Independent Home Health Care LLC

“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 establish an individual plan of care that included patient-specific interventions (G572); failed to include all pertinent services, supplies, and equipment (G574); failed to establish a plan of care reviewed and ordered by a physician (G580), failed to alert the physician to changes in the plan of care (G590); failed to integrate all orders (G604), and failed to coordinate care with the patient or patient’s caregiver(G608). These deficiencies had a potential cumulative effect on all 56 patients. 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 at 484.60 Care planning, coordination of services, and quality of care. Findings include: *”

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure the plans of care (POC) were individualized for 3 of 7 active clinical records reviewed. (Patients #1, 2, and 6) Findings Include: 3. A review of Patient #1’s clinical record evidenced a plan of care (POC) with a start of care (SOC) of 08-02-2024 and a certification period from 08-01-2024 to 09-29-2024. The POC evidenced the following diagnoses: Hidradenitis Suppurativa (a chronic skin condition which causes painful lumps and abscesses to form under the skin) and an unspecified open wound on the right buttocks. The POC evidenced a section titled “Orders for Discipline and Treatments” and indicated the clinician was to report the findings for a Fasting and Random Blood Sugar of 300 or more and less than 70 to the physician. The POC failed to evidence the patient had a diagnosis or history of Diabetes (where the body is unable to appropriately produce and use insulin). The POC failed to be individualized to the patient and included a standardized order set for blood sugar control. A review of Patient #1’s clinical record evidenced an “OASIS-E Start of Care” dated 08-02-2024 by Registered Nurse (RN) 1 evidenced the patient had the following diagnoses: Hidradenitis Suppurativa and an unspecified open wound on the right buttocks. The comprehensive assessment indicated the patient did not have Diabetes. During an interview with Patient #1 on 09-18-2024 at 3:40 PM, they indicated they had not checked their blood sugar and was not a Diabetic. During an interview with RN 1 on 09-19-2024 at 11:30 AM, they indicated Patient #1 was not a Diabetic and did not take their Blood sugar. They indicated the software and protocol include standing orders to notify the physician of blood sugars out of range, even if the patient did not have a Diabetic Diagnosis. 4. A review of Patient #2’s active clinical record evidenced a POC with a SOC of 08-23-2204 and certification period from 08-23-2024 to10-21-2024. The POC included the following diagnoses: Neurocognitive disorder with Lewy bodies (a disorder where proteins build up and cause cognitive changes and movement issues), Chronic kidney disease, stage 2 (the kidneys have some damage to them, but they are still able to function), Hypoxemia (low oxygen in the blood), and a burn on the chest wall. The POC evidenced a section titled “Orders for Discipline and Treatments” and indicated the clinician was to report the findings for a Fasting and Random Blood Sugar of 300 or more and less than 70 to the physician. The POC failed to evidence the patient had a diagnosis or history of Diabetes (where the body is unable to appropriately produce and use insulin). The POC failed to be individualized to the patient and included a standardized order set for blood sugar control. A review of Patient #2’s clinical record evidenced an “OASIS-E Start of Care” dated 08-23-2024 by RN 3 indicated in the section titled “Endocrine” Patient #2 had no issues with their endocrine system. During an interview on 09-20-2024 at 3:38 PM with the Clinical Manager (Admin 2), they indicated Patient #2 was not a Diabetic. 410 IAC 17-13-1(a) 1. A policy titled “Independent Home-Health Care Plan of Care-CMS 485 and Physician Orders” received from the administrator on 09-19-2024 at 9:05 AM, indicated but was not limited to “Each patient must receive an individualized written plan of care … must specify the care and services necessary to meet the patient-specific needs … must specify the patient and caregiver education and training … “ 2. A review of Patient #6’s plan of care with a start of care (SOC) of 08-21-2024 and a certification period of 08-21-2024 through 10-19-2024 evidenced a principal diagnosis of Nonrheumatic aortic (valve) disease (progressive condition when the aortic valve narrows and restricts blood flow from the heart to the body) and other diagnosis of end-stage renal disease ( a condition in which kidneys lose the ability to function). The plan of care indicated orders for physical therapy (PT) 1 time a week for 9 weeks and contained but was not limited to “ … PT to minimize/eliminate risk for hospitalization … assess integumentary system … assess integumentary status … provide skilled assessment, teaching/training and reinforcement of teaching to properly assess, manage, and mitigate pain … assess gait and instruct … perform balance training … transfer training … occupational therapy (OT) 1 time for 1 week to evaluate need for OT service …. ” An Oasis “Start of Care” assessment for Patient #6 dated 08-21-2023, contained a section titled “Active Diagnosis-Comorbidities and Co-exiting conditions” signed by PT 3, evidenced Diabetes Mellitus was not an active diagnosis. The plan of care evidenced blood sugar monitoring and contained standing orders (written protocols that are to be performed by a specific clinical staff) to notify the physician for Blood sugar, fasting: greater than 300 less than 70 without a diagnosis requiring blood sugar monitoring. During an interview on 09-19-2024 at 4:15 PM, the administrator explained the blood sugar orders were just “standing orders,” and the electronic medical records system automatically included them in the plan of care.”

“Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This Standard is not met as evidenced by: Based on record review and interview the agency failed to complete all sections of the plan of care for 2 of 7 active clinical records (Patients #2 and #3) and failed to complete all sections of the discharge summary for 1 of 1 patients discharged to a facility. (Patient #1) Findings include: 3. A review of Patient #1’s clinical record evidenced a POC with a start of care (SOC) of 08-02-2024 and a certification period from 08-01-2024 to 09-29-2024. The POC evidenced the following diagnoses: Hidradenitis Suppurativa (a chronic skin condition which causes painful lumps and abscesses to form under the skin) and an unspecified open wound on the right buttocks. The section titled “DME and Supplies” was left blank. A review of Patient #1’s clinical record evidenced a Start of Care (SOC) of 07-03-2024 and a discharge date of 08-01-2024. The clinical record also evidenced an unsigned and undated “OASIS-E Discharge Non-Visit.” The document indicated that the patient was discharged and readmitted because of insurance changes. During an interview with the Administrator and the Clinical Manager on 09-19-2024 at 4:21 PM, they indicated a Discharge Non-visit was to be completed and once it was completed a Discharge summary would populate from the Discharge Non-visit document and would be sent to the physician. They indicated the Discharge Non-visit had been deleted and was not completed, so a discharge summary was not sent to the physician for Patient #1. 4. A review of Patient #2’s active clinical record evidenced a POC with a SOC of 08-23-2204 and certification period from 08-23-2024 to 10-21-2024. The POC included the following diagnoses: Neurocognitive disorder with Lewy bodies (a disorder where proteins build up and cause cognitive changes and movement issues), Chronic kidney disease, stage 2 (the kidneys have some damage to them, but they are still able to function), Hypoxemia (low oxygen in the blood), and a burn on the chest wall. The section titled “DME and Supplies” was left blank. 5. During an interview with the Administrator on 09-19-2024 at 2:00 PM, they evidenced if the patient owns their supplies or if they received it from another company they do not include those items on the POC. 1. A policy titled “Independent Home-Health Care Plan of Care-CMS 485 and Physician Orders” received from the administrator on 09-19-2024 at 9:05 AM, indicated but was not limited to “The individualized plan of care must include the following . . . The patient’s mental, psychological, and cognitive status. The types of services, supplies, and equipment required . . . .” 2. A review of the clinical record for Patient #3 contained a Plan of Care for the certification period 09-04-2024 through 11-02-2024, signed by the Clinical Director/Registered Nurse (RN), and evidenced a section titled “Mental/Cognitive Status” was blank, a section titled “Functional Limitations” was blank, caregiver status stating “There is no data for this section,” and a durable medical equipment (DME) section that listed a tub/ shower bench and walker. The plan of care failed to evidence mental cognitive status, functional limitations, a complete durable medical equipment list, and caregiver status.”

