Ability 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 agency failed to develop a facility and community-based risk assessment utilizing an all-hazards approach (E0006), include a process for cooperation and collaboration with local, state and federal emergency preparedness officials to include documented attempts to contact officials in an effort of collaboration and cooperative planning (E0009), include follow up with patients to determine services needed due to interruption of services due to emergency nor notification of state or local officials for staff and patients that cannot be reached (E0021), names and contact information for staff, other entities providing services under arrangement, patient physicians, volunteers (E0030), contact information for federal, state, regional, or local emergency preparedness officials (E0031), communication plan include a primary and alternate means of communicating with staff and federal, state, regional, local emergency preparedness officials (E0032), address how the agency will share necessary information with the authority having jurisdiction and other health care providers to provide continuity of care (E0034), conduct and test the emergency preparedness program annually, a community based exercise, analyze the response and maintain documentation of the exercise events (E0039). The cumulative effect of this systemic problem resulted in the agency being out of compliance with 42 CFR 484.102 Condition of participation: Establishment of the Emergency Program. The Findings Include: A policy revised August 2023 titled “Emergency Preparedness Plan and Procedures,” failed to evidence a plan to follow up with patients to determine services that are needed due to emergency nor notification of state and local officials of on-duty staff and patients that are unable to be reached. A review of their Emergency Preparedness Plan (EPP) on 4/9/24 failed to evidence developed a facility and community-based risk assessment utilizing an all-hazards approach, failed to evidence a process for cooperation and collaboration with local, state and federal emergency preparedness officials to include documented attempts to contact officials in an effort of collaboration and cooperative planning, failed to evidence follow up with patients to determine services needed due to interruption of services due to emergency nor notification of state or local officials for staff and patients that cannot be reached, failed to evidence names and contact information for staff, other entities providing services under arrangement, patient physicians, volunteers, failed to evidence contact information for federal, state, regional, or local emergency preparedness officials, failed to evidence how the agency will share necessary information with the authority having jurisdiction and other health care providers to provide continuity of care, failed to evidence the agency conducted and tested the emergency preparedness program annually, a community based exercise, analyze the response and maintain documentation of the exercise events. On 4/9/24 beginning at 11:00 am during an interview, the Administrator and the Clinical Manager indicated the risk-base assessment had not been completed since 2019 and was not current; the Administrator indicated they attended a zoom meeting call February 2023, they had no documented information related to the call nor other documented attempts to contact or collaborate with local, state, or federal officials. The Administrator and CM indicated they would send a staff member to do wellness checks on individuals that could not be reached, but this was not in the policy nor plan and should be. The EPP included patient and employee rosters with names and telephone numbers dated April 2023. The Administrator indicated their EPP was not current and did not include all current patients nor their staff and indicated the EPP did not include other entities that provided services, patient providers or volunteers. The EPP contact information for federal, state, regional and local emergency officials indicated a yearly date of 2020; the Administrator and CM indicated it was not current nor did it include an alternate means of communication. The EPP indicated paper copies are kept in a locked cabinet for all patients; the EPP failed to identify who would have access or how it was maintained. The Administrator indicated all requests for information would be routed to the Administrator and that was not in the policy. The EPP failed to evidence an exercise had been completed on-site or community wide in the last two years; the Administrator indicated they had completed an agency exercise but was not able to provide documentation. The Administrator indicated the agency had not participated in a community-wide exercise in the last two years.”

“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 record review, observation and interview the agency failed to evidence an individualized Plan of Care with consultation of the attending physician to approve additions or modifications to the plan of care (G572), included all medications and treatments (G574), evidenced medications and treatments only as ordered by the physician (G580) or to coordinate care with other entities providing care (G606). 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 for the condition of participation of 42 CFR 484.60 Care planning, coordination, and quality of care. Based on record review and interview, the agency failed to meet patient needs and provide quality care in 1 of 1 active clinical record reviewed with home health aide and skilled nurse services (Patient #2) and with history of wounds. Findings Include: The clinical record for Patient #2 included a Plan of Care (POC) for the certification period of 3/7/24 to 5/5/24. The POC included an evaluation and treatment order for Physical Therapy, Occupational Therapy, and Home Health Aide. The POC indicated a skilled nurse visit frequency of 1 visit per week for 9 weeks. The record failed to evidence skilled nurse visits were provided for week 2, 3, and 4 of the certification period. During an interview on 4/3/24 beginning at 4:00 pm Registered Nurse 1 (RN 1) indicated Patient #2 had separate records, a Medicare, and a Medicaid record. RN 1 indicated the frequency of skilled nurse visits to be provided was once a week for the Medicare record and twice per month for the Medicaid record. RN 1 indicated they completed a skilled nurse supervisory visit of the home health aide on 3/19/24 for the Medicaid chart and indicated he/she did not make any visits to the patient for the purpose of an assessment or the provision of care since 3/07/24, other than the 3/19/24 aide supervisory visit. During a home visit observation for Physical Therapy services on 4/2/24 beginning at 12:30 pm Physical Therapist 2 (PT 2) was observed assisting Patient #2 with sit to stand exercises, marching exercises and ambulation with walker and assistance of HHA 1. During an interview on 4/2/24 beginning at 1:30 pm, PT 1 indicated they did not obtain physician order for care nor develop a plan of care for Patient #2. PT 1 indicated Patient #2 knew what exercise to do because they have worked with them in the past. During an interview with Home Health Aide 1 on 4/2/24 beginning at 1:18 pm indicated they knew what wound care to perform because the nurse practitioner from Entity 3 told them what to do. During a home visit observation of a skilled nurse visit, on 4/3/24 beginning at 1:00 pm, Home Health Aide 1 (HHA 1) removed the dressing from Patient #2’s right foot; Registered Nurse 1 (RN 1) measured two wounds on the right heel and 1 wound on right 3rd toe, HHA 1applied betadine to the two wounds on the right heel and wrapped the right heel with gauze; no treatment was applied to the right 3rd toe. The POC failed to evidence treatment orders for the wounds to Patient #2 right heel or lower extremity. In an interview with the Administrator and Clinical Manager on 4/3/24 beginning at 9:45 am indicated the attending physician for Patient #2 was not notified of the wound on Patient #2’s right foot. During an interview on 4/3/24 beginning at 11:30 am, the Clinical Manager (CM) indicated the agency maintained two separate records for Patient #2, due to receiving services under Medicare and Medicaid and indicated this had been their practice and was aware this is not standard practice. The Administrator and Clinical Manager (CM) indicated there were no PT treatment orders within the record, nor a PT Plan of Care (POC) for Patient #2. During the interview, the Administrator and Clinical Manager indicated they had consulted Entity 3 for wound care which they did not have an order to consult with Entity 3 from the attending nor did they have the care order from Entity 3. During an interview on 4/3/24 beginning at 4:00 pm Registered Nurse 1 (RN 1) indicated they had left a voicemail with the physician’s office on 3/19/24, but did not follow up with the physician’s office and did not know what the wound care orders were. 410 IAC 17-13-1(a)”

“Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA’s governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA’s performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This Condition is not met as evidenced by: Based on record review and interview the agency failed to evidence a Quality Assessment and Performance Improvement (QAPI) program capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care (G642), data collected to monitor effectiveness of services and quality of care, nor approval from the governing body (G644), maintain performance improvement activities that focus on high risk, high volume or problem prone areas (G648), maintain performance improvement activities that consider incidence, prevalence, and severity of problems (G650), maintain performance improvement activities that lead to immediate correction of identified problems that directly or potentially threatens the health and safety of the patients (G652), performance improvement activities that track adverse patient events, analyze their causes, and implement preventive actions (G654), the actions aimed at performance improvement, and, after implementing those actions, how the agency measured its success and track performance to ensure that improvements are sustained (G656), or maintain performance improvement projects with measurable progress achieved (G658). The cumulative effect of this systemic problem resulted in the agency being out of compliance with 42 CFR 484.65 Quality assessment / performance improvement. The findings include: A review of the Quality Assessment and Performance Improvement (QAPI) program was completed on 4/5/24 and failed to evidence measurable improvements in patient outcomes, safety and quality of care nor how adverse events were tracked and managed within the QAPI program. The agency’s QAPI program failed to evidence performance improvement activities that included objective data collected that monitored the effectiveness of services and quality of care. The program failed to identify governing body approval of data collected and monitoring the effectiveness of services and quality of care. The QAPI failed to evidence performance activities or actions that focused on high risk, high volume, or problem prone areas, failed to evidence performance activities that consider incidence, prevalence and severity of problems identified, failed to identify performance improvement activities that lead to immediate correction of identified problems that directly or potentially threatened the health and safety of their patients, The QAPI reviewed failed to evidence performance improvement activities that track adverse patient events, analyze the cause, and implement preventative actions nor how they measured and tracked the performance to ensure improvements were sustained. The QAPI failed to evidence documentation of performance improvement projects with measurable progress. On 4/5/24 during an interview beginning at 9:30 AM, the Administrator and Clinical Manager indicated they had not yet had a meeting and have not tracked adverse events, nor have evidence of measurable outcomes with improvements in patient outcomes. The Administrator and Clinical Manager indicated they met weekly to discuss events, though what was discussed was not documented and should be. They indicated there were no action plans in place and there should be; relayed they do not have action plans in place, indicated they did not have performance improvement plans or activities in place, and indicated they do not have performance improvement plans or activities, nor do they have performance improvement projects and they should have these items within their QAPI.”

“Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician or allowed practitioner and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. This Condition is not met as evidenced by: Based on observation, record review and interview, the home health agency failed to conduct a thorough and complete skin assessment as part of a comprehensive assessment and failed to coordinate care with 1 of 1 patient with an active wound (Patient #2) and the skilled professional failed to implement a thorough and complete ongoing assessment (See G706). The cumulative effect of these systemic problems resulted in the agency’s inability to ensure patients received appropriate skilled assessments and care which could result in the agency not providing quality care, which resulted in non-compliance with the Condition of Participation 42 CFR 484.75 Skilled Professional Services. Findings Include: On 4/1/24, during the entrance conference, the Administrator and Clinical Manger indicated they had no patients with active wounds. The record for Patient #2 indicated they were admitted to the agency for skilled services on 3/7/24 and included a past medical history of a Stage 4 pressure wound to the sacrum and a Stage 1 pressure wound to the bilateral heels. The Comprehensive Assessment dated 3/7/24 revealed Patient #2 had excoriation to the sacrum. During a home visit observation with physician therapy on 4/2/24, Home Health Aide 1 (HHA 1) indicated Patient #2 had a wound to the right heel where discoloration to the right heel had been present on 3/07/24, at the time of admission for skilled services. During an interview on 4/03/24, Registered Nurse 1 (RN 1) indicated they did not assess the right heel nor the sacrum at the start of care [3/07/24] and are not managing the wound; RN 1 further indicated they last assessed the right heel wound on 3/19/24 do to HHA 1 notification of an open wound. The Plan of Care for the certification period beginning 3/07/24 revealed orders for skilled nurse visits weekly for education and patient assessment; the record failed to evidence skilled nurse visits occurred weekly as ordered. During an interview on 4/02/24 with HHA 1, they indicated they notified the agency of an open wound to the right heel on 3/18/24. The record included a skilled nurse visit note dated 3/19/2024; RN 1 documented they assessed Patient #2’s heel on 3/19/24 and noted a Stage 2 pressure ulcer measuring 9.0 cm x 6.0 cm x 0.5 cm and failed to evidence an assessment of Patient’s sacrum. During an interview with RN 1 on 4/03/24 beginning at 4:00 pm, RN 1 indicated they left a voicemail with the attending physician’s office and failed to follow up with the attending physician for care orders. During an interview on 4/03/24, the Clinical Manager indicated they contacted a visiting physician company without permission from the attending physician’s office for the purpose of evaluation and treatment of Patient 2’s wounds. A clinical note authored by nurse practitioner [NP] from Entity 3, who visited Patient on 3/21/24, described the right heel wound as a Stage 2 and unstageable ulcer. The documentation of the NP visit note dated 3/21/24 included orders of betadine, dry gauze and prevalon boot to be completed to the right heel daily by caregiver when the agency is not in the home. The clinical record for Patient #2 failed to evidence the agency reported the NP findings and orders to the attending, obtained orders for the treatment, nor obtained orders to provide education to the caregiver to provide the wound care. During a home visit observation of RN 1 with Patient #2 conducted on 4/03/24, HHA 1 was observed by surveyor to provide the wound care. The visit revealed Patient #2 to have 2 stage 2 pressure ulcers to the right heel, one measured 0.5cm x 1.7cm x 0.2cm with thick brown drainage. The other heel wound measured 1.5cm x 1.5cm x 0.5cm and a wound to the 3rd right toe measured 0.5cm x 0.3cm x 0.1cm. HHA 1 indicated the wound on the toe was present for one week and he/she failed to report this to the agency. RN 1 failed to assess Patient #2’s sacrum and confirmed she did not assess during her visits and relied on HHA 1 to report. The record failed to evidence skilled nurse visits occurred weekly as ordered.”

