1ST Option Adult Day Services and Home Health LLC

The home health agency failed to evidence a plan which was updated at least every two years (Tag E0004); failed to include a process for cooperation and collaboration with local, state and federal emergency preparedness officials that included documented attempts to contact officials in an effort…

The home health agency failed to ensure the OASIS (Outcome and Assessment Information Set, a comprehensive assessment data collection tool) information was electronically reported.

The home health agency failed to evidence they had a QAPI program that measured, analyzed, and tracked quality indicators (G0642); utilized data to identify opportunities for improvement (G0644); improvement activities focused on high risk or problem prone areas (G0646); performance improvement…

The home health agency failed to ensure: the home health aide was evaluated for competency before providing patient care (see tag G0768); the home health aide was assigned with appropriate written instructions (see tag G0798); the home health aide provide services that were included in the plan of…

The home health agency failed to ensure the organization and management of the home health agency as follows: the services provided were set forth in writing (see tag G0940); the governing body failed to develop and review the budget (see tag G0942); the employment of qualified personnel (see tag…

The agency failed to ensure the patient and representative were informed of the agency’s transfer/discharge policy in 2 of 2 home visits conducted with an agency folder present.

The agency failed to ensure services were provided as directed in the POC in 3 of 5 active clinical records reviewed.

The agency failed to ensure that prior to patient contact, the home health aide would successfully have completed a competency skills evaluation with a pseudo-patient or a live patient in 4 of 4 home health aides with a hire date between 02/26/2025 and 07/02/2025 (Home Health Aide 1, 5, 7, 10); in…

The agency failed to ensure the RN assigned written tasks to the HHA in 3 of 5 active clinical records reviewed.

The agency failed to ensure the governing body reviewed the annual budget.

The agency failed to ensure the HHA documented the visit note accurately and timely in 4 of 5 active clinical records reviewed.

The agency failed to ensure the administrator’s name was provided in writing in 2 of 2 home visits conducted with an agency folder present.

The agency failed to ensure the comprehensive assessment included a review of all the medications to identify medication interactions and duplicative drug therapy in 1 of 1 active skilled record review in a total sample of 1 active skilled patient.

The agency failed to evidence coordination of care with all other agencies providing services to the patients in the home in 1 of 1 active skilled record reviewed in a total census of 1 active skilled patient and in 1 of 1 active clinical record reviewed with personal services provided by the…

The agency failed to ensure the agency provided services only as ordered by a physician in 1 of 5 active clinical records reviewed.

The agency failed to notify the physician of drug interactions and continued behaviors in 1 of 1 skilled clinical record reviewed in a total sample of 1 active skilled patient.

The agency failed to evidence coordination of care with all other agencies providing services to the patients in the home in 1 of 1 active skilled record reviewed in a total active census of 1 skilled patient.

The agency failed to ensure the HHA provided the tasks as directed in the HHA Care Plan in 4 of 5 active clinical records reviewed.

The agency failed to ensure the HHA reported changes in the patient’s status in 1 of 1 active clinical record review of a patient receiving HHA services only with a hospitalization in a total sample of 5 active clinical records with HHA services.

The agency failed to ensure the RN made an on-site supervisory visit to the patient’s home where both skilled and HHA services were provided in 1 of 1 skilled record review in a total active census of 1 skilled patient.

The agency failed to ensure the RN provided supervision of the HHA to ensure the tasks were provided as directed in 4 of 5 active clinical records reviewed.

The agency failed to ensure the administrator provided oversight of the day-to-day operations of the agency to include notifying the Indiana Department of Health of changes in the administrative staff.

The administrator failed to ensure the employment of qualified personnel to ensure certification of the HHA.

The agency failed to ensure the clinical manager provided clinical oversight of the patient and personnel assignments.

The agency failed to ensure the CM followed the agency’s policies regarding referrals.

The agency failed to ensure the transfer summary was sent to the facility responsible for providing care within 2 business days of becoming aware of an unplanned transfer in 1 of 2 closed records reviewed.