“Within 48 hours of the patient’s return CFR(s): 484.55(d)(2) Within 48 hours of the patient’s return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the Start of Care (SOC) was completed 48 hours after the patient discharged from the hospital for 1 of 1 active clinical records reviewed with a Skilled Nurse (SN) Home visit. (Patient #1) Findings Include: 1. A policy titled “Initial Assessments/Comprehensive Assessments” indicated but was not limited to, “ … 5. Initial Assessment and Time Frame: A RN (sic Registered Nurse) … must conduct the initial assessment visit within 48 hours of referral, within 48 hours of the patient’s return home or on the physician-ordered start of care date …” 2. A review of Patient #1’s clinical record evidenced a referral document dated 07-17-2024 from Entity 17, a hospital. The document evidenced the patient was discharged from the hospital on 07-18-2024. A document titled “Physician Order” dated 07-19-2024 and signed by the Administrator, indicated Patient #1 was discharged from the agency and the patient was to have Skilled Nursing (SN) services resumed on 07-22-2024. The order was signed by the wound care physician, Person 7, on 08-05-2024 Patient #1’s clinical record evidenced a Resumption of Care assessment was completed on 07-24-2024 by Registered Nurse (RN) 1. A review of Patient #1’s plan of care (POC), SOC date of 07-03-2024, and a certification period from 07-03-2024 to 08-31-2024, signed by the physician, Person 7, on 08-05-2024 evidenced the patient had SN 2 times a week for 9 weeks starting 07-24-2024. A review of the communication notes from 06-25-2024 to 09-12-2024 failed to evidence the physician was notified of the delay in the resumption of care and failed to indicate Patient #1 requested a delayed resumption of care assessment. During an interview with Admin 1 and the Clinical Manager (Admin 2) on 09-19-2024 at 4:21 PM, Admin 2 explained RN 1 saw the patient on 07-24-2024, a Wednesday because it was their “normal day” to see the patient on a Wednesday. They evidenced they were to see the patient within 48 hours after discharge from the hospital. Admin 2 indicated an order should have been made for the resumption on 07-24-2024. 410 IAC 17-14-1(a)(1)(A)”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure the plans of care (POC) included all necessary elements for 3 of 4 active clinical records reviewed with home visits. (Patients #1, 2, and 3) Findings Include: 3. A review of Patient #1’s clinical record evidenced a POC with a start of care (SOC) of 08-02-2024 and a certification period from 08-01-2024 to 09-29-2024. The POC evidenced the following diagnoses: Hidradenitis Suppurativa (a chronic skin condition which causes painful lumps and abscesses to form under the skin) and an unspecified open wound on the right buttocks. The section titled “DME and Supplies” was left blank. A home visit was conducted at Patient #1’s residence on 09-18-2024 at 3:40 PM, Registered Nurse (RN) 1 was observed performing an assessment on the patient because the patient had already performed their wound care. During the home visit, it was observed the patient had a 2-wheel walker, a urinal, saline solution, wound cleanser, ABD pad, Silver Calcium alginate (a dressing to help prevent and treat wound infections), and 4x4 gauze. The POC failed to evidence all of the patient’s DME and supplies. During an interview with Patient #1 on 09-18-2024 at 3:40 PM, they indicated they used the walker to move around the house and had the box containing their medications and wound care supplies. right next to them so they could easily access them. During an interview with RN 1 on 09-19-2024 at 11:30 AM, they indicated they had not included Patient #1’s DME and supplies on the POC because it would have generated an order. 4. A review of Patient #2’s active clinical record evidenced a POC with a SOC of 08-23-2204 and certification period from 08-23-2024 to 10-21-2024. The POC included the following diagnoses: Neurocognitive disorder with Lewy bodies (a disorder where proteins build up and cause cognitive changes and movement issues), Chronic kidney disease, stage 2 (the kidneys have some damage to them, but they are still able to function), Hypoxemia (low oxygen in the blood), and a burn on the chest wall. The section titled “DME and Supplies” was left blank. A home visit was conducted at Patient #2’s residence on 09-18-2024 at 6:15 PM, the Clinical Manager was observed providing wound care to the patient. During the home visit, it was observed the patient had briefs, silicone foam dressing, 4x4 gauze, DermaKlenz wound cleanser, rollator/walker, elevated toilet seat, and shower chair. The POC failed to evidence all of the patient’s DME and supplies. 5. During an interview with the Administrator on 09-19-2024 at 2:00 PM, they evidenced if the patient owns their supplies or if they received it from another company they do not include those items on the POC. 410 IAC 17-13-1(a)(1)(D)(i, ii, vi, xiii) 1. A policy titled “Independent Home-Health Care Plan of Care-CMS 485 and Physician Orders” received from the administrator on 09-19-2024 at 9:05 AM, indicated but was not limited to “The individualized plan of care must include the following . . . The patient’s mental, psychological, and cognitive status. The types of services, supplies, and equipment required . . . .” 2. A review of the clinical record for Patient #3 contained a Plan of Care for the certification period 09-04-2024 through 11-02-2024, signed by the Clinical Director/Registered Nurse (RN), and evidenced a section titled “Mental/Cognitive Status” was blank, a section titled “Functional Limitations” was blank, caregiver status stating “There is no data for this section,” and a durable medical equipment (DME) section that listed a tub/ shower bench and walker. The plan of care failed to evidence mental cognitive status, functional limitations, a complete durable medical equipment list, and caregiver status. During an observation at Patient #3’s residence on 09-19-2024 at 1:00 PM, it was discovered that the Patient’s residence contained an intravenous pole, tubing for intravenous infusions, and a sharps container for disposing of medical waste. During an interview on 09-19-2024 at 1:00 PM. Patient #3 reported receiving therapy and nursing services from Independent Home Health Agency. They reported the nurse assisted them with the antibiotic therapy infusion and performed weekly blood draws. Patient #3 reported they have family nearby but lives alone. During an interview on 09-19-2024 at 4:15 PM, the Clinical Director/RN reported Patient #3 does get nursing services for antibiotic intravenous therapy and they did not include that information in the durable medical equipment section for the intravenous antibiotic therapy.”