“Exercise of rights CFR(s): 484.50(b)(1)(2)(3) Standard: Exercise of rights. (1) If a patient has been adjudged to lack legal capacity to make health care decisions as established by state law by a court of proper jurisdiction, the rights of the patient may be exercised by the person appointed by the state court to act on the patient’s behalf. (2) If a state court has not adjudged a patient to lack legal capacity to make health care decisions as defined by state law, the patient’s representative may exercise the patient’s rights. (3) If a patient has been adjudged to lack legal capacity to make health care decisions under state law by a court of proper jurisdiction, the patient may exercise his or her rights to the extent allowed by court order. This Standard is not met as evidenced by: Based on observation, record review, and interview, the agency failed to exercise patient rights by obtaining advance directive legal documents signed by appropriate legal authority in 1 of 5 active records reviewed (Patient #3). Findings include: The record review of Patient #3 evidenced a signed do-not-resuscitate order (DNR: a medical order signed by a physician to not provide life sustaining interventions) signed by Patient primary caregiver/HHA 1 dated from the year 2022. The record failed to evidence further advance directives (legal documents that provide instructions for medical care, such as DNR). During an interview with HHA 1/primary caregiver of Patient #3, HHA indicated Patient had a healthcare power of attorney (POA: person legally appointed to make decisions of behalf of another) who is a family member (Person 10) who lived out of state. The review of advance directive paperwork for Patient #3 obtained by HHA 1/primary caregiver on 4/4/24 evidenced “Authorization to Caregiver” signed by Patient’s POA/Person 10 in 2020. Document stated HHA 1 “cannot make any decisions that require authorization of a Power of Attorney or permission of a a family member.” During an interview with Administrative Staff (admin) 2 on 4/5/25 starting at 12:49 PM, she denied having advanced directive or POA paperwork for Patient #3. Admin 2 admitted the DNR on file is not valid as it was signed by HHA 1/caregiver. She stated it is the responsibility of quality assurance (QA), a role held by Admin 2, to review and verify the advance directive paperwork upon admission. The review of POA for Healthcare paperwork obtained by Admin 2 on 4/5/24 at 2:49 PM indicated Person 10 as valid POA for patient #3 effective May 2019. Admin 2 received this document for agency on 4/5/24. *”

“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 home health agency failed to evidence a discharge summary was sent to the discharging patient’s primary care practitioner (PCP) for 1 of 2 closed records reviewed (Patient #7). Findings include: Findings include: The review of a list of patients discharged from the agency between 10/01/23 – 3/31/24 evidenced Patient #7 was discharged due to “noncompliance.” The review of Patient #7’s clinical record included a plan of care for the initial certification period 11/07/23 – 1/05/24 which indicated Patient was to receive physical therapy (PT) services. The record included a discharge assessment and summary, completed on 12/15/23 by PT 1, which indicated Patient was discharged due to “noncompliance.” The record failed to evidence a discharge summary was sent to Patient’s PCP. During an interview with PT 1 on 4/09/24 beginning at 10:58 AM, the therapist reported he completed a discharge summary for Patient on 12/15/23. PT 1 reported it was responsibility of the agency’s office staff to send the discharge summary to the patient’s PCP. During an interview with Administrator and Clinical Manager on 4/09/24 beginning at 3:11 PM, Clinical Manager reported the record should evidence a discharge summary was sent to the ordering provider at the time of discharge.”

