Prairie Healthcare Services LLC

“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 enteral nutrition information was included in the plan of care for 1 of 1 patient receiving enteral nutrition. (Patient #6) The findings include: 1. An agency policy titled “Plan of Care-CMS #485 and Physician Orders,” revised 11/4/2022 indicated the individualized care plan must include nutritional requirements and all medication and treatments. 2. A review of the clinical record for Patient #6 evidenced the start of care assessment dated 1/2/2023 and electronically signed by Registered Nurse (RN) 2 which indicated the patient is unable to take nutrients orally and is fed through a gastrostomy tube. A review of the clinical record for Patient #6 evidenced a Plan of Care for certification period 1/2/24 to 3/1/24. The POC failed to include the instructions for what formula of feeding the patient was on, failed to include the quantity of feedings and the frequency of the feedings, and the amount and frequency of the gastrostomy tube flushes. During a home visit on 1/9/2024 beginning at 1:45 AM, Patient #6 was observed to have a tube feed infusing. Person C (family member) was queried about the tube feeding and indicated Patient #6 prescription was for Nestle Compete standard vegan 1.4, but they are trying different types to see if there is one Patient #6 can tolerate better. Person D indicated she has the feeding running continuously at 60 milliliters (ml) per hour for 18 hours but lets one carton infuse and then stops the feeding for an hour and repeats the process for 18 hours. During an interview on 1/9/2024 at 3:38 PM, RN 2 indicated the feeding information is not listed on the plan of care because the family does the feedings. During an interview on 1/11/2024 at 10:31 AM, the Clinical manager indicated the plan of care should include the type of formula, frequency, and duration of the feedings, peg tube care, and dressings. 17-13-1(a)(1)(D)(viii)”

“Discharge Planning CFR(s): 484.58 Condition of Participation: Discharge planning. This Condition is not met as evidenced by: Based on record review and interview, the home health agency failed to establish and follow policies for discharge planning to ensure patient needs were adequately met upon discharge (G0560) and failed to send all necessary medical information pertaining to the patient’s current course of illness and treatment to the receiving health care practitioner to ensure a safe and effective transition of care (G0564). 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 42CFR 484.58 Discharge Planning. Based on record review and interview, the agency failed to ensure the patient’s needs have been met adequately upon discharge in 1 of 2 discharge records reviewed (Patient #1) The findings include: 1. An agency policy revised 11/4/2023, titled “Discharge Criteria,” indicated the agency would provide the patient with contact information for other agencies or providers who may be able to provide care. The patient will be informed of a of a discharge plan in a timely manner. 2. A clinical record review for Patient #1 evidenced a communication note dated 11/11/2023 which indicated the patient had critical lab values for Potassium and Calcium. The Nurse Practitioner was notified and advised the patient should go the emergency room. A review of Patient #1’s clinical record evidenced a Nursing visit note dated 11/11/2023 which indicated home care was necessary to monitor vital signs, Foley catheter care, wound care and patient education. A review of Patient #1’s clinical evidenced a communication note dated 11/13/2023 which indicated Patient #1 called the office and indicated he/she did not go to the Emergency Room on 11/11/2023. During an interview on 11/30/2023 at the alternate Clinical Manager indicated she discharged Patient #1 due to noncompliance with the Physician Order to go to the Emergency Room. When queried as to what was done to ensure patient safety if the patient was discharged with critical labs, the Clinical Manager indicated the patient would have lab work done at the Physician’s office. A review of Patient #1’s clinical record evidenced a paper copy the laboratory results with the corrected values. This documented evidenced the corrected values were called and reported to the Administrator on 11/11/2023 and faxed to the agency on 11/12/2023. A clinical record review for Patient #1 evidenced a discharge summary dated 11/13/2023, which indicated the patient was discharged for noncompliance. The agency failed to ensure the patients’ needs were met upon discharge. During an interview on 11/30/2023 at 2:57 PM, Patient #1 indicated the agency told him/her he/she had critical lab results but was unable to tell him/her what lab results were critical. He/She indicated she told the agency they did not have transportation and would need to call an ambulance and would like to let them know the reason she needed to go to the Emergency Room. He/She indicated since it was Saturday, he/she decided to wait to contact the Physician on Monday. He/She indicated the Physician’s office informed him/her laboratory results were contaminated and would need to be redone. Patient #1 indicated the alternate Clinical Manager called Patient #1 and discharged Patient #1 telling him/her he/she is fine, and he/she doesn’t need services any longer.”

“Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient’s medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This Condition is not met as evidenced by: Based on observation, record review, and interview, the home health agency failed to ensure: the agency met the patient’s needs (G0570); the plan of care was reviewed by the physician, individualized and followed by all agency staff (G0572); services and treatment were provided as ordered by a physician (G0578); all treatments provided by agency staff were ordered by a physician (G0580); coordination of care for all services provided to the patient (G0606); coordinate care delivery (G0608); the written visit schedule was provided to patients (G0614); written instructions were provided to the patient for the patient’s medication schedule and instructions (G0616); the treatments to be administered by agency personnel were provided to the patient and caregiver in writing (G0618). The cumulative effect of these systemic problems has resulted in the home health agency inability to ensure provision of quality health care in a safe environment for the condition of participation 42CFR 484.60 Care Planning, Coordination of Care. 410 IAC 17-13-1(a) The findings include: Findings include: Review of policy, “Plan of Care-CMS #485 and Physician Orders,” revised 11/4/2022, indicates “Skilled nursing and other home health services will be in accordance with a Plan of Care based on the patient’s diagnosis and assessment…needs…Patients are accepted for treatment on the reasonable expectation that the agency can meet the patient’s…needs…”. *Review of clinical record for Patient #6 which included an initial comprehensive assessment, completed by Registered Nurse (RN) 2 on 10/16/2023, which indicated Patient #6 had a need for assistance with activities of daily living; grooming, dressing, bathing, toileting, and transferring. The assessment failed to evidence RN 2 assessed if Patient # 6 had need of home health aide services. *During an interview with caregiver of Patient #6 conducted on 11/30/23, beginning at 4:07 PM, caregiver confirms agency did not offer home health aide services to assist with Patient # 6’s personal care needs. 1. A review of an agency policy revised 11/4/2022, titled “Patient Admission Criteria,” indicated patients ae accepted for treatment on the basis of a reasonable expectation that the patient’s medical, nursing, and social needs can be adequately met. 2. A clinical record review for Patient #2 evidenced an agency document titled “Start of Care” which evidenced Patient #2 need assistance with grooming assistance, bathing assistance, toileting hygiene. During a home visit on 11/29/2023 at 5:00 PM, Patient #2 indicated the Occupational Therapist came the day before and she was able to finally shower for the first time since the end of September. Patient #2 indicated she was not offered a home health aide service from the agency. During an interview on 11/29/2023 at 2:30 PM, Registered Nurse (RN) 2 indicated Patient #2 was not offered an aide because the Physician did not order one. RN 2 indicated Patient #2 could use a homemaker and a home health aide to help until they find out what is going on with his/her back, but it is so hard to find home health aides and Patient #2 particular about who he/she wants to see. 3. A clinical record review for Patient #3 evidenced an agency document titled “Start of Care,” dated 11/3/2023, which evidenced Patient #3 need assistance with grooming assistance, bathing assistance, toileting hygiene. A record review for Patient #3 evidenced an skilled nursing notes dated 11/6/2023, 11/8/2023, 11/10/2023, 11/13/2023, 11/16/2023, 11/18/2023, 11/20/2023, 11/22/2023, 11/24/2023, 11/28/2023, evidenced Patient #3 had Cerebral Palsy (a group of disorders that affect a person’s ability to move and maintain balance and posture), left hand contracture poor hand coordination inability to safely ambulate without human assistance has the inability to manage home care needs independently, and was unable to perform activities of daily living without considerable assistance. A review of Patient #3’s clinical record failed to indicate the Agency offered a Home Health Aide to meet Patient #3’s needs. During a interview of 12/1/2023 at 12:54 PM, the Alternate Administrator indicated they did not offer a home health aide and family lived with Patient #3. 4. A clinical record review for Patient #4 evidenced a Physician Order dated 6/24/2023 for a Medical Social Worker. The patient called and had to reschedule visit and was told the MSW would not be able to see the Patient until 7/16/2023. A clinical record review of Patient #4 electronical medical record evidenced the MSW Evaluation was completed om 7/16/2023. The MSW failed to meet Patient #4’s needs and have a timely MSW evaluation, During an interview on 12/1/2023 at 11:45 AM, the Alternate Administrator indicated the Patient was unable to be seen by the MSW because she was going on vacation and the do not have another MSW on staff or contracted. 1. An agency policy revised 11/4/2022, titled “Patient Admission Criteria,” indicated patients are accepted for treatment on the basis of a reasonable expectation that the patient’s medical, nursing, and social needs can be adequately met. 2. A clinical record review for Patient #2 evidenced an agency document titled, “Start of Care” (SOC)which evidenced Patient #2 needed assistance with grooming assistance, bathing assistance, toileting hygiene. During a home visit on 11/29/2023 at 5:00 PM, Patient #2 indicated the Occupational Therapist came the day before and she was able to finally shower for the first time since the end of September. Patient #2 indicated she was not offered home health aide services from the agency. During an interview on 11/29/2023 at 2:30 PM, Registered Nurse (RN) 2 indicated Patient #2 was not offered an aide because the Physician did not order one. RN 2 indicated Patient #2 could use a homemaker and a home health aide to help until they find out what is going on with his/her back, but it is so hard to find home health aides and Patient #2 is particular about who he/she wants to see. 3. A clinical record review for Patient #3 evidenced an agency document titled “Start of Care,” dated 11/3/2023, which evidenced Patient #3 needed assistance with grooming assistance, bathing assistance, and toileting hygiene. A record review for Patient #3 evidenced an skilled nursing notes dated 11/6/2023, 11/8/2023, 11/10/2023, 11/13/2023, 11/16/2023, 11/18/2023, 11/20/2023, 11/22/2023, 11/24/2023, 11/28/2023, evidenced Patient #3 had Cerebral Palsy (a group of disorders affecting a person’s ability to move and maintain balance and posture), left hand contracture poor hand coordination inability to safely ambulate without human assistance has the inability to manage home care needs independently, and was unable to perform activities of daily living without considerable assistance. A review of Patient #3’s clinical record failed to indicate the Agency offered a Home Health Aide to meet Patient #3’s needs. During a interview of 12/1/2023 at 12:54 PM, the Alternate Administrator indicated they did not offer a home health aide and family lived with Patient #3. 4. A clinical record review for Patient #4 evidenced a Physician Order dated 6/24/2023 for a Medical Social Worker. The patient called and had to reschedule visit and was told the MSW would not be able to see the Patient until 7/16/2023. A clinical record review of Patient #4 electronical medical record evidenced the MSW Evaluation was completed om 7/16/2023. The MSW failed to meet Patient #4’s needs and have a timely MSW evaluation, During an interview on 12/1/2023 at 11:45 AM, the Alternate Administrator indicated the Patient was unable to be seen by the MSW because she was going on vacation and the do not have another MSW on staff or contracted. 5. Review of clinical record for Patient #6 which included an initial comprehensive assessment, completed by Registered Nurse (RN) 2 on 10/16/2023, which indicated Patient #6 had a need for assistance with activities of daily living; grooming, dressing, bathing, toileting, and transferring. The assessment failed to evidence RN 2 assessed if Patient # 6 had need of home health aide services. 6. During an interview with caregiver of Patient #6 conducted on 11/30/23, beginning at 4:07 PM, caregiver confirms agency did not offer home health aide services to assist with Patient # 6’s personal care needs.”