“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 and interview the agency failed to follow physician’s orders for wound care in 1 of 1 wound care observed. (Patient #1) Findings include: 1. A policy titled “Plan of care-CMS#485 and Physicians Orders” contained but was not limited to “Care and services will be provided according to physicians orders . . . .” 2. A review of Patient #1’s plan of care for the Certification period dated 08-01-2024 to 09-24-2024, evidenced wound care orders dated 08-02-2024 for skilled nursing two times a week to perform wound care to the right perineal area (area between the anus and genitals). The orders indicated cleansing the perineal area with Dakin’s solution ( a solution with a mixture of peroxide and hydrochloric acid used to prevent infections, painting with gentian violet, applying silver alginate, and covering with ADB pads (gauze dressing). 3. During a home observation at Patient #1’s residence on 09-20-2024 at 12:48 PM observed Registered Nurse 1 perform wound care. During the wound treatment application, RN 1 cleansed the wound and applied a dressing without the application of the physician-ordered Dakin’s solution. 4. On 09-20-2021 at 1:20 PM when queried why the Physician’s order for Dakin’s solution was not applied, Nurse 1 reported the patient was out of the solution but was not sure how long they had been without the solution and had not been applying it. 410 IAC 17-13-1(a)”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the physician was notified of a change in condition for 1 of 2 active clinical records reviewed with a change in condition. (Patient #1) Findings Include: 1. A policy titled “Plan of Care - CMS (sic Center for Medicare and Medicaid Services) #485 and Physician Orders” indicated but was not limited to, “ … 9. … The Agency professional staff will promptly alert the physician to any changes that suggest a need to alter the Plan of Care. …” 2. A review of Patient #1’s clinical record evidenced a POC with a SOC of 08-02-2024 and a certification period from 08-01-2024 to 09-29-2024. The POC evidenced the following diagnoses: Hidradenitis Suppurativa (a chronic skin condition which causes painful lumps and abscesses to form under the skin) and an unspecified open wound on the right buttocks. The section titled “Wound Care Orders” evidenced the patient had 2 different wounds, one on the left axilla (under the armpit) and one on the right buttocks to their perineal area. The section indicated the dressing for the left axilla was changed on Mondays, Wednesdays, and Fridays and changed independently by the patient 2 times a week. The POC evidenced the wound was cleaned with Dakin’s solution (a cleanser with sodium peroxide and hydrochloric acid in it to help prevent and stop infections in wounds), Prisma (a sterile wound dressing to assist with healing wounds) applied, and secured with an ABD pad and tape. A review of Patient #1’s clinical record evidenced SN visit notes from 08-02-2024 to 09-18-2024. The SN Visit note dated 08-07-2024 indicated the left axilla wound “opens and closes”. The SN Visit note dated 08-09-2024 described the left axilla wound as “closed and scabbed over”. The visit notes on 08-14, 08-16, 08-21, 08-23, 08-28, 08-30, 09-04, 09-06, 09-11, and 09-13-2024 evidenced the left axilla wound was closed and healed. A review of the communication notes from 06-25-2024 to 09-12-2024 failed to evidence the physician was notified the left axilla wound was healed and had not reopened. During an interview with the Clinical Manager (Admin 2) on 09-19-2024 at 2:00 PM, they indicated they were working with the clinicians on documentation and the nurse was supposed to document when they contacted the physician. During an interview with the Manager, Person 10, from Entity 1 (a wound clinic) on 09-19-2024 at 3:40 PM, indicated Patient #1 had not been seen since 06-24-2024 and they were not notified by Independent Home Health Care staff of changes in Patient #1’s wounds. During an interview with the Administrator (Admin 1) on 09-20-2024 at 9:48 AM, they indicated they were unable to find any communication notes notifying the physician, Person 12, of the left axilla wound being healed. During an interview with Person 12’s (an infectious disease physician) Medical Assistant, Person 13 at Entity 11, on 09-20-2024 at 10:05 AM, they indicated that Person 12 was not following Patient #1 because they had not seen the patient in a year and had not been contacted by anyone from the agency. The agency failed to ensure the physician following Patient #1 was informed of the healed left axilla wound. 410 IAC 17-13-1(a)(2)”