The home health agency failed to ensure home health aides provided care which was ordered on the plan of care in 4 of 4 clinical records reviewed.

The Registered Nurse (RN) failed to provide a patient-specific Home Health Aide (HHA) care plan in 7 of 7 clinical records reviewed (#1, 2, 3, 4, 5, 6, 7).

The home health agency failed to: ensure the emergency preparedness plan included an all-hazards, community-based risk assessment, and/or strategies for addressing emergency events identified by the risk assessment (see tag E0006); ensure the emergency preparedness plan included a process for…

The home health agency failed to: ensure the initial assessment visit was held within 48 hours of referral, the patient’s return home, or on the physician ordered start of care date (see tag G514); ensure the comprehensive assessment accurately reflected the patient’s status (see tag G526); ensure…

The home health agency failed to: ensure patients received the home health services which were written in an individualized plan of care (see tag G572); ensure the plan of care included, all pertinent diagnoses, types of supplies and equipment required, nutritional requirements, all medications and…

The home health agency failed to: to ensure the QAPI program demonstrated measurable improvement in indicators which would improve health outcomes, patient safety, and quality of care, and failed to measure, analyze, and track these indicators (see tag G642); collect and utilize quality indicator…

Agency failed to: ensure home health aides received competency training (see tag G768); ensure home health aide services were provided appropriately and as ordered on the plan of care, and allowed by state law (see tag G800); and ensure home health aides were directly supervised every 60 days for…

The home health agency failed to: ensure the administrator was appointed by the governing body (see tag G946); ensure the administrator was responsible for all day-to-day operations of the home health agency (see tag G948); ensure the clinical manager provided oversight of all patient care services…

The home health agency failed to ensure the emergency preparedness plan included an all-hazards, community-based risk assessment, and/or strategies for addressing emergency events identified by the risk assessment.

The home health agency failed to ensure the emergency preparedness plan included a process for cooperation and collaboration with regional, state, and/or federal emergency preparedness officials’ efforts to maintain an integrated response during an emergency.

The home health agency failed to ensure patients had individual emergency preparedness plans as a part of the comprehensive assessment in 2 of 3 home visits conducted.

The agency failed to ensure the emergency preparedness policies and procedures included procedures to inform state and/or local officials of on duty staff or patients they were unable to contact.

The agency failed to ensure the emergency preparedness communication plan was updated at least every 2 years.

The home health agency failed to ensure the emergency preparedness communication plan included names and contact information for staff and patients’ physicians.

The agency failed to ensure the emergency preparedness communication plan which included contact information for federal, state, regional and local emergency preparedness staff.

The home health agency failed to ensure the emergency preparedness communication plan included a primary and alternate means of communicating with federal, state, regional, and local emergency management agencies and facility staff.

The agency failed to provide and maintain documentation of emergency preparedness training at least every 2 years.

The agency failed to conduct any exercises to test the emergency plan annually.

The home health agency failed to ensure the comprehensive assessment accurately reflected the patient’s status in 4 of 5 active clinical records reviewed.

The home health agency failed to send transfer/discharge summaries containing all necessary medical information pertaining the the current course of illness and treatment, post-discharge goals of care, and treatment preferences to the receiving facility or health care practitioner in 2 of 2…

The home health agency failed to ensure patients received the home health services which were written in an individualized plan of care in 5 of 5 active clinical records reviewed.

The home health agency failed to review and revise the plan of care in 5 of 5 active clinical records reviewed.

The home health agency failed to ensure the QAPI program demonstrated measurable improvement in indicators which would improve health outcomes, patient safety, and quality of care, and failed to measure, analyze, and track these indicators.

The home health agency failed to collect and utilize quality indicator data in the QAPI program to monitor the effectiveness and safety of services and quality of care and identify opportunities for improvement.

The home health agency failed to ensure performance improvement activities tracked adverse patient events, analyzed their causes, and implemented preventative actions.

