprehensive] emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements: * (Unless otherwise indicated, the general use of the terms “facility” or “facilities” in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This Condition is not met as evidenced by: Based on record review and interview, the home health agency failed to include complete individualized emergency plans (see tag E0017); failed to include the procedure to address the agency’s responsibility in contacting local and state officials of patients in need of evacuation (see tag E0019); failed to include the procedure to locate on-duty staff and patients that are unable to be contacted during an emergency (see tag E0021); failed to include the use of emergency staffing or volunteers (see tag E0024); failed to include a communication plan that complied with federal, state and local laws (see tag E0029); failed to include in the communication plan contact information for entities providing services under arrangement, and patients’ physicians (see tag E0030); failed to include primary and alternate means of communicating with staff and federal, state, regional and local emergency officials (see tag E0032); and failed to include procedures for sharing medical documentation for patients under the agency’s care with other health care providers during an emergency (see tag E0033) for 1 of 1 agency. The cumulative effect of these systemic problems resulted in the home health agency’s inability to ensure the provision of quality health care in a safe environment and results in the agency being out of compliance with condition 42 CFR §484.102 Emergency Preparedness Requirements for Medicare Participating Providers and Suppliers.”

“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 administrative and supervisory functions were not delegated to another agency or organization and the organizational structure was set forth, in writing, including lines of authority and services furnished; failed to ensure a clinical manager was available during all operating hours (See G950); and failed to ensure failed to ensure a qualified individual was available to assume the responsibilities and obligations as the administrator in the Administrators absence (See G954) in 1 of 1 agency. The cumulative effect of these systemic problems has resulted in the home health agency’s inability to ensure provision of quality health care in a safe environment for the condition of participation 42 CFR 484.105 Organization and Administration of Services. The findings include: 4. A review of an agency policy revised in April 2020, titled “Use of Organizational Chart,” indicated, There will be defined lines of authority, which clearly establishes responsibility and accountability for all organization personnel. Organizational charts will be used to define relationships and the lines of authority within the organization. Organizational charts will be reviewed revised and dated as changes occur. 5. A review of the agency organizational chart, which was revised on 8/17/23023, indicated the organization chart was for the Indiana location. A review of this chart evidenced Corporate Staff was the QAPI Coordinator and that Corporate Staff 5 was the Nurse Educator. Review evidence Corporate Staff was not an employee of the Indiana Agency but was a corporate employee. Review evidenced Corporate Staff 5 was not an employee of the Indiana agency and did not have an Indiana Nursing License and Corporate Staff 5’s Indiana Nursing license expired in 2021. These positions were to report to Corporate Staff 1. A review of the Indiana license verification website (https://mylicense.in.gov) evidenced Corporate Staff 3 did not have an Indiana Nursing License, and Corporate Staff 5 had an Indiana Nursing License which expired on 10/31/2021. A review of the Organizational chart indicated clinical staff was to report to the clinical manager. A review of the Organizational chart for the Indiana agency failed to ensure only agency employees and failed to ensure the line ensure responsibility and lines of authority were not delegated to an outside agency. During an interview on 10/25/2023 at 12:01 PM, the Administrator indicate they do not have a clinical manager we don’t have a clinical manager. She indicated the previous Clinical Manager left in 2021. During a home visit on 10/24/2023 at 4:15 PM, PTA 1 indicated the agency did not have a clinical manager. 1. A review of an agency policy dated 04/2020, titled, “Branch Control,” indicated branch locations will maintain patient clinical/service records in the identical manner as the parent location including protection of protected health information. The policy indicated the administrator would maintain agreements and vendor contracts. 2. A review of an agency policy revised on 04/2020, titled, “Home Health Contracted Services,” indicated the policy would define the nature and scope of services provided by clinicians and others not directly employed by the organization. The policy indicated the contracted services would be defined by a written agreement prior to the individuals being permitted to provide services on behalf of the organization. 3. A review of personnel records for corporate staff 3 evidenced a job description signed on 11/09/2022, titled, “Position: Quality Improvement Registered Nurse [RN],” which indicated qualifications included a Registered Nurse with a current license to practice in states of operation. A review of the personnel records indicated corporate staff 3 held an Illinois RN license and did not have an Indiana RN license where the agency was located. The job description indicated the RN implemented and monitored the agency’s Quality Improvement Program by preparing reports, identifying trends, and monitored the SHP (Strategic Healthcare Programs) scorecards and outcome and star rating reports at least quarterly. A review failed to evidence corporate staff 3 had a contract with the Indiana home health agency. During an interview on 10/26/2023, at 2:00 PM, the Administrator indicated corporate staff 3 collected the quality assessment and performance improvement data from the Strategic Healthcare Programs for the Indiana agency. During an interview on 10/27/2023, at 12:22 PM, the Administrator indicated the Indiana agency did not have a contract with corporate staff 3. During an interview on 10/30/2023, at 12:17 PM, the Administrator confirmed corporate staff 3 did not hold an Indiana RN license.”