“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 interviews, the home health agency failed to provide all services as indicated on the plan of care for 1 for 2 home visits with a skilled nurse (Patient #3) and failed to evidence one plan of care which incorporated all services provided for 2 of 3 active records reviewed of patients receiving therapy services (Patients #3 and 4). Findings include: Findings include: 1. The review of Patient #3’s clinical record included a Plan of Care (POC) for the recertification period of 2/04/24 – 4/03/24. The POC indicated Patient was to receive skilled nursing services with nursing interventions to include “Set up medications ….” During a home visit observation with Patient #3 on 4/02/24 at 3:00 PM, Registered Nurse (RN) 1 was observed completing a recertification comprehensive assessment. RN 1 failed to set up Patient’s medications in a pill box or tray. During an interview with HHA (home health aide) 2, who was also the primary caregiver for Patient #3, on 4/2/24 at 4:30pm, she reported she gave Patient his/her medication doses directly from the medication bottles every day. During an interview with Administrative (Admin) Staff 2 on 4/03/24 at 9:30 AM, when asked what the nurse was to do for the intervention “set up medications,” Admin Staff 2 stated the nurse was to place Patient’s medications into a pill box for either 1 week, 2 weeks, or 30 days at a time. 2. The review of Patient #4’s record included a POC for the initial certification period 2/20/24 - 4/19/24. The POC evidenced Patient was to receive Physical Therapy (PT) and Occupational Therapy (OT) services. The record revealed a separate POC for Patient’s OT services was created by OT 1 on 2/20/24. During an interview with OT 1 on 4/02/24 at 10:05 AM, he stated that he created his own POC for OT services, independent from other services. 410 IAC 17-13-1(a)”

“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, interview, and record review, the home health agency failed to ensure all staff followed its policies and procedures regarding infection prevention, specific to healthcare bag technique, on 1 of 2 skilled nurse (SN) patient care visits (Patient #3). 410 IAC 17-12-1(m) Findings include: The review of policy entitled “Healthcare Bag Technique for Home Healthcare Clinicians” last revised 8/2023 indicated to “disinfect the equipment and supplies that had direct patient or environmental contact prior to placing them in the bag.... Allow the items to dry in accordance with the manufacturer’s instructions for the disinfectant.” During an observation of a home visit with Patient #3 on 4/2/24 at 3:30 PM, RN 1 used a barrier for her vital signs equipment and tablet. After use, RN 1 wiped the equipment with antibacterial wipes and returned them to the barrier stacked on top of one another to dry before placing them back in her bag. In an interview with RN 1 on 4/2/24 at 3:59 PM, when asked what the dry time is for the antibacterial wipes she used, she was unsure and proceeded to take out the package. The brand was “Good & Clean” and indicated a four minute dry time per package instructions.”

“Patient refuses services CFR(s): 484.50(d)(4) The patient refuses services, or elects to be transferred or discharged; This Element is not met as evidenced by: Based on record review and interview, the home health agency failed to document measures it took to investigate a patient’s noncompliance with physical therapy (PT) visits, interventions the agency attempted in order to obtain patient participation with the PT visits, and communication with the patient’s physician prior to discharge, including obtaining an order for discharge, for 1 of 1 closed records reviewed of a patient discharged for noncompliance (Patient #7). Findings include: The review of a list of patients discharged from the agency between 10/01/23 – 3/31/24 evidenced Patient #7 was discharged due to “noncompliance.” The review of Patient #7’s clinical record included a plan of care for the initial certification period 11/07/23 – 1/05/24 which indicated Patient was to receive physical therapy (PT) services with visits occurring once per week for 6 weeks. The plan of care also indicated Patient had a history of noncompliance with his/her medications. The record indicated Physical Therapist 1 conducted 4 physical therapy visits with Patient between 11/07/23 – 11/29/23. 2 PT visits were marked as not completed on 12/07/23 and 12/14/23. A missed visit note, documented on 12/07/23 by PT 1, indicated Patient “refused” services when the therapist arrived at the home. The note indicated Patient wanted to “wait until next week” for his/her PT visit. A visit was scheduled for 12/13/23. A missed visit note, documented 12/13/23 by PT 1, indicated when the therapist arrived for the scheduled visit, Patient did not answer the door, and the therapist then contacted Administrator. PT 1 documented Administrator contacted Patient and he/she declined further services. The record included a communication note, documented on 12/14/23 by Administrator, which indicated Patient had been “changing [his/her] mind regarding home physical therapy visit[s] … Patient [had] been back and forth changing [his/her mind] but agreed [he/she] needs help at home and [had] no support otherwise. [Agency] will discharge patient due to refusal of care. Patient seems talkative but confused.” The record included a discharge assessment, completed on 12/15/23 by PT 1, which indicated Patient was discharged due to “noncompliance.” The record failed to evidence measures the agency took to investigate Patient’s noncompliance with PT visits nor interventions the agency attempted in order to encourage Patient’s participation with PT visits prior to Patient’s discharge. The record failed to evidence the agency’s communication with Patient’s physician regarding Patient’s noncompliance and potential for discharge. The record also failed to evidence the agency obtained a physician order for discharge. During an interview with PT 1 on 4/09/24 beginning at 10:35 AM, the therapist reported Patient was discharged from agency at Patient’s request. PT 1 stated Patient was noncompliant with PT visits, with several incidents of PT 1 arriving at Patient’s home and Patient not answering the door. The therapist reported Patient then requested to stop PT services. During a follow-up interview with PT 1 on 4/09/24 beginning at 10:58 AM, the therapist reported the agency sent notification of each missed visit to Patient’s physician. PT 1 stated he notified Patient’s physician of Patient’s noncompliance and request to stop services and also obtained an order for discharge. PT 1 stated the physician notification should be documented within Patient’s record, however the agency was unable to provide evidence of this documentation. During an interview with Administrator and Clinical Manager on 4/09/24 beginning at 3:11 PM, Administrator reported Patient #7 was discharged due to noncompliance with PT visits. During a follow-up interview with Clinical Manager on 4/09/24 beginning at 4:04 PM, Clinical Manager reported the agency did not have a standard number of missed or cancelled visits which would lead to a patient discharge. An attempt to interview Patient #7 was conducted on 4/09/24 at 10:20 AM, however Patient declined to participate in the interview. A second attempt to contact Patient #7 was conducted on 4/15/24, however Patient did not answer nor return the call.”