The home health agency failed to conduct and document performance improvement projects.

The home health agency failed to ensure home health aides completed competency evaluations prior to providing patient care in 6 of 7 home health aide personnel records reviewed.

The home health agency failed to ensure the clinical manager provided oversight of all patient care services and personnel.

The home health agency failed to provide patients with contact information for the administrator, including name, address, and/or phone number in 3 of 3 home visits conducted.

The home health agency failed to ensure patients were informed about the completion of all assessment and the care to be furnished in 1 of 3 home visits conducted.

The home health agency failed to document complaints and the resolution of complaints.

The home health agency failed to ensure the initial assessment visit was held within 48 hours of referral, upon the patient’s return home, or on the physician ordered start of care date in 1 of 3 home visits conducted.

The home health agency failed to ensure the comprehensive assessments included the patient’s current health, psychosocial, functional, and/or cognitive status in 5 of 5 active clinical records reviewed.

The home health agency failed to complete a review of all medications the patient was currently using in order to identify potential drug interactions, duplicative drug therapy, and/or noncompliance with drug therapy in 4 of 5 active clinical records reviewed.

The home health agency failed to ensure the plan of care included, all pertinent diagnoses, types of supplies and equipment required, nutritional requirements, all medications and treatments, patient and caregiver education and training, and/or measurable outcomes and goals in 5 of 5 active…

The home health agency failed to ensure services were provided, only as ordered by the physician in 1 of 5 active clinical records reviewed.

The home health agency failed to ensure the physician was promptly notified of any changes in patients’ condition which suggested goals were not being achieved or the plan of care should be altered in 2 of 5 active clinical records reviewed.

The home health agency failed to provide patients with written visit schedules in 3 of 3 home visits conducted.

The home health agency failed to ensure patients received written medication schedule/instructions including medication name, dose and frequency of medications to be taken in 2 of 3 home visits conducted.

The home health agency failed to provide patients with written instructions outlining treatments to be administered by home health personnel or personnel acting on behalf of the home health agency in 1 of 3 home visits conducted.

The home health agency failed to ensure patients received written name and contact information for the clinical manager in 3 of 3 home visits conducted.

The home health agency failed to ensure performance improvement activities considered incidence, prevalence, and severity or problems.

The home health agency failed to ensure clinical notes were prepared accurately in 2 of 3 home visits conducted.

The home health agency failed to ensure skilled professionals communicated with all physicians involved in the plan of care regarding the plan of care in 4 of 5 active clinical records reviewed.

The home health agency failed to ensure home health aides provided services which were included in the plan of care, permitted to be performed under state law, and consistent with home health aide training in 1 of 3 home visits conducted.

The home health agency failed to ensure the registered nurse made an on-site visit every 60 days to observe and assess the home health aide performing care in 3 of 7 clinical records reviewed.

The home health agency failed to ensure the administrator was appointed by the governing body.

The administrator failed to be responsible for all day-to-day operations of the home health agency.

The home health agency failed to ensure the clinical manager coordinated patient care with other home health agencies and the physician in 3 of 5 active clinical records reviewed.

The home health agency failed to ensure the clinical manager assured the implementation of the individualized plan of care in 1 of 3 home visits conducted.

The agency failed to develop and implement emergency preparedness policies and procedures which addressed staffing strategies during an emergency.

The agency failed to follow standards of practice including the use of standard precautions to prevent the transmission of infections and communicable diseases for 1 of 1 patient observed receiving a bed bath from a home health aide.

The agency failed to have an active infection control program to maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infections and communicable diseases.

The home health agency failed to ensure the patient rights evidenced the patient was to be free from verbal, mental, sexual and physical abuse and neglect; failed to ensure they adhered to patient rights by failing to ensure patients/ patient representatives were informed in advance of any changes…

The agency failed to ensure all visits were made as ordered on the plan of care; failed to ensure the plan of care was individualized and specific to the patients' needs; failed to ensure the skilled nurse put orders into writing and sent to the physician for signature; and failed to ensure…

The agency failed to develop an effective, ongoing, home health agency wide, data driven Quality Assessment Performance Improvement (QAPI) program; failed to show measurable improvement in health outcomes, patient safety, and quality of care and failed to measure, analyze, and track the quality…

The agency failed to ensure skilled professionals at the agency participated in coordination of care activities.