“HHA Comprehensive Assessment in Disaster CFR(s): 484.102(b)(1) §484.102(b)(1) Condition for Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (1) The plans for the HHA’s patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure each patient had an individualized emergency plan in 12 of 14 records reviewed. (Patient #1, 3, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14) The findings include: *On 10/27/23 starting at 11:39 AM, during home visit observation, Patient # 4’s home folder contained Patient Individualized Emergency Plan that failed to evidence all safety precautions for patient that include bleeding precautions. * On 10/26/23, record review evidenced Patient #4 taking Eliquis (a medication used to treat and prevent blood clots and to prevent stroke). Eliquis can cause bleeding, which can be serious, and may rarely lead to death and bleeding precautions should be included for patients taking Eliquis. Safety precautions failed to evidence bleeding precautions for Patient #4’s Individualized Emergency Plan. *During review, the clinical record failed to evidence documentation of plans for evacuation location of Patient #8 if evacuation due to emergency or disaster is needed. XX. A review of the start of care assessment dated 10/19/2023 evidenced Patient #3 had a surgical wound and required wound care. A review of the individualized emergency plan dated 10/19/2023 failed to evidence Patient #3 required wound care as well as transportation / evacuation plans. XX. A review of the individualized emergency plan for Patient #5 dated 10/17/2023 failed to evidence transportation / evacuation plans. XX. A clinical record review for Patient #10, start of care 10/25/2023 failed to evidence a completed individualized emergency plan. *. Observation of a home visit for patient #1, on 10/24/2023, at 4:15 PM, to observe a routine physical therapy assistant visit. During the visit, a home health folder was reviewed. The home folder contained an undated document titled “Patient Individualized Emergency Plan” which failed to specify an evacuation location and instructions and failed to include wound care instructions. A clinical record review for patient #1, evidenced a start of care assessment dated 8/25/2023 which evidenced the patient had wounds. This document failed to evidence an evacuation address and instructions. A review of Patient #1’s Individualized Emergency Plan failed to evidence an evacuation address and instructions and failed to include wound care instructions. * A clinical record review for patient #7, evidenced a start of care assessment dated 8/30/2023 which evidenced Patient #7 went to Dialysis on Tuesday Thursday Saturday at Entity 2 (Dialysis Center). This document failed to evidence an emergency evacuation address. A review of Patient #11’s Individualized Emergency Plan failed to evidence an evacuation address and instructions, and dialysis days and location. * A clinical record review for patient #11, evidenced a start of care assessment which evidenced Patient #11 used oxygen and a CPAP machine (for sleep apnea). This document failed to include an evacuation address and instructions. A review of Patient #11’s Individualized Emergency Plan failed to evidence an evacuation address and instructions, oxygen, and CPAP machine. * A clinical record review for patient #12, evidenced a start of care assessment dated 10/6/2023 This document failed to evidence Patient #12’s evacuation location was home. The document failed to evidence an evacuation location and instructions. A review of Patient #12’s Individualized Emergency Plan failed to evidence an evacuation address and instructions. ##. A review of an agency policy revised April 2020, titled, “Emergency Management Plan,” indicated individualized plans for patients during a disaster would be included as part of the comprehensive patient assessment. ##. A review of the initial assessment for patient #6, dated 07/06/2023, indicated the patient had a port a cath (implanted device for access to patient’s veins). A review of the plan of care for certification period 07/06/2023-09/03/2023 indicated the patient had weekly intravenous infusions. A review of the patient’s individualized emergency plan dated 07/06/2023, failed to evidence the patient’s port a cath or the intravenous infusions ordered. ##. A review of the initial assessment for patient #9, dated 08/29/2023, indicated the patient had an cardiac pacemaker (an implantable device that sends electrical pulses to the heart to regulate the heart rate). A review of the patients individualized emergency plan dated 08/28/2023, failed to evidenced the patient’s cardiac pacemaker. ##. A review of the initial assessment for patient #11, dated 04/03/2023, indicated the patient required hemodialysis (a process in which a machine filters blood when the kidneys are no longer healthy). A review of the patient’s individualized emergency plan dated 04/03/2023, failed to evidence the patient’s hemodialysis. ##. A review of the initial assessment for patient #14, dated 08/02/2023, indicated the patient required hemodialysis and a had a feeding tube (tube into the stomach for nutrition). A review of the patient’s individualized emergency plan dated 08/02/2023, failed to evidence the patient’s hemodialysis or the feeding tube. ##. During an interview on 11/08/2023, at 1:50 PM, the Administrator indicated dialysis, pacemakers, feeding tubes, port a cath, intravenous infusions, diabetic care, wounds and oxygen use should all be included on the patient’s individualized emergency plan.”

“Homebound HHA/Hospice Inform EP Officials CFR(s): 484.102(b)(2) §418.113(b)(2), §460.84(b)(4), §484.102(b)(2) [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] *[For homebound Hospice at §418.113(b)(2), PACE at §460.84(b)(4), and HHAs at §484.102(b)(2):] The procedures to inform State and local emergency preparedness officials about [homebound Hospice, PACE or HHA] patients in need of evacuation from their residences at any time due to an emergency situation based on the patient’s medical and psychiatric condition and home environment. This Standard is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure they included the procedures to inform state and local emergency preparedness officials about patients in need of evacuation from their residences at any time due to an emergency situation based on the patient’s medical, psychiatric, and home environment conditions for 1 of 1 agency. Findings include: A record review of an agency policy revised April 2020, titled, “Emergency Management Plan,” indicated the agency would have a means of informing state and local emergency preparedness officials of patients in need of evacuation due to their medical, behavioral health or conditions of the home environment. A review of the emergency preparedness binder on 11/08/2023, failed to evidence documentation of the procedure to inform state and local emergency preparedness officials about patients in need of evacuation from their residence due to an emergency situation. During an interview on 10/07/2023, at 2:20 PM, the Administrator indicated the agency did not have documentation of a procedure to notify state and local emergency preparedness officials about patients in need of evacuation.”

