Indiana Signal Health Group Skilled Inc.

“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 notify the physician of missed skilled nursing visits for 1 of 3 wound care patients reviewed. (Patient #1) Findings Include: 1. A policy titled, “Interruption of Services/Missed Visits” indicated but was not limited to, “If the Agency misses visits or services as required by the plan of care, the Agency must notify the responsible physician of the missed visit if there is any potential for clinical impact upon the patient. The physician will determine whether the patient visit may be skipped or additional intervention is required by the Agency due to the impact on the patient. All documentation will be filed in the patient chart”. 2. A document titled, “Communication Note” was sent to the physician on 09/18/2024 by the Administrator. The note indicated dates of missed visits. 08/15/2024, 08/19/2024, 08/20/2024, 08/22/2024, 08/23/2024, 08/29/2024, 09/02/2024, 09/05/2024, and 09/12/2024. 3. The clinical record for Patient #1 evidenced missed visits by skilled nursing regarding wound care on 08/15/2024, 08/19/2024, 08/20/2024, 08/22/2024, 08/23/2024, 08/29/2024, 09/02/2024, 09/05/2024, and 09/12/2024. The agency failed to notify the physician of the missed visits until the surveyor identified them. 4. During an interview on 09/18/2024 at 10:35 AM, the Administrator indicated that all missed visits should be sent to physicians for notification. The Scheduler typically sends them all at once every 2-4 weeks. The missed nursing visits for Patient #1 were not sent to the physician and he plans to send them now. The Administrator, indicated, after a discussion with the Scheduler, that he has only sent home health aide missed visits to the physician. Nursing missed visits are to be sent by the Administrator. IAC 17-13-1(a)”

“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 home health agency failed to obtain a signed physician order for services in 1 of 3 new admissions reviewed. (Patient #6) Findings Include: 1. A policy titled, “Orders: Signed in 30 Days”, indicated but was not limited to, “Orders are signed by the physician within time frames established by state/federal regulations and our Agency policy, but at least within 30 days. All plans of care, verbal orders, and changes in orders will be signed by the certifying physician in 30 days and filed in the patient’s clinical file. Every effort will be made to ensure the order is signed within the timeframe, including refaxing and in person visit to the MD office. All efforts to obtain the MD signature will be documented”. 2. A policy titled, “Verbal Orders”, indicated but was not limited to, “Verbal orders must be authenticated and dated by the physician in accordance with applicable state laws and regulations, and Agency policy”. 3. A policy titled, “Plan of Care (POC)” indicated but was not limited to, “Must be signed by the attending medical professional acting within the boundaries of all applicable state laws and regulations”. 4. A Clinical Record for Patient #6, Start of Care 07/29/2024, Certification Period 07/29/2024--09/26/2024 failed to include a signed physician order for services. Services included a start of care skilled nursing visit one time and Physical Therapy services once weekly for 1 week, then twice weekly for 8 weeks. 5. During an interview on 09/20/2024 at 12:09 PM, the Administrator indicated starting care for Patient #6. The expectation is to obtain a signed physician order for services and typically does this, however, this one got missed. The Plan of Care was signed by the physician on 09/17/2024 with orders for skilled nursing for the start of care and physical therapy but agreed this signature was not obtained in the Agency timeframe expectation, of 30 days.”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on observation, record review, and interview, the home health agency failed to ensure that all medical equipment in the home was listed on the Plan of Care for 3 of 3 home visits completed. (Patient #1, #2, & #9) Findings Include: 1. A policy titled, “Plan of Care (POC)” indicated but was not limited to, “Required to include ... supplies and equipment required ...”. 2. During a home visit observation for Patient #1 on 09/18/2024 at 1:00 PM, the surveyor observed a glucometer (used to assess blood glucose levels), a Dexcom (device worn to assess continuous blood glucose level monitoring), and a Continuous Positive Airway Pressure (CPAP) machine (a device used to keep airways open while sleeping) in the home. The Clinical Record/POC for Patient #1, Certification Period 09/13/2024--11/11/2024, failed to include a glucometer, a Dexcom, and a CPAP. 3. During a home visit observation for Patient #2 on 09/20/2024 at 9:30 AM, the surveyor observed a glucometer in the home. The Clinical Record/POC for Patient #2, Certification Period 08/11/2024--10/09/2024, failed to include a glucometer. 4. During a home visit observation for Patient #9 on 09/20/2024 at 10:00 AM, the surveyor observed hearing aides, a bedside commode, and a urinal in the home. The Clinical Record/POC for Patient #9, Certification Period 07/28/2024--9/25/2024, failed to include hearing aides, a bedside commode, and a urinal. 