“5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient’s immediate needs, but no later than 5 calendar days after the start of care. This Element is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the nursing portion of the comprehensive assessment was completed within 5 days of the start of care (SOC) for 1 of 2 patients with multiple active clinical records (Patients #5). Findings include: 1. The review of a list of all active patients, provided by the agency on 4/01/24, evidenced two separate and active records for Patient #2 and Patient #5 3. The review of Patient #5’s clinical records evidenced one clinical record with a SOC of 11/15/22. This clinical record indicated Patient was to receive skilled nursing and home health aide services under Medicaid. The record evidenced Registered Nurse (RN) 2 was Patient’s primary nurse, including conducting Patient’s recertification comprehensive assessments. A second clinical record for Patient, with a SOC of 3/28/24, included a plan of care for the initial certification period of 3/28/24 – 5/26/24. The plan of care indicated Patient was to receive physical therapy, skilled nursing, and home health aide services under Medicare. The second record evidenced Physical Therapist (PT) 1 completed the therapy portion of the comprehensive assessment on 3/28/24 and home health aide visits were conducted on 3/29/24, 4/01/24, 4/02/24, 4/03/24, 4/04/24, and 4/05/24. The plan of care evidenced an order for skilled nursing visits twice a week for 9 weeks as well as nursing goals and interventions, however the record failed to evidence a Registered Nurse had conducted the nursing portion of Patient’s comprehensive assessment as of 4/05/24. During an interview with RN 2 on 04/09/24 beginning at 10:23 AM, the nurse confirmed he/she was the primary nurse for Patient #5. The nurse reported she had not completed Patient’s admission comprehensive assessment for his/her Medicare admission. RN 2 reported she had not conducted a skilled nurse visit with Patient in “2-3 weeks.””

“Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient’s current health, psychosocial, functional, and cognitive status; This Element is not met as evidenced by: Based on record review, observation and interview the agency failed to evidence the comprehensive assessment accurately reflect the patient’s current health status for 1 of 1 patient’s receiving skilled nursing, physical therapy, occupational therapy, and home health aide services (Patient #2). The Findings Include: The record reviewed on 4/1/24 for Patient #2 revealed a comprehensive assessment was initiated on 3/7/24 with a completion date of 3/11/24. The integumentary assessment indicated Patient #2 to have an excoriated bottom. No other skin integrity issues were identified in the comprehensive assessment. During a Physical Therapy home visit observation on 4/2/24 beginning at 12:30 pm, Home Health Aide 1 (HHA 1) indicated the discoloration on Patient #2 right foot that had been present since returning home from a hospitalization was now open. During an interview with Registered Nurse 1 on 4/3/24 beginning at 4:00 pm they indicated they did not assess Patient #2 skin integrity and relied on HHA 1 observations for the comprehensive assessment. 17-14-1(a)(1)(A) or (B)”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the patient’s medications were reconciled by agency staff during the initial and recertification comprehensive assessment for 2 of 2 active patients who had multiple open records (Patients #2 and 5). Findings include: 2. The review of Patient #5’s clinical records evidenced one clinical record with a start of care (SOC) of 11/15/22. This clinical record indicated Patient was to receive skilled nursing and home health aide services under Medicaid. The record indicated a comprehensive recertification assessment was completed by Registered Nurse (RN) 2 on 3/05/24. A second clinical record for Patient, with a SOC of 3/28/24, included a plan of care for the initial certification period of 3/28/24 – 5/26/24. The plan of care indicated Patient was to receive physical therapy, skilled nursing, and home health aide services under Medicare. The second record evidenced Physical Therapist (PT) 1 completed the therapy portion of the comprehensive assessment on 3/28/24. Comparison of the plans of care for Patient’s two medical records evidenced the following medication discrepancies: a. The medication list for Patient’s Medicaid chart indicated Patient used Lidocaine patches for pain daily. The medication list for Patient’s Medicare chart failed to evidence this medication. b. The medication list for Patient’s Medicare chart indicated Patient was taking Lithium (a medication used to treat Bipolar disorder) 450 milligrams (mg) once a day. The medication list for Patient’s Medicaid chart indicated the Patient was taking Lithium 300 mg twice a day. During an interview with PT 1 on 4/08/24 beginning at 1:00 PM, the therapist reported he reconciled Patient’s medications by reviewing all medication bottles during the comprehensive assessment visit on 3/28/24. During an interview with RN 2 on 4/09/24 beginning at 10:23 AM, the nurse reported she would reconcile Patient’s medications “every 2-3 visits … about once a month” by looking at Patient’s medication bottles. RN 2 reported Patient administered his/her own medications and the nurse to not fill a pill planner. During an interview with Patient #5 on 4/09/24 beginning at 1:10 PM, Patient confirmed he/she was using Lidocaine patches topically for pain and he/she was taking Lithium 450 mg once a day. Patient reported RN 2 would fill his/her medications into a pill planner during the nurse visits. 410 IAC 17-14-1(a)(1)(B) 1.The record reviewed for Patient #2 on 4/1/24 included a comprehensive assessment dated 3/7/24 with a time in of 12:00 pm that indicated Glipizide 5 mg oral extended release tablet (a medication used for the management of diabetes) take1 tablet by mouth daily. In another separate comprehensive assessment dated 3/07/24 with a start time of 1:00 pm indicated Glipizide 5 mg oral extended-release tablet, take 2 tablets by mouth daily. One assessment was for the Medicaid chart and one assessment was for the Medicare record. Both assessments indicated use of Oxygen at 1 liters/min no route indicated. During a home visit observation for skilled nursing services of Patient #2 on 4/3/24 beginning at 1:00 pm the caregiver for Patient #2 indicated the patient takes Glipizide 5 mg oral extended-release tablet, 1 tablet per day. The caregiver also indicated Patient #2 Oxygen use to be 2 liters at night with mask via the Bipap when sleeping as well as 2 liters oxygen via the Bipap as needed with activity. During an interview on 4/3/24 beginning at 4:00 on with Registered Nurse 1 (RN 1) indicated Patient #2 used Oxygen at 1liter/min as needed via nasal cannula and indicated it should be on the medication list and that it was not. RN 1 indicated Patient #2 took Glipizide 5 mg, 1 tablet daily; RN 1 indicated they used the hospital discharge paperwork to verify the medications and relayed they did not go through the medications with the patient nor their caregiver. In an interview on 4/3/24 beginning at 11:30 am with the Administrator and the Clinical Manager (CM), the CM indicated they did not know which dose of Glipizide was correct and indicated the clinician should look at the bottles to determine the medication, they weren’t sure the clinician did. The CM indicated they weren’t sure if Oxygen was considered a medication, they would include it in an assessment, further indicating it was not included for Patient #2.”