“HHA- Procedures for Follow up Staff/Pts. CFR(s): 484.102(b)(3) §484.102(b)(3) Condition of Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (3) The procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency. The HHA must inform State and local officials of any on-duty staff or patients that they are unable to contact. This Standard is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure procedures were included to inform the state and local emergency official of any on-duty staff or patients that the agency were unable to contact for 1 of 1 agency. Findings include: A record review of an agency policy revised April 2020, titled, “Emergency Management Plan,” indicated the agency would maintain an emergency preparedness communication plan that would include a means of informing state and local emergency officials of patients and on-duty staff that the agency were unable to contact. The policy failed to address what actions would be required due to the inability to make contact with staff or patients and reporting capabilities to the local and state emergency officials. A review of the emergency preparedness binder on 11/08/2023, failed to evidence documentation of a communication plan that would include a means of informing state and local emergency officials of patients and on-duty staff that were unable to be contacted. During an interview on 11/08/2023, at 2:20 PM, the Administrator indicated the agency did not have a communication plan to contact local and state emergency officials of their patients or on-duty staff that the agency was unable to contact.”

“Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This Standard is not met as evidenced by: Based on record review and interview, the home health agency failed to evidence the process for the use of volunteers or other emergency staff strategies to address surge needs during an emergency for 1 of 1 agency. FIndings include: A record review of an agency policy revised April 2020, titled, “Emergency Management Plan,” indicated the agency would define their role to the emergency management program related to the use of volunteers and other emergency staffing to address the agency’s surge needs. A review of the emergency preparedness binder on 11/08/2023, failed to evidence documentation of the agency’s procedure to define their role related to the use of volunteer and other emergency staffing to address the agency’s surge needs. During an interview on 11/08/2023, at 12:28 PM, the Administrator indicated the agency did not have a procedure to address volunteer and emergency staffing during an agency’s surge needs.”

“Development of Communication Plan CFR(s): 484.102(c) §403.748(c), §416.54(c), §418.113(c), §441.184(c), §460.84(c), §482.15(c), §483.73(c), §483.475(c), §484.102(c), §485.68(c), §485.542(c), §485.625(c), §485.727(c), §485.920(c), §486.360(c), §491.12(c), §494.62(c). (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]. This Standard is not met as evidenced by: Based on record review and interview, the home health agency failed to develop and maintain a communication plan that complies with federal, state and local laws and that was reviewed every 2 years for 1 of 1 agency. Findings include: A record review of an agency policy revised April 2020, titled, “Emergency Management Plan,” indicated the agency would maintain an emergency preparedness communication plan that complied with federal, state, and local laws that would include name and contact information for patients’ physicians and entities providing care under arrangement, primary and alternate means for communication with staff, federal, state, tribal, and local emergency officials, a method for sharing medication documentation for patients, a means for informing state and local emergency officials with patients that agency were unable to reach, patients in need of evacuation, or on-duty staff that the agency were unable to contact. A review of an agency document dated 06/01/2022, titled, “Review Record,” indicated the Administrator reviewed and updated the employee contact list. A review failed to evidence documentation the communication plan was reviewed every 2 years. A review of the agency’s emergency preparedness binder on 11/08/2023, failed to evidence documentation of the agency’s communication plan that complied with the federal, state and local laws to include name and contact information for patients’ physicians and entities providing care under arrangement, primary and alternate means for communication with staff, federal, state, tribal, and local emergency officials, a method for sharing medication documentation for patients, a means for informing state and local emergency officials with patients that agency were unable to reach, patients in need of evacuation, or on-duty staff that the agency were unable to contact. During an interview on 11/08/2023, at 2:20 PM, the Administrator indicated the agency did not have documentation the communication plan was reviewed every 2 years and complied with the federal, state and local laws.”

“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 record review and interview, the home health agency failed to maintain an emergency preparedness communication plan which included names and contact information for patients’ physicians and other entities providing services under arrangement to patients for 1 of 1 agency. Findings include: A review of an agency policy revised April 2020, titled, “Emergency Management Plan,” indicated the agency would maintain an emergency preparedness communication plan that would include name and contact information for entities providing services under arrangement and patients’ physicians. A review of the emergency preparedness binder on 11/08/2023, failed to evidence documentation of a communication plan that included entities providing services under arrangement and patients’ physicians. During an interview on 11/08/2023, at 2:20 PM, the Administrator indicated the agency did not have an communication plan that included entities providing services under arrangement and patients’ physicians.”