5. During an interview on 09/19/2024 at 9:56 AM, the Administrator indicated that all durable medical equipment in the home should be on the plan of care. 410 IAC 17-13-1 (a)(1)(C)(ii)”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on record review and interview the agency failed to follow physician orders for wound care in 3 of 3 wound care patients reviewed. (Patient #1, #2, #3) Findings Include: 1. A policy titled “Verbal Orders” indicated but was not limited to: “Conformance with Physician Orders: ... Drugs and treatments are administered by the Agency staff only as ordered by the physician.” 2. A record review for Patient #1, Certification Period 08/11/2024–10/09/2024, evidenced the following: An 08/01/2024 physician wound care order for Patient #1’s coccyx indicated but was not limited to, Cleanser: Soap and water, two times per day for 30 days. Primary dressing: Wet to dry, two times per day for 30 days. Secondary dressing: Telfa Island 4x4 (a soft non-woven dressing that conforms around the wound and seals on all four sides), two times per day for 30 days. An 08/12/2024 Skilled Nursing Visit Note: Treatment performed: Skilled nurse performed pressure ulcer care to the coccyx, cleansing/irrigating the wound with Normal Saline (NS), applying a wet-to-dry dressing, and covering and securing with foam dressing using an aseptic technique. The skilled nurse was also to teach the patient/caregiver to perform wound care. LPN 1 failed to cleanse the wound with soap and water and apply a Telfa Island 4x4 dressing twice daily as ordered. An 08/13/2024 Skilled Nursing Visit Note: Treatment performed: Skilled nurse performed pressure ulcer care to the coccyx, cleansing/irrigating the wound with NS, applying a wet-to-dry dressing, and covering and securing with foam dressing using an aseptic technique. The skilled nurse may teach the patient/caregiver to perform wound care. LPN 1 failed to cleanse the wound with soap and water and apply a Telfa Island 4x4 dressing twice daily as ordered. An 08/14/2024 Skilled Nursing Visit Note: Treatment performed: Cleansed wound with NS, patted dry, applied wet to dry dressing, covered and secured with an island dressing using an aseptic technique. The Administrator failed to cleanse the wound with soap and water twice daily as ordered. An 08/15/2024 physician wound care order for Patient #1’s coccyx indicated but was not limited to, Cleanser: Soap and water, two times per day for 30 days. Primary dressing: Dry gauze, two times per day for 30 days. Secondary dressing: Telfa Island 4x4, two times per day for 30 days. An 08/16/2024 Skilled Nursing Visit Note: Treatment performed: Cleansed wound with NS, patted dry, applied wet to dry dressing, covered and secured with an island dressing using an aseptic technique. The Administrator failed to cleanse the wound with soap and water and apply dry gauze twice daily as ordered. An 08/21/2024 Skilled Nursing Visit Note: Treatment performed: Cleansed wound with soap and water, patted dry, applied wet to dry dressing, and covered and secured with a 4x4 island dressing using an aseptic technique. The Administrator failed to apply dry gauze twice daily as ordered. A 09/06/2024 physician wound care order for Patient #1’s coccyx indicated but was not limited to, Cleanser: Soap and water, once per day for 30 days. Primary dressing: Silver 4x4 Melgisorb AG (absorbent calcium alginate dressing with silver), once per day for 30 days. Secondary dressing: Telfa Island 4x4, once per day for 30 days. A 09/06/2024 Skilled Nursing Visit Note: Treatment performed: Cleansed wound with NS, applied silver 4x4 Melgisorb AG, covered and secured with Optifoam dressing using aseptic technique. LPN 1 failed to cleanse the wound with soap and water and apply Telfa Island 4x4 dressing daily as ordered. A 09/09/2024 Skilled Nursing Visit Note: Treatment performed: Cleansed wound with NS, applied silver 4x4 Melgisorb AG, covered and secured with Optifoam dressing using aseptic technique. LPN 1 failed to cleanse the wound with soap and water and apply Telfa Island 4x4 dressing daily as ordered. A 09/10/2024 Skilled Nursing Visit Note: Treatment performed: Cleansed wound with NS, applied silver 4x4 Melgisorb AG, covered and secured with Optifoam dressing using aseptic technique. LPN 1 failed to cleanse the wound with soap and water and apply Telfa Island 4x4 dressing daily as ordered. 3. A record review for Patient #2, Certification Period 09/13/2024–11/11/2024, evidenced the following: A 09/10/2024 physician wound care order for Patient #2’s right lateral lower leg indicated but was not limited to, Cleanser: Soap and water, one time per day for 30 days. Primary Dressing: Silver 4x4 Melgisorb AG, one time per day for 30 days. Secondary Dressing: Kerlix (bandage roll providing wicking action, aeration, and absorbency), one time per day for 30 days. Compression Wrap: Ace Wrap, one time per day for 30 days. A 09/14/2024 Skilled Nursing Visit Note: The following treatment was performed: Skilled nurse performed wound care for the right lower leg venous ulcer, cleansing the wound with soap and water, rinsing, patting dry, applying Melgisorb AG, and covering and securing the dressing with an ACE bandage, using aseptic technique. The Administrator failed to apply Kerlix as ordered. A 09/16/2024 Skilled Nursing Visit Note: The following treatment was performed: Skilled nurse performed wound care for the right lateral leg venous ulcer, cleansing the wound with soap and water, rinsing, patting dry, applying Melgisorb AG, and covering and securing the dressing with an ACE bandage, using aseptic technique. LPN 1 failed to apply Kerlix as ordered. 