“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 7 of 7 records reviewed. (Patient #1, 2, 3, 4, 5, 6, 7) The findings include: *During record review for Patient # 6, the clinical record failed to evidence documentation of plans for evacuation location and directions for Patient #6 if evacuation required due to emergency or disaster is needed. *On 11/29/23, beginning at 12:01 PM, during home observation, Patient # 7’s home folder contained Individual Patient Emergency Preparedness Plan that failed to evidence emergency contact phone number as well as documentation of plans for evacuation location and instructions due to emergency or disaster if needed. 1. A review of an agency policy revised 5/26/2022 titled, “Disaster Preparedness Policies and Procedures,” indicated individualized plans for patients during a natural or man-made disaster must be included as part of the comprehensive patient assessment. 2. A review of the initial assessment for patient #1, dated 07/23/2023, indicated the patient required a foley catheter (medical device that helps drain urine from your bladder. and had a port (an implantable device used for blood work and intravenous medication administration). A review of the patient’s individualized emergency plan, failed to evidence the patient’s foley catheter, port, and supplies and instructions for them. 2. During a home visit for patient #2, on 11/29/2023, at 5:15 PM, the home folder was observed. The home folder contained an undated document titled “Individual Patient Emergency Plan” which failed to specify an evacuation location and an emergency contact person. A clinical record review for patient #2, evidenced an undated document titled “Individual Patient Emergency Plan” which failed to specify an evacuation location and an emergency contact person. During an interview on 12/1/2023 at 11:32 Am, the Alternate Administrator indicated the patient lives alone that’s why there was no emergency contact person one the emergency plan. 3. A clinical record review for patient #3, evidenced a start of care assessment dated 6/15/2023 which evidenced the patient had wounds. A review of Patient #3’s Individualized Emergency Plan failed to evidence an evacuation address and instructions and failed to include wound care instructions. 4. A review of the individualized emergency plan for Patient #4 failed to evidence evacuation and transportation plans. 5. A clinical record review for patient #5, evidenced a resumption of care assessment dated 6/29/2023 which evidenced the patient had wounds. A review of Patient #3’s Individualized Emergency Plan failed to evidence an evacuation address and instructions and failed to include wound care instructions.”

“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 based on the patient’s medical, psychiatric, and home environment conditions for 1 of 1 agency. Findings include: An agency policy revised 5/26/20023, titled, “Disaster Preparedness Policies and Procedures,” 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 11/29/2023, failed to evidence documentation of the procedure to inform state and local emergency preparedness officials about patients in need of evacuation from their residence if there is an emergency. During an interview on 12/1/2023, at 11:20 AM, the Alternate Administrator indicated the policy says the clinical manager will follow up with staff and patients and contact authorities if needed.”