“Primary/Alternate Means for Communication CFR(s): 484.102(c)(3) §403.748(c)(3), §416.54(c)(3), §418.113(c)(3), §441.184(c)(3), §460.84(c)(3), §482.15(c)(3), §483.73(c)(3), §483.475(c)(3), §484.102(c)(3), §485.68(c)(3), §485.542(c)(3), §485.625(c)(3), §485.727(c)(3), §485.920(c)(3), §486.360(c)(3), §491.12(c)(3), §494.62(c)(3). [(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: (3) Primary and alternate means for communicating with the following: (i) [Facility] staff. (ii) Federal, State, tribal, regional, and local emergency management agencies. *[For ICF/IIDs at §483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID’s staff, Federal, State, tribal, regional, and local emergency management agencies. This Standard is not met as evidenced by: Based on record review and interview, the home health agency failed to develop and maintain an emergency preparedness communication plan that included primary and alternate means for communication with the facility, staff, federal, state, tribal, regional, and local emergency management for 1 of 1 agency. Findings include: A review of an agency policy revised April 2020, titled, “Emergency Management Plan,” indicated the agency would maintain an emergency preparedness communication plan that would include primary and alternate means for communication with the staff, federal, state, tribal, regional and local emergency management agencies. A review of the emergency preparedness binder on 11/08/2023, failed to evidence a communication plan that included primary and alternate means for communication with staff, federal, state, tribal, regional and local emergency management agencies. During an interview on 11/08/2023, at 1:50 PM, the Administrator indicated the agency did not have an emergency preparedness communication plan that included primary and alternate means for communication with the staff, federal, state, tribal, regional and local emergency management agencies.”

“Methods for Sharing Information CFR(s): 484.102(c)(4)-(5) §403.748(c)(4)-(6), §416.54(c)(4)-(6), §418.113(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §482.15(c)(4)-(6), §483.73(c)(4)-(6), §483.475(c)(4)-(6), §484.102(c)(4)-(5), §485.68(c)(4), §485.542(c)(4)-(6), §485.625(c)(4)-(6), §485.727(c)(4), §485.920(c)(4)-(6), §491.12(c)(4), §494.62(c)(4)-(6). [(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: (4) A method for sharing information and medical documentation for patients under the [facility’s] care, as necessary, with other health providers to maintain the continuity of care. (5) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii). [This provision is not required for HHAs under §484.102(c), CORFs under §485.68(c)] (6) [(4) or (5)]A means of providing information about the general condition and location of patients under the [facility’s] care as permitted under 45 CFR 164.510(b)(4). *[For RNHCIs at §403.748(c):] (4) A method for sharing information and care documentation for patients under the RNHCI’s care, as necessary, with care providers to maintain the continuity of care, based on the written election statement made by the patient or his or her legal representative. *[For RHCs/FQHCs at §491.12(c):] (4) A means of providing information about the general condition and location of patients under the facility’s care as permitted under 45 CFR 164.510(b)(4). This Standard is not met as evidenced by: Based on record review and interview, the home health agency failed to a method for sharing information and medical documentation for patients under the agency’s care with other health care providers to maintain continuity of care, and in the event of an evacuation, a means of releasing patient information about the general condition and location of the patient for 1 of 1 agency. Findings include: A record review of an agency policy revised on April 2020, titled, “Emergency Management Plan,” indicated the agency’s communication plan would include a method for sharing information, medical documentation, and provide information about the general condition and location of the patients under the agency’s care. A review of the emergency preparedness binder on 11/08/2023, failed to evidence the procedure to include a method to share information, medication documentation, and provide information about the general condition and location of the patients under the agency’s care. During an interview on 11/08/2023, at 2:20 PM, the Administrator indicated the agency did not have a procedure to share patient medical documentation and provide information of the general condition and location of the patients under the agency’s care.”

“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 care was provided as established in the plan of care in 4 of 10 active clinical records reviewed. (Patient #1, #4, #7, #10). The findings include: 1. A review of an agency policy titled, “Care Planning Process”, revised 4/2020, indicated the agency shall provide services based on the needs of the patient as directed in the plan of care. 2. Review of Job Description No. C-210 “Position: Registered Nurse”, included but not limited to, “Performs comprehensive assessments of client status, including physical…develops and/or follows an individualized Plan of Care…” 3. A review of the plan of care for Patient #10, certification period 10/25/2023 to 12/23/2023, indicated the licensed professional was to report a pain rating greater than 6. The plan of care indicated physical therapy was to provide gait training and use of an appropriate assistive device to ensure patient safety. In a visit note dated 10/26/2023, OT (Occupational Therapist) 2 indicated the patient complained of pain rating a 7. A clinical record review failed to evidence OT 2 informed the physician of the patient’s pain. In an initial visit note dated 10/25/2023, PT (Physical Therapist) 1 indicated they did not instruct the patient on the basic use of assistive devices to ensure the patient was safe until next visit because it was not applicable. During an interview on 10/27/2023 at 2:52 PM, Patient #10 indicated they were not used to using a walker, and they did not use one before surgery. During an interview on 10/30/2023 at 12:25 PM, the administrator indicated the clinician should notify the physician for a pain rating outside of the parameters. When informed of the findings, the administrator indicated PT 1 should have assessed the patient’s use of the walker in order to ensure their safety at the initial visit and ongoing. 4. A clinical record review for patient #7, start of care 8/30/2023, evidenced an agency document titled “Home Health Certification And Plan Of Care” for certification period 8/30/2023 -10/28/2023. This document evidenced the nurse was to notify the physician if the Patient’s systolic blood pressure (BP) was greater than 165 and diastolic greater than 95. A review of Patient #7’s electronic record evidenced an RN Visit Note dated 9/8/2023. During this visit, Patient #7’s BP was 172/98. There failed to be evidence the RN contacted the Physician as indicated in the plan of care. 5. A clinical record review for Patient #1, start of care 9/25/2023, evidenced an agency document titled “Home Health Certification And Plan Of Care” for certification period 9/25/2023 to 11/23/2023. This document evidenced the RN was to notify the nurse of a pain level of greater than 6 on a scale of one to ten (one being less pain 10 being the most pain). A clinical record review for Patient #1, start of care 9/25/2023, evidenced an agency document for an RN visit on 9/29/2023. This document evidenced Patient #1 had a pain level of 6-7. There failed to be evidence the nurse notified the Physician of the Patient pain as ordered in the plan of care. 6. During a home observation visit of RN 3 providing care for Patient #4 on 10/27/23 beginning at 11:39 AM, observed RN 3 auscultate apical heart rate for approximately 5 seconds then auscultate all posterior breath sounds bilaterally. The registered nurse (RN) failed to auscultate any of the patient’s anterior breath sounds and failed to auscultate an apical pulse for a full 60 seconds. 7. On 10/26/23, the clinical record review for Patient #4 evidenced a POC for the period 10/23/23 through 12/21/23 that included “skilled nurse to…assess cardiovascular system…” and “SN (skilled nurse) for assessment of lung sounds...” 8. During an interview on 10/27/23 at 3:31 PM, Administrative Staff 1 reported the expectation was for nurse to check apical pulse for full 60 seconds every patient visit and all lung fields should be auscultated, back-to-back, front, for every patient visit.”