4. A record review for Patient #3, Certification Period 08/31/2024–10/29/2024, evidenced the following: An 08/12/2024 physician wound care order for Patient #3’s left ischial pressure wound (buttock) indicated but was not limited to, Applying antifungal powder once every other day. A 09/05/2024 Skilled Nursing Visit Note: The following treatment was performed: The skin around the wound was cleansed with soap and water, rinsed with water, and patted dry. The wound was cleaned with a sterile cotton-tipped applicator and sterile gauze, and a scant amount of ground Metronidazole (500 mg antibiotic tablet) was applied to the wound bed. Prisma (used to optimize wound healing) was loosely placed in the wound, and the area was covered with 3x3 gauze and secured with a cover roll. LPN 1 failed to apply antifungal powder once every other day and failed to obtain updated physician wound orders. A 09/09/2024 Skilled Nursing Visit Note: The following treatment was performed: The skin around the wound was cleansed with soap and water, rinsed, and patted dry. The wound was cleaned with a sterile cotton-tipped applicator and sterile gauze, and a scant amount of ground Metronidazole 500 mg tablet was applied to the wound bed. Prisma was loosely placed in the wound, and the area was covered with 3x3 gauze and secured with a cover roll. LPN 1 failed to apply antifungal powder once every other day and failed to obtain updated physician wound orders. A 09/12/2024 Skilled Nursing Visit Note: The following treatment was performed: The skin around the wound was cleansed with soap and water, rinsed, and patted dry. The wound was cleaned with a sterile cotton-tipped applicator and sterile gauze, and a scant amount of ground Metronidazole 500 mg tablet was applied to the wound bed. Prisma was loosely placed in the wound, and the area was covered with 3x3 gauze and secured with a cover roll. LPN 1 failed to apply antifungal powder once every other day and failed to obtain updated physician wound orders. A 09/16/2024 Skilled Nursing Visit Note: The following treatment was performed: The skin surrounding the wound was cleansed with soap and water, rinsed, and patted dry. The wound was cleaned with a sterile cotton-tipped applicator and sterile gauze, and a scant amount of ground Metronidazole 500 mg tablet was applied to the wound bed. Prisma was loosely placed in the wound, and the area was covered with 3x3 gauze and secured with a cover roll. LPN 1 failed to apply antifungal powder once every other day and failed to obtain updated physician wound orders. 5. During an interview on 09/17/2024 at 3:13 PM, the Administrator indicated that physician orders for wound care were not followed for Patient #1. The Administrator further indicated that Patient #1’s orders change frequently and should be followed at all times. The Administrator was unable to change wound orders on the Plan of Care and could not figure out how to do so within the Electronic Medical Record (EMR) system. The Administrator also indicated that caregivers, specifically the grandson and niece, performed wound care in the evening or when a visit was missed by the nurse. The Administrator was unable to find or provide documentation showing that the caregivers were trained on wound care initially or with each wound care order change. The wound care completed by the caregivers was not documented or tracked, and the Administrator only knew it was completed because Patient #1 reported it. 6. During an interview on 09/17/2024 at 4:20 PM, Patient #1 indicated that a friend completes wound care in the absence of the nurse. Patient #1 communicates any new wound care orders to their friend, who then performs the care. Patient #1 did not recall the agency nurses training their friend on how to complete wound care but indicated satisfaction with the current services received from the home health agency. 7. During an interview on 09/18/2024 at 9:05 AM, the Administrator acknowledged being aware that Patient #1’s caregivers had not been trained on wound care and planned to schedule a date and time for the training. 8. During an interview on 09/18/2024 at 10:35 AM, the Administrator indicated that physician orders for wound care were not followed for Patient #2, and Kerlix was not included in the wound orders on the Plan of Care. 9. During an interview on 09/18/2024 at 1:30 PM, the Director of Marketing was asked to provide wound care orders for Patient #3. Wound care orders from January 2024 were provided. The Director denied having any further notes or orders from the wound center for review. The Director indicated that Patient #3’s wound orders had not changed but requested an update from the wound center. New orders were provided, which were noted to be significantly different from the current treatment being provided. The most recent wound order was dated 08/12/2024. 410 IAC 17-13-1(a)”