“Integrate all orders CFR(s): 484.60(d)(2) Integrate orders from all physicians or allowed practitioners involved in the plan of care to assure the coordination of all services and interventions provided to the patient. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure they included the appropriate physician and orders in the plan of care for 1 of 4 active clinical records reviewed with a home visit. (Patient #1) Findings Include: 1. A policy titled “Plan of Care - CMS (sic Center for Medicare and Medicaid Services) #485 and Physician Orders” indicated but was not limited to, “ … 7. The physician who establishes the Plan of Care must sign and date the recertification … 15. … Any revision to the plan of care … must be communicated to … all physicians issuing orders to the Agency plan of care.” 2. A review of Patient #1’s clinical record evidenced a POC with a SOC of 08-02-2024 and a certification period from 08-01-2024 to 09-29-2024. The POC evidenced the following diagnoses: Hidradenitis Suppurativa (a chronic skin condition which causes painful lumps and abscesses to form under the skin) and an unspecified open wound on the right buttocks. The clinical record for Patient #1 evidenced a Physician order dated 07-05-2024 by Registered Nurse (RN) 1 and by the physician, Person 12 (an infectious disease physician) on 07-12-2024. The order evidenced wound orders for the patient’s right buttocks wound. During an interview with the Manager, Person 10, from Entity 1 (a wound clinic) on 09-19-2024 at 3:40 PM, they indicated the agency had not contacted them recently regarding Patient #1. They indicated the patient had not been to the wound clinic to see the physician, Person 7, since 06-24-2024, for axilla, right buttocks, right and left groin, and lower back wounds. During an interview with the Administrator and the Clinical Manager on 09-19-2024 at 4:21 PM, the Clinical Manager indicated Person 7, the wound care physician, was not signing orders for the patient because they had not seen Patient #1 in a year. They evidenced they went to the wound care clinic for orders and Person 12 was following the patient at Entity 1, the wound care clinic. During an interview with Person 12’s (an infectious disease physician) Medical Assistant, Person 13 at Entity 11, on 09-20-2024 at 10:05 AM, they indicated Person 12 was not following Patient #1 because they had not seen the patient in a year. They indicated they had not been contacted by anyone from the agency. The agency failed to ensure the appropriate physician was contacted regarding wound care orders. 410 IAC 17-12-2(h)”

“Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient’s needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure care was coordinated with all physicians involved in patient care for 1 of 1 active clinical records reviewed who received care from a wound care clinic. (Patient #1) Findings Include: 3. During a home observation at Patient #1’s residence on 09-20-2024 at 12:48 PM, observed Registered Nurse (RN) 1 perform wound care. During the wound treatment application RN 1 cleansed the wound and applied a dressing without the application of the physician-ordered Dakin’s solution ( a solution with a mixture of peroxide and hydrochloric acid used to prevent infections). 4. On 09-20-2021 at 1:20 PM, when queried why the Physician’s order for Dakin’s solution was not applied, Nurse 1 reported the patient was out of the solution but was not sure how long they had been without the solution. When queried if the Physician had been notified for a refill, RN 1 and the Clinical Director (present on observation) reported the physician at the wound care center Patient #1 was seen, had not been notified. The Clinical Director stated, “They never call back.” 410 IAC 17-14-1 (a)(1)(F) 1. A policy titled “Plan of Care - CMS (sic Center for Medicare and Medicaid Services) #485 and Physician Orders” indicated but was not limited to, “ … 15. … Any revision to the plan of care … must be communicated to … all physicians issuing orders to the Agency plan of care.” 2. A review of Patient #1’s clinical record evidenced a Plan of Care (POC) with a Start of Care (SOC) of 08-02-2024 and a certification period from 08-01-2024 to 09-29-2024. The POC evidenced the following diagnoses: Hidradenitis Suppurativa (a chronic skin condition which causes painful lumps and abscesses to form under the skin) and an unspecified open wound on the right buttocks. A review of the communication notes from 08-02-2024 to 09-12-2024 failed to evidence Person 7, the wound care provider, was contacted regarding Patient #1’s care and the patient’s