“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 observations, record review, and interviews, the home health agency failed to implement an individualized plan of care which included all medical devices, patient-specific interventions, and measurable goals, for 3 of 5 active records reviewed (Patients #1 and 3). Findings include: During an interview with RN 1 on 4/3/24 at 3:20 PM, the nurse was asked how she measured the following goals to evaluate if they had been met or not: a. For the goal regarding “orthopedic safety,” RN 1 reported she would assess if the goal was met or not by asking Patient if he/she was compliant with crutches. b. For the goal regarding pain control measures, RN 1 reported she would assess if the goal was met or not by asking Patient how his/her pain has been over the week and if there were any spikes. c. For the goal regarding nutrition, RN 1 reported she would assess if the goal was met or not by if Patient’s surgery site was healing. 410 IAC 17-13-1(a)(1)(C)(ii, ix) Findings include: 1. The review of Patient #1’s comprehensive assessment, completed on 3/04/24 by Registered Nurse (RN) 1, evidenced Patient had a wound vac (negative pressure wound therapy, a therapeutic technique to remove excess exudate and promote healing) to a surgical wound on the right hip. The Plan of Care (POC) failed to evidence interventions for care, assessment, or patient education and training in regard to the wound vac. During an interview with Patient #1 on 4/3/24 at 1:53 PM, he/she stated the wound vac was placed 2/26/24 and was left on for approximately one week. When asked who was managing the wound vac, patient stated he/she was managing it him/herself. When asked who removed the wound vac, Patient #1 said he/she removed it him/herself. During an interview with RN 1 on 4/2/24 at 4:09 PM, the nurse stated Patient #1 had the wound vac for “a couple” weeks. RN 1 reported she assessed the wound vac by verifying the pressure setting and observing the outer dressing. The nurse was unsure who managed the wound vac. The review of Patient #1’s POC evidenced the following non measurable goals: “Patient/caregiver will verbalize understanding and demonstrate orthopedic safety within cert [certification] period … Patient will demonstrate effective pain control measure within [no timeframe specified] … Patient will have improved pain status as evidenced by decrease in pain level within cert period … Patient/caregiver will demonstrate compliance with pain medications, as prescribed by doctor within cert period … Patient/caregiver will understand non-medical pain relief measures within cert period … Patient will maintain appropriate nutrition/hydration status to avoid wound healing complications within cert period.” During an interview with RN 1 on 4/3/24 at 3:20 PM, it was asked how the following goals are measured from the POC: Orthopedic safety? Remind the patient not to walk without an ambulatory aid and ask if they are compliant with crutches. Pain control measures? Educate the patient on taking the meds when the pain starts. Ask the patient how pain has been over the week and if there were any spikes. Nutrition? Educate patient to eat well and eat a high protein diet to prevent infection and allow wound healing. Measured by if surgery site is healing. 2. During a home visit observation with Patient #3 on 4/2/24 at 2:30 PM, Home Health Aide (HHA) #2 (who was also Patient’s primary caregiver) reported to RN 1 that Patient used a Purewick (a female external urinary catheter that draws urine away from the body using suction) while sleeping. The Purewick system was observed in patient’s bedroom. The review of Patient’s Plan of Care for the recertification period of 2/04/24 – 4/03/24 failed to evidence interventions for care, assessment, or patient education and training in regard to Patient’s Purewick. During an interview with HHA 2 on 4/2/24 at 4:30 PM, she stated the Purewick catheter was changed each night and she purchased the supplies out-of-pocket. During an interview with RN 1 on 4/2/24 at 3:39 PM, the nurse reported HHA 2 managed Patient’s Purewick. The nurse did not know the suction settings for the device. When asked how the nurse assessed the Purewick, she stated by checking if supplies were needed and teaching HHA 2 to assess for skin integrity. RN 1 then asked HHA 2 what the Purewick suction settings were, and the aide reported she did not know the settings and only turned the machine on and off.”