“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 record review and interview, the home health agency failed to implement policies and procedures for the control of communicable diseases in 1 of 1 patients records reviewed with antibiotics prescribed while on service with the home health agency (Patient # 6). The findings included: A review of an agency policy dated April 2020, titled, “Evaluating and Maintaining Records of Infections Among Patients,” indicated all patients with a new or suspected infection will have a patient infection report completed within 24 hours of discovery. The policy indicated the patient report form would be completed when a new, actual, or suspected infection is clinically observed by personnel, or a new antibiotic is ordered, and the form will be sent to the Performance Improvement Coordinator to analyze the reports and the information will be used as part of the organization’s risk analysis for the organization’s infection prevention activities. A clinical record review for patient #6, start of care 07/06/2023, evidenced a coordination note dated 10/11/2023, which indicated the patient had a boil (skin infection) to the right arm that ruptured with purulent drainage (fluid from wound that could be sign of infection). The coordination note indicated the patient was started on Keflex (antibiotic). A review of the Quality Improvement Event Summary for 10/24/2022-10/24/2023, failed to include the infection report for the patient. During an interview on 10/26/2023, at 2:18 PM, the Administrator indicated the infection for the patient should have been included on the Quality Improvement Event Summary.”

“Supervise skilled professional assistants CFR(s): 484.75(c) Standard: Supervision of skilled professional assistants. This Standard is not met as evidenced by: Based on record review and interview, the therapist failed to direct the activities of the therapy assistant in 1 of 1 Occupational Therapy Assistant Visits conducted (Patient #10). The findings include: The review of an agency policy titled “Scope of Services”, revised 4/2020, indicated the therapists shall develop and revise a plan of care for each patient as well as supervise therapy assistants. The policy indicated therapy assistants shall provide services that are planned, delegated, and supervised by the therapist. A review of the plan of care for Patient #10, certification period 10/25/2023 to 12/23/2023 indicated the patient was to receive OT (Occupational Therapy) services but failed to evidence specific interventions for what was to be done at patient visits. During an interview on 10/27/2023 at 3:30 PM, Occupational Therapist Assistant (OTA) 1 indicated the Occupational Therapist did not give them specific instructions for what to do in the patient’s home. OTA 1 indicated the therapist would write the goals, but it was up to her to come up with the interventions.”