transfer to the hospital on 07-13-2024. During an interview with the Clinical Manager on 09-19-2024 at 2:00 PM, they indicated they were working with the clinicians on documentation and the nurse was supposed to document when they contacted the physician. During an interview with the Manager, Person 10, from Entity 1 (a wound clinic) on 09-19-2024 at 3:40 PM, they indicated the agency had not contacted them recently regarding Patient #1. They indicated the patient had not been to the wound clinic to see the physician, Person 7, since 06-24-2024. The Manager indicated the patient was seen by Person 7, the wound care physician, for their axilla, right buttocks, right and left groin, and lower back wound. During an interview with the Administrator and the Clinical Manager on 09-19-2024 at 4:21 PM, The Clinical Manager indicated Person 7 was not signing orders for the patient because they had not seen Patient #1 in a year. They evidenced they went to the wound care clinic for orders and Person 12 was following the patient at Entity 1, the wound care clinic.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure a completed discharge summary was written and sent to the physician responsible for the patient’s care after discharge within five (5) business days of the patient’s discharge (Patients: #5 and #10) and within 2 days of a patient being transferred to another facility (Patient: #9) of 3 of 3 discharged records reviewed. Findings include: 5. A review of Patient #1’s clinical record evidenced a Start of Care (SOC) of 07-03-2024 and a discharge date of 08-01-2024. The clinical record also evidenced an unsigned and undated “OASIS-E Discharge Non-Visit.” The document indicated that the patient was discharged and readmitted because of insurance changes. Patient #1’s clinical record failed to evidence the wound care physician, Person 7 of Entity 1 (a wound care clinic), was notified the patient was discharged on 08-01-2024, and a discharge summary was sent to the physician. During an interview with the Administrator and the Clinical Manager on 09-19-2024 at 4:21 PM, they indicated a Discharge Non-visit was to be completed and once it was completed a Discharge summary would populate from the Discharge Non-visit document and would be sent to the physician. They indicated the Discharge Non-visit had been deleted and was not completed, so a discharge summary was not sent to the physician for Patient #1. 6. A review of Patient #9’s clinical record evidenced a SOC of 07-19-2024, and a discharge date of 08-19-2024. The record evidenced a “Transfer Summary” dated 08-22-2024, signed by Registered Nurse (RN) 4. A review of a document titled “Verification Form” evidenced a Transfer Summary was ordered on 08-19-2024, and was sent to the physician, Person 15 with Entity 14 (a primary care provider office), on 08-28-2024. The agency failed to follow its policy and send a transfer summary to the physician within 5 days of them becoming aware of the patient’s admission to the hospital. During an interview on 09-20-2024 at 11:07 AM with a Nurse, Person 16, from Entity 14, they indicated they received an order for holding Home Health services on 08-19-2024 for Patient #9 because they were in the hospital. Person 16 indicated the hold order was the only document they received at the time from the agency. During an interview with Admin 1 on 09-20-2024 at 3:20 PM, they indicated Patient #9 was discharged from the agency and a transfer summary was sent to the physician. Admin 1 indicated the transfer summary was not sent to the physician within 5 days. 410 IAC 17-15-1(a)(6) 1. A policy titled, “Discharge Summary” indicated but was not limited to, “ … “A Discharge Summary will be sent within 5 business days of patient discharge to the primary care practitioner …who will be responsible for providing care and services to the patient …” 2. A review of Patient #10’s clinical record failed to evidence a discharge summary was sent to physician when Patient #10 discharged from the home care agency on 04-19-24, as evidenced by a physician’s discharge order and OASIS discharge assessment. 3. During an interview with administrator on 09-20-24 at 9:45 AM, they indicated the discharge summary was under “deleted documents.” Administrator contacted the Electronic Medical Record (EMR) provider and they confirmed the discharge summary was, “deleted by the Electronic Medical Record (EMR) automation” and was not sent to the physician. 4. During an interview with Person #18, office manager for Physician #5 on 09-20-24 at 10:37 AM, found no evidence the discharge summary for Patient #10 was sent to the physician.”