“Patients receive education and training CFR(s): 484.60(d)(5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge. This Element is not met as evidenced by: Based on record review and interview the agency failed to provide initial and on-going wound care training/education to the caregiver for wound care that was to be provided in the absence of agency nursing staff in 1 of 3 wound care patients reviewed. (Patient #1) Findings Include: 1. A policy titled, “Admission Documentation/Patient Education” indicated but was not limited to, “Patient/Family Education: Starting with the admission visit, Agency staff will provide education to the patient and caregiver related to: Infection prevention & control... Treatments/care/services ... Such education may be oral or written educational materials sourced from the Agency or any other agency/authority in the topic, and documented in the permanent clinical record that information was provided”. 2. A policy titled, “Wound Care” indicated but was not limited to, “a. Wound care education will be provided to each patient/caregiver as applies ... c. All education on wound care will include, but not be limited to: ... Self wound care ... Dressings to be utilized in wound care ... Symptoms to report to your nurse or physician ... d. All wound care education is to be documented in nursing notes”. 3. The Clinical Record for Patient #1, Certification Period 08/11/2024--10/09/2024, failed to include documentation demonstrating that the caregiver received initial and ongoing education/training on wound care to be completed in the absence of the agency nurse. Caregiver infection prevention & control was also absent from the clinical record. 4. During an interview on 09/17/2024 at 3:13 PM, the Administrator indicated that the caregivers complete wound care in the absence of agency nursing staff. Caregivers include a grandson and a niece. Agency nursing staff complete home visits once a day, Monday-Friday. The caregivers provide wound care each evening as ordered and on the weekends. 5. During an interview on 09/17/2024 at 4:20 PM, Patient #1 indicated that a friend completes wound care in the absence of nursing staff. Cannot recall a friend receiving training/education on wound care initially or ongoing. Patient #1 tells a friend what the wound doctor’s orders are and he/she completes wound care. 6. During an interview on 09/19/2024 at 9:05 AM, the Administrator indicated that documentation of caregivers’ training and education regarding Patient #1’s wound care was not found in the clinical record, neither initial or ongoing. Wound care has been and will continue to be provided by the caregiver in the absence of nursing staff. The agency plans to set up a date/time for the caregivers to be trained. 7. During an interview on 09/20/2024 at 12:09 PM, the Administrator indicated that the caregiver was trained today on wound care/infection control. 410 IAC 17-14-1 (a)(1)(G)”

“Aides are members of interdisciplinary team CFR(s): 484.80(g)(4) Home health aides must be members of the interdisciplinary team, must report changes in the patient’s condition to a registered nurse or other appropriate skilled professional, and must complete appropriate records in compliance with the HHA’s policies and procedures. This Element is not met as evidenced by: Based on record review and interview the Home Health Aide (HHA) failed to report a change in condition to the Registered Nurse in 1 of 3 active records reviewed with HHA services. (Patient #4) Findings Include: 1. A document titled, “Job Title: Home Health Aide (HHA)” indicated but was not limited to, “Reports any changes in the patient’s status or home situation immediately to the supervisor, staff nurse, or aide supervisor, including recognizing & reporting skin changes”. 2. A document dated 09/13/2024 titled, “Client Notes Report” indicated that HHA #2 noted that Patient #4 had a couple of “open spots” on his/her backside, and “cream” was applied. HHA 2 failed to notify the nurse of the change in condition. 3. During an interview on 09/20/2024 at 12:49 PM, the Administrator was reviewing Patient #4’s clinical record with the surveyor and read aloud the note entered by HHA #2 and indicated that she was not made aware of these open spots and confirmed that the documentation did not include a note indicating any nurse was made aware. She stated the expectation is for the HHA to notify the nurse of any changes in condition. 4. During an interview on 09/23/2024 at 3:30 PM, HHA #2 indicated that Patient #4 did have new open spots identified on his/her bottom on 09/13/2024. She indicated that this was an ongoing thing with Patient #4 and was not uncommon. Surveyor clarified with HHA #2 that these were new open spots and HHA #2 confirmed they were. HHA #2 further indicated that if they were “really open and raw” the nurse would be notified. HHA #2 indicated that the open spots had not cleared to date and planned to notify the Administrator later today.”