“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 agency failed to ensure the plan of care included all medications, supplies, safety precautions, equipment, and treatments in 8 of 14 clinical records reviewed. (Patient #1, 2, 3, 4, 7, 10, 11, 14) The findings include: 1. A review of an agency policy titled, “Care Planning Process”, revised 4/2020, indicated the agency would create an individualized plan of care for each patient which included all medications and treatment for the patient. 2. A review of the plan of care for Patient #3, certification period 10/19/2023 to 12/17/2023, indicated the nurse was to perform / teach wound care to the incision on the right hip. The plan of care evidenced a goal that the patient / caregiver will demonstrate the ability to perform wound care. The plan of care failed to evidence what wound care was to be performed and at what frequency. A review of the list of supplies on the plan of care evidenced the patient required alginate dressing (a specialized wound care dressing). A clinical record review failed to evidence an order or instruction for the patient to use alginate dressing. During an interview on 10/30/2023 at 11:10 AM, the administrator indicated the plan of care should include specific orders for what wound care was to be done, by whom, and at what frequency. The administrator indicated alginate dressing was not currently used by the patient and should not have been on the plan of care. 3. A clinical record review for patient #7, start of care 8/30/2023, evidenced an agency document titled “Home Health Certification And Plan Of Care” for certification period 8/30/2023 -10/28/2023. This document evidenced Patient #7 had end-stage kidney failure and was dependent on Renal Dialysis. The plan of care failed to include Patient #7’s Dialysis Center and the dates of his dialysis treatments. The document evidenced Patient #7 was diabetic and received insulin twice daily. The document failed to include blood sugar parameters for physician notification. During an interview on 10/20/2023 at 2:31 PM, the Administrator indicated the plan of care should include where and when the Patient goes to dialysis, She also indicated there should be blood sugar parameters on the plan of care for diabetic patients. 4. A clinical record review for Patient #1, start of care 9/25/2023, evidenced an agency document titled “Home Health Certification And Plan Of Care” for certification period 9/25/2023 to 11/23/2023. This document evidenced the patient was taking the following medications: Atorvastatin (for high cholesterol), Calcium (supplement), Furosemide (for fluid retention) levothyroxine (for thyroid), lidocaine topical cream (for pain), methylprednisolone (for inflammation), metoprolol (For high blood pressure), Montelukast (for asthma), tramadol (for pain) Valsartan (for high blood pressure), Xarelto (prevents blood clots). The plan of care failed to include Patient #1’s complete list of medications. During a home visit on 10/24/2023 at 4:15 PM, Patient #1’s home folder was reviewed. The medication list in Patient #1’s home folder evidenced Patient #1 was taking Turmeric (supplement). During an interview with Patient #1 on 10/24/2023 at 4:45 PM, Patient #1 when reviewing the current medications taken, Patient #1 indicated he/she takes Klor Con (for low potassium) and Turmeric. These medications failed to be included in the medications on the plan of care. During an interview on 10/27/2023 at 2:17 PM, the Administrator indicated all medications and supplements the Patient is taking should be listed on the plan of care. 5. A review of a plan of care for patient #2 for certification period 10/21/2023-12/19/2023, evidenced the patient had a right knee replacement. During an observation of a home visit for patient #2 on 10/25/2023, starting at 9:30 AM, registered nurse (RN) 1 instructed the patient to use an ice machine to the right knee in 20-minute increments. A review of the plan of care failed to evidence the use of the ice machine to the right knee. During an observation of the home visit the patient indicated the use of supplements magnesium 400 micrograms one tablet twice a day and Iron 65mg one tablet twice a day. A review of the plan of care failed to evidence the magnesium and iron supplements. During an interview on 10/26/2023, at 2:15 PM, the Administrator indicated the use of the ice machine should have been included on the plan of care and magnesium and iron should have been verified with the physician and added to the plan of care medication list. 6. A review for patient #11 evidenced an initial RN admission note, dated 04/03/2023, which indicated patient was receiving hemodialysis (a process to filter wastes from the blood when the kidneys are no longer healthy). A review of the plan of care for certification period 04/03/2023-06/01/2023, failed to evidence the patient’s dialysis center or frequency of treatments. 7. A review for patient #14 evidenced an initial RN admission note, dated 08/02023, which indicated patient was receiving hemodialysis. A review of the plan of care for certification period 08/02/2023-09/30/2023, failed to evidence the patient’s dialysis center or frequency of treatments. 8. During an interview on 10/30/2023, at 11:19 AM, the Administrator indicated the dialysis location center name and days of the week of dialysis should be included on the plan of care. 9. Review of Policy 4-001 “Care Planning Process,” revised April 2020, included but not limited to, “the patient-specific clinical plan of care includes:…safety measures to protect against injury…supplies and equipment required…” 10. During a home visit observation on 10/27/23 beginning at 11:39 AM, Patient # 4 reported use of a glucometer to monitor blood sugar levels being performed by Patient # 4’s children every few days. 11. Review of Patient #4’s clinical record evidenced a POC for certification period 10/23/23 through 12/21/23 which failed to include the patient’s glucometer and failed to include bleeding precautions as the patient takes an oral anticoagulant (Eliquis). 12. A review of the plan of care for Patient #10, certification period 10/25/2023 to 12/23/2023 indicated the patient was to receive OT (Occupational Therapy) services but failed to evidence specific interventions for what was to be done at patient visits. During an interview on 10/27/2023 at 3:30 PM, Occupational Therapist Assistant (OTA) 1 indicated the Occupational Therapist did not give them specific instructions for what to do in the patient’s home. OTA 1 indicated the therapist would write the goals, but it was up to her to come up with the interventions. 13. During interviews conducted on 10/26/23 at 2:21 PM and 10/27/23 at 3:31 PM, Administrative Staff 1 failed to demonstrate evidence of glucometer equipment as well as bleeding precautions listed in Patient # 4’s POC for certification period 10/23/23 through 12/21/23.”