“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 the agency was unable to contact for 1 of 1 agency. Findings include: An agency policy revised 5/26/20023, titled, “Disaster Preparedness Policies and Procedures,” indicated the agency would maintain an emergency preparedness communication plan that would include how the agency coordinated patient care within the agency, across healthcare providers, and with the state and local public health departments. The plan indicated the agency should include how the agency interacts with emergency management agencies and systems. The policy failed to address what actions would be required due to the inability to contact staff or patients and reporting capabilities to the local and state emergency officials. A review of the emergency preparedness binder on 11/29/2023, failed to evidence documentation of a communication plan to include a means of informing state and local emergency officials of patients and on-duty staff who were unable to be contacted. During an interview on 12/1/2023, at 11:17 AM, the Alternate Administrator indicated the Administrator would be responsible for contacting local and state health officials.”

“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. The findings include: An agency policy revised 5/26/20023, titled, “Disaster Preparedness Policies and Procedures,” indicated the agency would use volunteers in an emergency or other emergency staffing strategy to address surge needs during and emergency. A review of the emergency preparedness binder on 11/29/2023, 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 12/1/2023, at 11:28 AM, the Alternate Administrator indicated the agency does not use volunteers and does not have contact information for volunteers at this time.”

“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 identify 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: An agency policy revised 5/26/20023, titled, “Disaster Preparedness Policies and Procedures,” 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 11/29/2023, 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 11/29/2023, at 11:29 PM, the Alternate Administrator indicated the Administrator would set up a command center and would be responsible for sharing information in the event of an emergency.”

“Discharge or Transfer Summary Content CFR(s): 484.58(b)(1) Standard: Discharge or transfer summary content. The HHA must send all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure the discharge/transfer summary contained all necessary information regarding the patient’s discharge including medications and treatments in 1 of 2 discharged records reviewed The findings include: 1. An agency policy revised 11/4/2023, titled “Discharge Summary,” indicated the summary will include any instructions given to the Patient. 2. A review of Patient #1’s clinical record evidenced an agency document titled “SN [Skilled Nurse] Discharge Summary” dated 11/13/2023, which failed to include the instructions on medications, diagnosis, wound care orders, frequency of foley catheter changes, and frequency of port flushes. During an interview on 11/30/2023 at 4:37 PM, the Alternate Clinical Manager indicated she verbally instructed the patient and put all information in the discharge instructions. She indicated she did not specify what she instructed the patient on in the discharge summary. 410 IAC 17-15-1-(a)(6)”

“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 observation, record review and interview, the home health agency failed to ensure the plan of care was individualized to include patient-specific measurable outcomes and goals in 5 of 7 clinical records reviewed. (#1, #2, #3, #4, #5) These findings include: 1. An agency policy revised 11/4/2023 titled “Plan of Care,” indicated each patient must receive an individualized written plan of care and identifies patient specific goals. 2. A clinical record review for Patient #1 evidenced a plan of care, for the certification period 9/19/2023 -11/17/2023. The patient’s goals were for all vital signs to be within normal limits. The patient will recognize the individual disease process, signs and symptoms, cause, risk factors, aggravating factors, complications, and prevention measures of aggravation of symptoms within five weeks. Patient/caregiver will verbalize understanding and adherence to prescribed medications and dietary regimen within five weeks. Patient/caregiver will be able to notify the physician for any significant changes in the patient’s condition. The Patient caregiver will verbalize understanding regarding measures to promote safety to reduce risk of falls and injuries in the home environment. Patient will remain safe in the home environment setting without a fall or injury throughout the certification. Patient caregiver will be able to contact the assigned clinicians for medical questions or needs. Patient will have input on patient’s medical needs and included and comprehensive discharge planning. Patient will demonstrate ability to effectively manage medication regimen. Patient will avoid direct sunlight and use sunscreen protection and wear protective clothing when going out within the episode of care. This plan of care failed to evidence individual goals for Patient #1. 3. A clinical record review for Patient #2 evidenced a plan of care for the certificationperiod 11/1/2023 -12/30/2023. The patient’s goals were for all vital signs to be within normal limits. The patient will recognize the individual disease process, signs and symptoms, cause, risk factors, aggravating factors, complications, and prevention measures of aggravation of symptoms within five weeks. Patient/caregiver will verbalize understanding and adherence to prescribed medications and dietary regimen within 7 weeks. Patient will remain safe in the home environment setting without a fall or injury throughout the certification. Patient will avoid direct sunlight and use sunscreen protection and wear protective clothing when going out within the episode of care. 4. A clinical record review for Patient #3 evidenced a plan of care, for the certification period 11/3/2023 -1/1/2024. The patient’s goals were to be free of Cellulitis and wound infection for the certification period, (Patient #3 was prescribed an antibiotic on 10/30/2023 for Cellulitis) for all vital signs to be within normal limits. The patient will recognize the individual disease process, signs and symptoms, cause, risk factors, aggravating factors, complications, and prevention measures of aggravation of symptoms within six weeks. Patient/caregiver will verbalize understanding and adherence to prescribed medications and dietary regimen within eight weeks. Patient will remain safe in the home environment setting without a fall or injury throughout the certification. 5. A clinical record review for Patient #4 evidenced a plan of care, for the certification period 6/15/2023 -8/3/2023. The patient’s goals were for all vital signs to be within normal limits. The patient will recognize the individual disease process, signs and symptoms, cause, risk factors, aggravating factors, complications, and prevention measures of aggravation of symptoms within seven to eight weeks. Patient/caregiver will verbalize understanding and adherence to prescribed medications and dietary regimen within eight weeks. Patient will remain safe in the home environment setting without a fall or injury throughout the certification. Patient/caregiver will be able to notify the physician for any significant changes in the Patient’s condition within three weeks, Patient/caregiver will verbalize understanding regarding measures to promote communication within three weeks, Patient will demonstrate measures to improve breathing capacity and activity tolerance within three to four weeks. 6. A clinical record review for Patient #5 evidenced a plan of care, for the certification period 6/9/2023 -8/7/2023. The patient’s goals were for all vital signs to be within normal limits. The patient will recognize the individual disease process, signs and symptoms, cause, risk factors, aggravating factors, complications, and prevention measures of aggravation of symptoms within eight weeks. Patient/caregiver will verbalize understanding and adherence to prescribed medications and dietary regimen within eight weeks. Patient will remain safe in the home environment setting without a fall or injury throughout the certification. Patient/caregiver will be able to notify the physician for any significant changes in the Patient’s condition within three weeks, Patient/caregiver will verbalize understanding regarding measures to promote communication within six weeks. 7. During an interview on 12/1/2023 at 12:44 PM, the Alternate Administrator indicated the plan of care should have included patient specific goals. 410 IAC 17-13-1(a).”

“Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This Standard is not met as evidenced by: Based on observation, record review, and interview, the home health agency failed to ensure physician orders were conformed with regard to an integumentary assessment (skin) and call parameters for a heart rate less than 60 beats per minute in 1 of 7 clinical records reviewed. (Patient #7). Findings include: 1. During home visit on 11/29/2023 beginning at 12:01 PM, the Alternate Clinical Manager failed to complete the skin asssessment on Patient #7. Patient #7 asked the Alternate Clinical Manager if they were going to look at the patient’s sacral area, the Alternate Clinical Manager refused and verbalized the patient was good. A review of clinical record for Patient # 7 evidenced a Plan of Care (POC) for certification period 10/26/23 to 12/24/23. The POC indicated an assessment of the integumentary status was to be completed with each visit as well as parameters to notify the physician of a heart rate less than 60 beats per minute. On 10/31/23, 11/2/23, 11/24/23, and 11/27/23 the agency visit notes indicated the heart rate was documented as less than 60 beats per minute and the physician was not notified. During an interview with Alternate Clinical Manager on 11/30/23 at 4:37 PM, Alternate Clinical Manager confirmed the attending physician was never notified about the out-of-range heart rate for Patient #7. During an interview on 12/1/23 at 11:35 AM with Administrator 2, Administrator 2 confirmed a skin assessment should be performed by nursing staff at each 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 observation, record review, and interview, the agency failed to follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections in 2 of 3 home visits with the registered nurse (RN). (#1, 6) The findings include: 1. An agency policy revised 11/4/2023 tilted “Hand Hygiene,” indicated staff should perform hand hygiene before and after direct care, before and after each procedure, after removal of gloves, when hands are soiled, after any contact with contaminated materials, before reentering nursing bag or patients’ clean supplies. 2. An agency policy revised 11/4/2023 titled “Specific Procedures for Employee and Patient Infection Control Training,” indicated hands should be washed before and after wearing gloves, and should be worn with any contact with a moist body site any fluids or solids when handling items soiled with bodily fluids or substances. 3. An agency policy revised 11/4/2023 titled “Standard Precautions,” indicated gloves will be worn before touching body and bodily fluids or non-intact skin of all patients. Gloves will be changed, and hands will be washed after contact with each patient. 4. During a home visit for Patient #1 at 6:25 PM on 12/28 2023 an observation was completed for a skilled nurse wound care visit. Registered Nurse (RN) 1 placed her bag on the bed, took out a trash bag from her bag and placed it on the bed and then placed the bag on top of the trash bag. RN 1 removed her stethoscope from her bag listened to the patient’s lungs and put the stethoscope back into her bag failing to clean the stethoscope. RN 1 took out a small plastic box with supplies: tape thermometer etcetera, and placed it on the table without a barrier. RN 1 placed a blue pad on the floor, placed the dressing on the pad, removed the patient’s sock and old dressing, took off her gloves went back into her bag failing to wash or sanitize her hands. Removed another dressing then went into the patient’s supply bag failing to sanitize her hands removed additional dressings. Placed theses supplies on the pad on the floor, placed scissors on the pad on the floor, she donned new gloves failing to wash her hands, removed the adhesive dressing from the wound, cleaned the wound with normal saline and gauze, and removed her gloves. RN 1went into the patient’s supply bag, failing to sanitize her hands, went back into her bag and removed gloves, donned her gloves, failing to sanitize her hands, measured the wound with the outside of the dressing package, applied a cream to the dressing and applied the dressing to the wound and wrapped the wound with gauze. RN 1 applied the patient socks on, and removed her gloves. RN 1 put hand sanitizer on her thermometer and cleaned her thermometer with gauze. She cleaned her blood pressure cuff with the gauze and obtained patient #1’s vital signs with one glove on and one glove off. She removed the glove she had on her left hand and placed the plastic boxes from the patient’s table back into her bag failing to sanitize her hand prior to going into her bag. 5. A home visit for Patient #6 on 11/29/2023 at 12:00 PM was scheduled to observe a skilled nurse wound care visit. The alternate clinical manager was observed performing wound care. The Alternate Administrator used the wipe cleaned her scissors placed the dirty wipe on top of clean gauze. RN 1 opened a dressing, cut the dressing to size, and poured normal saline on the dressing, while on top of the package, she cleaned the wound and applied the dressing. RN 1 failed to remove her gloves and wash her hands prior to applying the clean dressing. The alternate clinical manager removed her gloves and donned new gloves but failed to sanitize her hands prior to donning the gloves, she cleaned and applied a new dressing to the second wound. 6 During an interview the Alternate Clinical Manager indicated hands need to be washed with soap and water before and after each patient. Hand sanitizer should be used when going from a dirty to clean task, before going into the Nurse’s bag or Patient supplied and before and after donning gloves. 410 IAC 17-12-1(m)”