The home health agency failed to ensure the home health aide successfully completed a competency evaluation program; the Registered Nurse failed to ensure the HHA (home health aide) care plans were individualized and home health aides had a complete, updated aide care plan; and the home health…

The administrator failed to ensure patients with services from other agencies had a written agreement; failed to ensure patients with services from other agencies had a written agreement of who is the primary agency (overall responsibility) for all services being provided to patients; and failed to…

The agency failed to ensure all Outcome and Assessment Information Set (OASIS) questions were answered/ completed accurate for 1 of 1 records reviewed (#8) for OASIS submissions / transmissions.

The agency failed to ensure all care and services were provided per the plan of care for 8 of 10 clinical records reviewed.

The agency failed to have an active infection control program to maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infections and communicable diseases and incorporated the information into the agencies QAPI (quality assurance…

The home health agency failed to ensure the home health aide successfully completed a competency evaluation program for 9 of 11 home health aide (HHA) files reviewed (Employees #E, F, I , J, K, L, M, N, O) of home health aides hired since August 2016. The findings included: 1 The undated agency…

The Registered Nurse failed to ensure the HHA (home health aide) care plans were individualized and home health aides had a complete, updated aide care plan for 7 of 7 active records reviewed (#1 - #7) of patients with home health aide services.

The agency failed to provide skilled nursing services for 7 of 7 active patients (#1 - 7) reviewed of a sample of 25 active patients.

The agency failed to ensure the patient rights evidenced the patient was to be free from verbal, mental, sexual and physical abuse and neglect for 1 of 1 agency rights documentation.

The agency failed to ensure they adhered to patient rights by failing to ensure patients/ patient representatives were informed in advance of any changes in the care for 1 of 7 active records reviewed (#1).

The agency failed to ensure patients were advised about the purpose of Indiana State Department of Health (ISDH) hotline number and given the correct phone number for the hotline for 10 of 10 clinical records reviewed (#1 - #10).

The agency failed to ensure the patients / patient representatives received names, addresses and telephone numbers of the Federally Funded and state funded entities that serve the area where the patients reside for 10 of 10 records reviewed (#1 - #10).

The agency failed to evidence documentation of their efforts to resolve the problem presented by the patient's situation for 1 of 1 patient discharged for cause (#9).

Based record review and interview, the agency failed to ensure they documented the existence and resolution of complaints for 2 of 10 records reviewed (#1, #2) and 1 of 1 agency.

The agency failed to ensure the plan of care was individualized and specific to the patients' needs for 7 of 7 active records reviewed (#1, #2, #3, #4, #5, #6, #7).

The home health agency failed to ensure the skilled nurse put orders into writing and sent to the physician for signature in 5 of 7 active clinical records (#1, #2, #4, #6, #7) reviewed.

The agency failed to ensure coordination of care activities occurred and were documented for 8 of 8 records (#1 - #4, #6 - #9) reviewed with patients with outside services / resources used.

The home health agency failed to ensure a home health aides only completed tasks allowed under state law during home visits for 2 of 4 home visits observed (patients #2 and #6) with a home health aide (Employee O, HHA and Employee P, HHA) after interviews conducted with these employees.

The agency failed to ensure patients with services from other agencies had a written agreement for 8 of 8 records reviewed with patients receiving services from other entities (#1 - 4, #6 - #9) The findings included: 1. A review of clinical record #1 failed to evidence a written agreement with…

The administrator failed to ensure patients with services from other agencies had a written agreement of who is the primary agency (overall responsibility) for all services being provided to patients for 8 of 8 records reviewed with patients receiving services from other entities (#1 - 4, #6 - #9)…