“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 alert the physician to changes in the patient’s condition in 2 of 2 clinical records reviewed in which the Patients experienced a change in condition (Patient #1, #5). The findings include: 1. A review of the agency’s Registered Nurse job description, revised 12/10/2012, evidenced the nurse shall report changes in patient status to the physician in a timely manner. 2. A review of the agency’s Occupational Therapy Assistant job description, dated 2017, evidenced the OTA (Occupational Therapy Assistant) shall report any changes to the therapist and / or nursing supervisor. 3. A review of the start of care assessment dated 10/17/2023 by RN (Registered Nurse) 2, indicated Patient #5 had bruising. A clinical record review failed to evidence the nurse informed the physician of the bruising. In a skilled nurse visit note dated 10/19/2023, RN 2 indicated the patient had a new skin tear to the left inner arm. A clinical record review failed to evidence the nurse informed the physician of the new wound. In a visit note dated 10/24/2023, OTA 1 indicated the patient had hemoptysis (coughing up blood). A review of all prior visit notes (skilled nurse 10/17/2023 and 10/29/2023; occupational therapy 10/18/2023 and 10/20/2023; physical therapy 10/20/2023) failed to evidence hemoptysis. A clinical record review failed to evidence the physician was informed of the patient’s hemoptysis. During an interview on 10/27/2023 at 3:09 PM, the administrator indicated the nurse should inform the physician if a patient has bruising or a new wound. If a new patient symptom or complaint is found by an OTA, the administrator indicated they should inform the OT who would contact the physician and document the communication in the patient’s record. 4. A clinical record review for Patient #1, start of care 9/25/2023, evidenced an agency document for an RN visit on 9/29/2023. This document evidenced Patient #1 had a pain level of 6-7 on a scale of 1-10 (1 less pain 10 most pain) but did not want to take his/her tramadol due to potential constipation. RN 3 educated the patient to increase fluids and take a stool softener every day. A review of the patient’s medical record failed to evidence RN 3 notified the Physician of the patient’s pain and concern with taking the pain medication and failed to obtain an order for the stool softener. A review evidenced an agency document titled “Home Health Certification And Plan Of Care” for certification period 9/25/2023 to 11/23/2023. This document evidenced the patient was taking the following medications: Atorvastatin (for high cholesterol), Calcium (supplement), Furosemide (for fluid retention) levothyroxine (for thyroid), lidocaine topical cream (for pain), methylprednisolone (for inflammation), metoprolol (For high blood pressure), Montelukast (for asthma), tramadol (for pain) Valsartan (for high blood pressure), Xarelto (prevents blood clots). This document failed to evidence the patient was prescribed Tylenol or a stool softener. A review of the patient medication list failed to evidence the patient was prescribed a stool softener or Tylenol. A review for patient #1 evidenced a Client Note Report dated 10/10/2023. This document evidenced Patient #1 was experiencing diarrhea. The document evidenced RN 3 educated the patient to eat yogurt several times a day as antibiotics can cause diarrhea. RN 3 also informed the Patient to start a daily probiotic. There failed to be evidence the Nurse called the Physician about the diarrhea and failed to evidence an order for a probiotic. During an interview on 10/30/2023 at 3:15 PM, the Administrator indicated the Physician should have been called and the medications should have been added to the plan of care.”

“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 home health agency failed to ensure they coordinated care with other health care providers that provided care to agency patients in 3 of 3 clinical records reviewed of patients who received dialysis (Patient #7, #11, #14) and 1 of 1 patient discharged to hospice care. The findings include: 1. Review of an agency policy titled “Coordination of Services with Other Providers,” revised April 2020, indicated the case manager will act as a liaison with other organizations or individuals also providing care to the patient to assure effective coordination of related service.” 2. A clinical record review for patient #7, start of care 8/30/2023, evidenced an agency document titled “Home Health Certification And Plan Of Care” for certification period 8/30/2023 -10/28/2023. This document evidenced Patient #7 had end-stage kidney failure and was dependent on Renal Dialysis. A review of Patient #7’s electronic medical record (EMR) failed to evidence coordination with the dialysis center. During an interview on 10/20/2023 at 12:20 PM, the Administrator indicated Patients usually have been on dialysis for a while when they come onto service. She indicated they know their schedule and have transportation, so the agency does not coordinate with the dialysis centers. 3. A review on 11/08/2023, for patient #9 of the patient’s electronic medical records evidenced the patient was last seen on 10/25/2023, and the patient was discharged to hospice on 10/30/2023. Review of the electronic medical records failed to evidence any communication or coordination with the hospice agency related to the patient discharge. During an interview on 11/08/2023, at 2:18 PM, Administrative Staff 2 indicated the patient was discharged to hospice on 10/30/2023, and there was not documentation of coordination of care with the hospice agency to take over patient care. 4. A review of a visit note dated 04/11/2023, for patient #11, indicated the patient received hemodialysis (a process to filter wastes from the blood when the kidneys are no longer healthy) 3 days per week. A review of the patient’s electronic medical records failed to evidence coordination with the dialysis center. 5. A review of the initial registered nurse assessment dated 08/02/2023, for patient #14, indicated the patient received hemodialysis 3 days per week. A review of the patient’s electronic medical records failed to evidence coordination with the dialysis center. 6. During an interview on 10/30/2023, at 11:19 AM, the Administrator indicated the agency does not coordinate patient care with the dialysis centers.”

“Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on observation and interview, the agency failed to ensure their patients received a written schedule of visits in 3 of 5 home visits conducted (Patient #1, 3, 10). The findings include: *. Observation of a home visit for Patient #1 on 10/24/2023 at 4:15 PM failed to evidence a completed visit schedule. During the home visit for Patient #1 on 10/24/2023 at 4:21 PM, Physical Therapy Assistant (PTA) 2, indicated Patients were informed what day their visit would be, and the patient would get a call the night before to give them an approximate visit time. During an interview at a home Visit for Patient #1 on 10/24/2023 at 5:02 PM, Patient #1 indicated there was not a calendar filled out by staff. Patient #1 indicated Staff usually comes either Tuesdays or Wednesdays, and they will call the night before to give an approximate visit time. During an interview on 11/8/2023 at 1:56 PM, The Administrator indicated there is a calendar in the Patient’s booklet in their home. By the end of the evaluation visit the frequency is put on the calendar. The Administrator indicated the days of the Patients next visit should be added to the calendar. The times are not given until the night before. XX. Observation of a home visit on 10/27/2023 at 8:05 AM failed to evidence a complete written visit schedule in Patient #3’s home. XX. Observation of a home visit on 10/27/2023 at 2:37 PM failed to evidence a complete written visit schedule in Patient #10’s home. At 3:27 PM, OTA (Occupational Therapy Assistant) 1 documented their upcoming visits in the patient’s calendar and indicated the physical therapist failed to document their upcoming visits in the calendar.”

“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: The agency failed to ensure there was a Clinical Manager available during all operating hours. The findings include: A review of an agency Policy titled “Branch Control,” revised 4/2020 indicated a clinical supervisor shall be available during all operating hours and when the clinical supervisor was unavailable a health professional with experience, education, and qualifications to see all care and services provided would be available. During the entrance conference on 10/24/2023 at 10:38 AM, the Administrator indicated the Agency did not have a Clinical Manager. During an interview on 10/24/2023 at 12:01 PM, the administrator indicated the Clinical Manager left in 2021. A review of the State Agencies Home Health Agency Report, received from the Administrator on 10/25/2023 at 12:45 AM, failed to evidence a Clinical Manager nor an interim or an alternate Clinical Manager. During an interview on 10/25/2023 at 10:36 AM, the Administrator indicated the form was correct and there was not a current Clinical Manager; that the agency was trying to hire someone. During an interview on 10/30/2023 at 2:23 PM, the Administrator indicated the agency did not have a clinical manager, nor a was there a current backup clinical manager. The administrator indicated the previous clinical manager left in 2021.”

“Ensures qualified pre-designated person CFR(s): 484.105(b)(2) When the administrator is not available, a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator. The pre-designated person may be the clinical manager as described in paragraph (c) of this section. This Element is not met as evidenced by: Based on record review and interview the administrator failed to ensure that a qualified person was authorized to act in the administrator’s absence (Corporate Staff 1). Findings include: A review of an agency policy dated 12/2018, titled, “Personnel Records,” indicated the employee personnel record would include criminal history and background checks as required by law. A review of an agency job description titled, “Alternate Administrator,” received on 10/26/2023, indicated that the alternate administrator would ensure that a clinical manager was available during all operating hours. A review of the agency governing body minutes dated 03/01/2022 indicated corporate staff 1 was approved and appointed to the role of alternate administrator. A review of personnel records for corporate staff 1 evidenced a job description signed on 03/07/2022, titled, “Alternate Administrator,” which indicated in the absence of the administrator the alternate administrator is responsible for planning, coordinating, and directing all activities and programs of the home health agency at all times during operating hours. The job description indicated the position qualification would be a licensed physician, a registered nurse (RN) or hold an undergraduate degree. A review of the personnel records indicated corporate staff 1 held an Illinois RN license and did not have an Indiana RN license where the agency was located. The personnel records reviewed evidenced a limited background check for the state of Illinois dated 09/16/2019 and did not include a national background check or an Indiana background check. During an interview on 10/26/2023, at 2:23 PM the Administrator indicated she does what the clinical manager would do as the agency did not have a current clinical manager. The Administrator indicated that if he/she was not available Corporate Staff 1 would have to come in. During an interview on 10/30/2023, at 11:00 AM, the Administrator indicated he/she had direct patient contact and would see patients if required. During an interview on 10/30/2023 at 2:23 PM, the Administrator indicated there was not a current clinical manager, and there is not a current backup clinical manager. During an interview on 10/30/2023, at 12:17 PM, the Administrator confirmed corporate staff 1 did not have an Indiana RN license or a National Criminal Background Check.”

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on record review and interview, the agency failed to maintain a clinical record with all pertinent patient information in 1 of 1 patient with a Do Not Resuscitate order (Patient #5). The findings include: A review of an agency policy titled “Advanced Directives”, revised 4/2020, indicated if a patient has completed an Advance Directive or DNR (Do not resuscitate) order, a copy of the document should be entered in the patient’s clinical record. If a copy is not immediately available, the clinician will discuss the contents of the Advance Directive with the patient and / or their representative and document the contents of the directive in the patient record. A review of an agency document titled “Home Health Updated Plan of Care Report”, for certification period 10/17/2023 to 12/15/2023 evidenced Patient #5 had a Do Not Resuscitate order, and the document was in the patient’s home. The area of the form where content of the Advance Directive was to be documented stated “NA”. A clinical record review failed to evidence a copy of the DNR order or any discussion of contents of the Advance Directive as stated in the agency’s policy. During an interview on 10/27/2023 at 2:47 PM, the administrator indicated the admitting clinician should request a copy of the DNR order from the patient or physician to enter into the patient’s chart. During an interview on 10/27/2023 at 2:53 PM, Administrative Staff 2 indicated the patient’s clinical record failed to evidence a copy of their Advance Directive.”