“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 administer services and treatments administered as ordered by a physician for 2 of 5 active records reviewed (Patients #1 and 3). Findings include: 1. The clinical record of Patient #1 included a skilled nurse visit note dated 3/18/24, which evidenced documentation that RN 1 removed stitches on Patient’s [right] hip “without any complications.” During an interview with Patient #1 on 4/3/24 at 1:53 PM, Patient stated RN 1 removed the stitches during a patient care visit “with my doctor’s approval”. Patient relayed the doctor, Other 7, sent an order into Ability. During an interview on 4/3/24 at 3:20 PM, RN 1 relayed she did not see an order in Patient’s record to remove sutures and was informed of the task via phone from Administrative Staff 1 (admin). During an interview with Admin 1 on 4/3/24 starting at 3:56 PM, he/she did not remember how an order was obtained to remove sutures. A copy of the order to remove sutures was requested from Admin 1 on 4/3/24 at 4:30 PM and on 4/4/24 at 09:00 AM. No order was provided nor identified by agency by survey exit. 2. The clinical record of Patient #3 included a Plan of care (POC) for the recertification period 02/04/24 - 04/03/24 that that evidenced Patient was to receive skilled nursing and home health aide services. The record included a recertification comprehensive assessment, dated 04/02/24 by RN 1. The Patient’s record was reviewed on 4/5/24 and failed to evidence an updated plan of care or verbal physician orders for recertification or the care to be provided after 04/03/2024. During an interview with Admin 2 on 4/5/24 at 12:49 PM, he/she relayed there were no current physician orders for Patient #3. A POC for the recertification period 4/4/24 to 6/2/24 was signed by RN 1 and dated 04/09/24 and by Patient’s physician on 4/11/24. The POC indicated RN 1 spoke with a staff member at Patient’s physician office on 4/03/24 “regarding medication interactions and verbal orders for recertification of home health services.” During an interview with RN 1 on 4/09/24 beginning at 3:40 PM, the nurse reported he/she did not review the services Patient was to receive nor the frequency of visits when he/she obtained a verbal order for recertification from Patient’s physician. The record evidenced Home health aide (HHA) visits were completed on 4/04, 4/05, 4/08, and 4/09/24; the documentation revealed direct care was provided during these visits.”

“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 observation, record review, and interview the agency failed to coordinate care with other entities providing care for 1 of 1 home visit observation with an occupational therapist (OT) (Patient #4). Findings include: During observation of Patient #4 visit with OT 1 on 4/2/24 at 9:35, Person 8 entered and identified herself as Patient’s aide. OT 1 was noted as familiar/social with Person 8. OT 1 was asked if Person 8 works for Ability home health, he stated she worked for another company. Person 8 then stated that she works for Entity 9, a home health agency. The review of Patient #4’s plan of care (POC) failed to include coordination of care with Entity 9. Interviews were conducted on 4/2/24 starting at 10:30 AM with Person 4 and Person 5, employees of Entity 6, an assisted living facility where Patient #4 resided. Both employees denied receiving a POC for care coordination from Ability Home Health for services provided to resident. Person 5 had never heard of Ability home health. 410 IAC 17-12-2(h)”

“Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This Element is not met as evidenced by: Based on observation, record review, and interview, the skilled professional failed to implement a thorough and complete ongoing assessment of the patient for 2 of 5 active records reviewed (Patients #1, 3). Findings include: 1. The record review of Patient #1’s comprehensive assessment, dated 3/4/24 and completed by RN 1, indicated Patient had a wound vac (Negative pressure wound therapy, also known as a vacuum assisted closure, to remove excess exudate and promote healing) to right hip over a surgical wound. The summary of the same date stated, “Pt also has woundvac to carry around.” The visit note failed to evidence any further assessment of the wound or wound vac device. During an interview with RN 1 on 4/2/24 at 4:09 PM, he/she stated Patient #1 had wound vac for a couple of weeks though had since been removed. RN stated she did not assess the wound because it was covered and she was unsure of the settings. 2. During a home visit observation of Patient #3 recertification visit on 4/02/24, starting at 2:35 PM, RN 1 directed questions to assess Patient’s cognitive status to HHA 1 and asked if Patient was confused. RN 1 failed to complete a cognitive assessment, questions were directed to Patient during the comprehensive assessment. Patient was noted as verbally responsive during visit. During the physical assessment by RN, HHA 1 stated Patient has had wounds on the right upper extremity with contracture (a condition of shortening and hardening of muscles, tendons, or other tissue) and Patient’s preferred positioning. RN 1 failed to complete a full skin integrity assessment of the right upper extremity during the comprehensive recertification assessment. During an interview with RN 1 on 4/3/24 at starting at 3:20 PM, when asked how she assessed Patient #3’s orientation, the nurse stated she asked the caregiver because she read in the chart that Patient had aphasia (loss of ability to understand or express speech). When asked how the right upper extremity skin was assessed during the visit, she stated that it wasn’t fully assessed as she only looked at visible skin.”

“Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This Element is not met as evidenced by: Based on record review and interview, the home health aide (HHA) failed to provide services only included in the plan of care, permitted to be performed under state law, and consistent with the home health aide training, for 1 of 1 active records reviewed of patients receiving home health aide services with a gastrostomy-jejunostomy tube (Patients #8). Findings include: 1. “IC 16-27-1.5-6 (a) A registered home health aide may administer gastrointestinal and jejunostomy tube feedings to a specific patient only if the following conditions are met: (1) The registered home health aide has completed the training curriculum described in subsection (b). (2) A registered nurse, providing registered nursing under IC 25-23-1-1.1(b)(6), either: (A) supervises the registered home health aide in administering the gastrointestinal and jejunostomy tube feedings; or (B) delegates responsibility for administering the gastrointestinal and jejunostomy tube feedings to the registered home health aide based on the registered nurse’s assessment of the registered home health aide’s competency to administer gastrointestinal and jejunostomy tube feedings … (b) Training curriculum for home health aides to administer gastrointestinal and jejunostomy tube feedings must: (1) be approved by the state department; and (2) include the following concerning the administration of gastrointestinal and jejunostomy tube feedings: (A) At least four (4) hours and not more than eight (8) hours of classroom training. (B) At least two (2) hours and not more than four (4) hours of practical training. (C) A written and practical examination administered by the trainer. (c) A registered home health aide may not administer gastrointestinal and jejunostomy tube feedings until the home health aide has successfully: (1) completed the curriculum described in subsection (b); and (2) passed the examinations described in subsection (b)(2)(C) ….” 2. The review of Patient #8’s clinical record included a plan of care for the recertification period of 3/17/24 – 5/15/24 which indicated Patient was to receive HHA services for 6 hours per day, 7 days per week and a skilled nurse was to complete HHA supervisory visits every 60 days. The POC indicated Patient had difficulty swallowing, a gastrostomy-jejunostomy tube (G/J tube, a tube surgically placed in the stomach and small intestine, often to administer nutrition and medications) was present, and Patient had nutritional feedings administered “10 hours at night.” The record included an aide care plan, signed on 3/29/24 by Administrative Staff 2, a Registered Nurse (RN). The aide care plan included an aide task for “Nutrition/Hydration … Family to [administer] tube feed.” The task was to be completed with each aide visit. The HHA visits for 4/01/24 – 4/04/24 evidenced HHA 3 marked this task as “not completed.” During an interview with HHA 3 on 4/05/23 beginning at 3:13 PM, the aide reported she was both Patient #8’s home health aide and primary caregiver. The employee/caregiver would work as a home health aide for Patient from 5 AM – 11 AM daily. HHA 3 reported Patient received tube feeding daily from 9 PM – 9 AM and the aide would disconnect Patient’s tube feeding each morning. HHA 3 also reported she administered Patient’s medications at 9 AM daily. The aide relayed he/she had not received any training from Ability Home Health on managing and/or disconnecting Patient’s tube feeding. When queried on the reason HHA 3 marked the “Nutrition/Hydration” task as “not completed” at each visit, the aide reported she had been instructed by agency staff to only mark the task as completed a few times a week. The review of HHA 3’s personnel file failed to evidence he/she had received and completed training and/or a competency evaluation for tube feeding according to IC 16-27-1.5-6. During an interview with Administrative Staff 2 on 3:25 PM, the RN reported the “Nutrition/Hydration” task on Patient #8’s aide care plan was for HHA 3 to remind the family of Patient’s tube feeding. Administrative Staff 2 reported the agency was not aware HHA 3 was managing Patient’s tube feeding nor administering medications while clocked in as a home health aide. Administrative Staff 2 reported the agency had not yet completed training and or competency evaluation of HHA 3 regarding tube feedings.”

“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 observation and interview, the agency failed to report changes in the patient’s condition to a registered nurse or other appropriate skilled professional for 1 of 1 Patient’s observed during a home visit with wounds (Patient #2). Findings Include: During a home visit observation, on 4/03/24 beginning at 1:00 PM, observed Patient #2 had a wound; the wound measured 0.5cm x 0.3cm x 0.1cm on the right 3rd toe that was not identified in the clinical record. During an interview on 4/03/24 beginning at 2:08 PM, Home Health Aide 1 indicated they had not notified anyone at the agency of the toe wound because he/she did not think it was a problem. During an interview on 4/15/24 beginning at 11:45 AM, the Clinical Manager indicated the home health aide is a member of the interdisciplinary team and should have contacted the nurse or office about the wound and indicated there was no record of notification.”

“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 interview and record review the agency failed to ensure they had a pre-designated qualified individual, who is authorized in writing to assume the role of the administrator, if and when the administrator is unavailable for 1 of 1 agency. Findings Include: During the entrance conference, conducted on 4/01/24, with the Administrator and the Director of Operations, they indicated the Administrator was also the Clinical Supervisor and identified an individual who was their Alternate Administrator / Clinical Supervisor. During an interview on 4/04/24 beginning at 11:20 AM, the Administrator indicated the individual acting as Alternate Administrator and alternate Clinical Supervisor stepped away from the position in September 2023 and indicated the Director of Operations was hired October 2023 and was to assume the roles vacated by the previous individual, though they have not yet accepted those roles in writing. The Administrator indicated that he/she and the Director of Operations perform the roles of Alternate Administrator and alternate Clinical Supervisor and that the staff communicate to the DO regarding clinical issues and concerns. During an interview with Home Health Aide 1 on 4/02/24, they identified the Administrator, was unable to identify the role of the Director of Operations, and identified a different member of the administration team as the Director of Nursing. In an email chain dated 02/06/24 between the Director of Operations and Person 11 at Entity 12, The Director of Operations identified themselves as RN Clinical Manager. During an interview with Occupational Therapist (OT) 1 on 4/02/24 beginning at 10:05 AM, the employee identified Director of Operations as the agency’s clinical supervisor. During an interview with Registered Nurse (RN) 1 on 4/02/24 beginning at 3:59 PM, the employee identified Director of Operations as the agency’s clinical supervisor.”

“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 interviews, the agency failed to maintain one current clinical record with all documentation, visit notes, and assessments in 2 of 2 active records reviewed (Patients #2 and 5) who were receiving Medicaid and Medicare services concurrently. Findings include: Findings include: 1. The review of the list of all active patients evidenced the agency had two active records for Patient #2 and Patient #5. 2. The review of Patient #2’s records revealed one was a Medicaid account, with an admission date of 10/19/22 and evidenced home health aide [HHA] visits were completed by HHA 1 on 4/4/24, 4/5/24 and 4/6/24. The second record revealed another account, listed insurance was Medicare, with admission date of 3/07/24 and evidenced completed HHA 1 visit notes dated 4/07/24 and 4/08/24 and physical therapy (PT) visits. 3. The record review of Patient #5 evidenced one active account was under Medicaid with an admission dated of 11/15/22 and revealed completed HHA visits were completed the week of 4/5/24. The second active record revealed to be receiving services under Medicare with an admission date of 3/24/24. This record revealed completed HHA and PT visits were provided the week of 4/9/24. 4. During an interview on 4/3/24 beginning at 11:30 AM, the Clinical Manager (CM) indicated their agency maintains two separate Medicare and Medicaid records as that is their practice.”