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on record review and interview the home health agency failed to ensure the comprehensive assessment was conducted within 48 hours of the referral in 1 of 2 discharged records reviewed. (Patient #1) The finding include: 1. An agency policy revised 11/4/20 2:22 titled “Initial Assessment/Comprehensive assessment indicated the initial assessment bridges the gap between when the patient encounter occurs and when a plan of care can be implemented. Immediate care and support needs are those items and services that will maintain the patient’s health and safety throughout the interim. A registered nurse must conduct the initial assessment within 48 hours of referral within 48 hours of the Patient’s return home or the physician ordered start date of care.” 2. A review of Patient #1’s clinical record evidenced a referral dated 6/28/2023 which indicated Patient #1 was referred for skilled nursing services for catheter changes. A clinical record review for Patient #1, start of care 7/21/2023, evidenced an initial comprehensive assessment dated 7/21/2023 and electronically signed by the alternate Clinical Manager. A review of Patient #1’s clinical record evidenced a communication note date 7/21/2023, which stated “Delay in start of care was due to infusion supplies (infusion needles)…” A review of patient #1’s clinical record failed to evidence an order for infusion supplies. During an interview on 11/30/2023, the alternate Clinical Manager indicated they were trying to obtain infusion needles. When queried as to why there was a need for infusion needles, she indicated when they called Patient #1, the patient told them she needed the supplies and wanted her port a cath (an implantable device used for blood work and intravenous medication administration) flushed on the first visit as it needed to be done every 3 weeks. During an interview on 11/30/2023 at 4:55 PM, the Administrator indicated they tried to get the needles from area pharmacies and could not find them. Supply companies only sold them in large quantities. He indicated Physician #1 gave him the name of a supply company and they were able to obtain the needles. 410 IAC 17-14-1(a)(1)(A).”

“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 observation, record review, and interview, the agency failed to ensure the services and treatments were provided only as ordered by a physician in 1 of 1 clinical record reviewed for a patient with a port a cath. The findings include: 1. A review of an agency policy revised 11/4/2022, titled “Plan of Care and Physician Orders,” indicated drugs, services and treatments are administered only as ordered by a Physician. A review of the clinical record for Patient #1 dated 10/9/2023, evidenced a Skilled Nursing Note which evidenced the Alternate Clinical Manager attempted to draw blood from the patient’s port (an implantable device used for blood work and intravenous medication administration) for labs. A review of the clinical record for Patient #1 dated 10/6/2023, evidenced a Skilled Nursing Note which evidenced the Alternate Clinical Manager flushed the patient’s port. A review of the clinical record for Patient #1 dated 11/11/2023, evidenced a Skilled Nursing Note which evidenced the Alternate Clinical Manager obtained labs from the patient’s port. A review of the clinical record for Patient #1 failed to evidence orders to flush the Patient’s port or obtain blood from the Patient’s port. During an interview on 11/30/2023 at 4:21 PM, the Alternate Clinical Manager indicated the plan of care should have had the order for accessing the port and obtaining blood for the labs. 410 IAC 17-3-1(a)”

“Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This Element is not met as evidenced by: Based on record review and interview, the agency failed to coordinate care with other agencies providing services to the patient in 2 of 2 clinical record reviewed receiving services from another home care agency. (Patient #1, #7) and 1 of 1 records requiring coordination of care for laboratory services. (Patient #6) The findings include: Findings include: A review of policy, “Coordination of Patient Care,” revised 11/4/2022, “Care will be coordinated with other involved external organizations…Staff will:…Communicate with other individuals or organizations involved in patient’s care when significant changes occur…Share relevant information to facilitate appropriate continuity and care coordination.” 3.Review of clinical record for Patient #6 included all lab work per physician order and consulting physicians can provide orders on Plan of Care (POC) for certification period 10/16/23 to 12/14/23. Record review failed to evidence any communication with other physicians regarding lab work or coordination of care for lab work. 4.Review of clinical record for Patient #7 demonstrated patient use of caregiver services without any documentation found of coordination of care throughout record. During home visit observation on 11/29/23, beginning at 12:01 PM, visually observed caregiver staff from Agency 1 at Patient # 7’s bedside assisting patient. 410 IAC 17-12-2(g). 1. An agency policy revised 11/4/2023 titled “Coordination of Patient Care,” indicated the clinicians must integrate services, whether provided directly or under the arrangement, to assure the identification of patient needs. 2. A review of Patient #1’s clinical record evidenced the initial comprehensive assessment indicated Patient #1 was receiving home health aide services through Entity 2. (home health agency). During a phone interview on 11/30/2023 at 2:57 PM, Patient #1 indicated he/she had a home health aide though Entity 2. During an interview on 11/30/2023 at 4:24 PM, the alternate Clinical Manager indicated there was not documentation of coordination of care with Entity 2. 410 IAC 17-12-2(g).”

“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 2 of 3 home visits conducted (Patient #1, 7). The findings include: 1. An agency policy revised 11/4/2022, titled “Coordination of Patient Care,” indicated the agency would coordinate with the patient by providing a copy of written instructions outlining a visit schedule including the frequency of visit. 2. Observation of a home visit for Patient #3 on 11/28/2023 at 6:20 PM, failed to evidence a completed visit schedule. During the home visit for Patient #3 on 11/28/2023 at 6:20 PM, Registered Nurse (RN) 1 indicated the patient is called the night before to let them know what time the visit will be. 3. Observation of a home visit for Patient #7 on 11/29/2023 at 12:00 PM, failed to evidence a completed visit schedule. During an interview on 11/30/2023 at 4:11 PM, the alternate Clinical Manager indicated the patient is called the night before to let them know what time the visit will be.”

“Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered 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 provide the patient a completed written medication schedule and instructions in 1 of 3 home visits. (Patient #3) The findings include: 1. An agency policy revised 11/4/2023 titled “Medication Reconciliation,” indicated they agency would provide the patient and/or caregiver with written patient medication schedule/instructions, including medication name, dose, schedule, route, and frequency as well as which medication will be administered by the agency staff. 2. During a home visit on 11/28/2023 at 6:25 PM, observation of the Patient’s medication schedule failed to evidence Silvadene cream (prevents infections in wounds), gabapentin (for nerve pain), and diclofenac (for pain). During an interview on 11/28/2023 from 6:20 to 6:55 PM, Registered Nurse (RN) 2 indicated the medications should have been included on the medication schedule.”

“Treatments and therapy services CFR(s): 484.60(e)(3) Any treatments to be administered by HHA personnel and personnel acting on behalf of the HHA, including therapy services. This Element is not met as evidenced by: Based on observation and interview, the agency failed to provide the patient in writing the services and treatments to be provided by the agency in 3 of 3 home visits. (Patient #2, #3, #7) The findings include: 1. An observation of a home visit was conducted on 11/28/2023, at 6:00 PM, for a skilled nursing visit with Patient #3. Observation failed to evidence the patient was provided with a copy of a current plan of care. During an interview on11/28/2023, at 9:31 AM, the Registered Nurse (RN) 1 indicated the plan of care does not get put in the Patient’s home. 2. An observation of a home visit was conducted on 11/29/2023, at 12:00 PM, for a skilled nursing visit with Patient #7. Observation failed to evidence the Patient was provided with a copy of a current plan of care. During a home visit interview on 11/29/2023, at 12:30 AM, the Alternate Clinical Manager indicated the plan of care does not get put in the Patient’s home folder. 3. An observation of a home visit was conducted on 11/29/2023, at 5:00 PM, for a skilled nursing visit with Patient #2. Observation failed to evidence the Patient was provided with a copy of a current plan of care. During an interview on 11/28/2023, at 5:00 PM at a home visit for Patient #2, the Registered Nurse (RN) 1 indicated the plan of care does was not in the Patient’s home.”

“Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This Element is not met as evidenced by: Based on observation, record review, and interview, the skilled professional failed to provide patient and caregiver education as directed in the plan of care in 5 of 7 clinical records reviewed. (Patient #1, 2, 3, 4, 5) The findings include: 1. An agency policy revised 11/4/2022 titled “Patient Education,” indicated the clinician will provide initial and ongoing education to meet each patients’ individual needs. 2. A review of Patient #1’s clinical record evidenced a plan of care for the certification period 9/19/2023 – 11/17/2023. This plan of care evidence the skilled nurse was to educate patient #1 on dietary restrictions, glucose monitoring , wound care, insertion, usage, and care of a urinary catheter, when to call 911, encourage patient to perform activities to keep blood pressure within normal limits educate on the importance of avoiding straining when eliminating bowel, how to prevent constipation, how to reduce edema, avoid direct exposure to sunlight, wear protective clothing an sunscreen when outside, educate on joint protection, educate on pain relief measures, and taking pain medication before pain escalates. A review of Patient #1’s clinical record evidenced nursing visit notes dated 9/29/2023, 10/9/2023, 10/24/2023, 9/22/2023, 11/1/2023, and 11/11/2023. These documents failed to evidence what teaching was done with the patient. During an interview on 12/1/2023, the Alternate Administrator indicated teaching is done throughout the certification period and not everything is taught each visit. She indicated the notes should indicate what teaching was provided. 3. A review of Patient #2’s clinical record evidenced a plan of care for the certification period 11/1/2023 – 12/30/2023. This plan of care evidenced the skilled nurse was to educate patient #2 on dietary regimen. Skilled nurse was to instruct on measures to promote safety with activities of daily living related to poor vision to reduce risks of falls and injuries. Skilled nurse was to instruct the patient to use appropriate assistive devices whenever ambulating. Skilled nurse was to instruct patient to avoid direct exposure to sunlight and encourage use of sunscreen protection and wear protective clothing when going out., educate patient on proper uses of glucometer machine, proper administration of oral diabetic medication, proper foot and skin care, management preventative measures for hypo and hyperglycemia (high and low blood sugar) and when to report to the skilled nurse or physician, instruct on importance of constant monitoring of blood glucose levels and emphasize no concentration sweet diet. Skilled nurse was to instruct patient to check blood sugar level at least once a day, educate on signs of emergency symptoms of asthma, educate patient on lifestyle and home remedies to lessen the possibility of an asthma attack, instruct the patient on correct use of prescribed inhalant and safety principles with use. Skilled nurse was to instruct patient on how to record a pulse and instruct on cardiac limitations. A review of Patient #2’s clinical record evidenced nursing visit notes dated 11/11/2023, 11/15/2023, and 11/24/2023 failed to evidence all of the teaching was completed on each visit. During an interview on 11/30/2023 at 2:30 PM, Registered Nurse (RN) 2 indicated she picks which topics to talk about each visit. She does not educate on everything. 4. A review of Patient #3’s clinical record evidenced a plan of care for the certification period 11/3/2023 – 1/1/2023. This plan of care evidenced the skilled nurse was to educate patient #3 on the individual disease process/other medical condition of the patient, its signs and symptoms, etiology, risk and aggravating factors, complications and preventative measures, educate on the measures to promote safety, instruct on the patient to use appropriate assistive devices whenever ambulating, instruct regarding measures to promote communication, lifestyle modification, instruct on the cognitive and physical limitations to Cerebral Palsy. A record review for Patient #3 evidenced skilled nursing notes dated 11/6/2023, 11/8/2023, 11/10/2023, 11/13/2023, 11/16/2023, 11/18/2023, 11/20/2023, 11/22/2023, 11/24/2023, 11/28/2023 failed to evidence all of the teaching was completed on each visit. During an interview on 11/30/2023 at 4:11 PM, the Alternate Clinical Manager indicated she picks which topics to talk about each visit. She does not educate on everything. 5. A review of Patient #4’s clinical record evidenced a plan of care for the certification period 6/15/2023 – 8/13/2023. This plan of care evidenced the skilled nurse was to educate Patient #4 on educate to avoid foods that will aggravate symptoms of GERD, educate on managing the patient’s behavioral problems, confusion, sleep problems and agitation, to call 911, and educate on the importance of avoiding straining when eliminating bowel, and how to prevent constipation, A review of Patient #4’s clinical record evidenced nursing visit notes dated 6/24/2023, 7/3/2023, 7/13/2023, 7/22/2023, 7/28/2023, and 8/3/2023. These documents failed to evidence all the teaching was done with the patient and or caregiver. 6. A review of Patient #5’s clinical record evidenced a plan of care for the certification period 6/9/2023 – 8/7/2023. This plan of care evidenced the skilled nurse was to educate patient/caregiver on orientation techniques, when to call 911, educate on preventative measures of reducing risk of reoccurrence of a stroke, instruct about safety measures with activities of daily living, and instruct on dietary needs. A review of Patient #5’s clinical record evidenced nursing visit notes dated 6/24/2023, 7/3/2023, 7/13/2023, 7/22/2023, 7/28/2023, and 8/3/2023. These documents failed to evidence all the teaching was done with the patient and or caregiver. 7. During an interview on 11/30/2023 at 2:30 PM, the Alternate Clinical Manager indicated they do not educate on everything each visit. She indicated during a wound visit they may only educate on wound care. 410 IAC 17-14-1(a)(2)(E)”