Every finding on record at A Better Tomorrow Health and Wellness LLC

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR §484.102. Survey Dates: 08/28, 08/29, and 09/02/2025. Active Census: 10 At this Emergency Preparedness survey, A Better Tomorrow Health and Wellness LLC. was found to be in compliance with Emergency Preparedness Requirements for a Medicaid Participating Providers and Suppliers, 42 CFR §484.102. QR completed by Area 3 on 9/5/2025.

This visit was for an Initial Federal Medicaid Certification and State Licensure survey for a Home Health provider. Survey Dates: 08/28, 08/29, and 09/02/2025. 12 Month Unduplicated Admissions: 14 This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Abbreviations: HHA Home Health Aide OASIS Outcome and Assessment Information Set RN Registered Nurse SOC Start of care CM Clinical Manager SN Skilled Nursing POC Plan of Care PT Physical Therapist QR completed by Area 3 on 9/5/2025.

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 individualized POC included a description of the patients’ risk for emergency department visits and hospital readmission, all necessary interventions to address the underlying risk factors and the specific education and training to be provided, and patient specific education to be provided by the SN, SN frequency, measurable outcomes and goals identified by the home health agency and patient for 4 of 6 active clinical records reviewed. (Patients: #1, 2, 4, and 5) Findings Include: 1. A review of an undated agency policy titled “Patient Assessment and Care Planning” indicated, but was not limited to, “ … Based on the initial assessment, develop an individualized care plan that addresses the identified needs, preferences, and goals of the patient. The care plan will specify the types of services required, the frequency of visits, the goals of care, and social instructions for the care team … ” 2. A review of an undated agency policy titled “Wound Care Policies for A Better Tomorrow Home Health Agency” indicated but was not limited to, “ … Develop a personalized care plan based on initial assessment … Include specific interventions, such as wound cleansing, dressing changes, and pain management … Set realistic goals for healing and monitor progress regularly … Educate patients and caregivers on proper wound care techniques … Provide information on signs of infection and when to seek medical attention … ” 3. A review of Patient #1's record, SOC date 08/08/2025, contained a POC for the initial certification period 08/08/2025 to 10/06/2025. The POC indicated, but was not limited to, the diagnoses Fournier’s gangrene (a rare life-threatening bacterial infection affecting the genital and perineal area requiring surgical debridement), Diabetes Mellitus Type 2 (a condition with high blood sugar levels), and Bipolar with Anxiety (a disorder characterized by periods of depression and abnormally elevated mood). The section titled “Orders for Discipline and Treatments” indicated Patient #1 had orders for one time a week for one week, two times a week for 9 weeks, and 3 as needed (PRN), but failed to list the discipline for those visits and the treatments. The section titled “Medications” listed “1-Pubis wound-Remove old dressing and discard per protocol. Cleanse wound with wound wash. Pack Aquacel AG rope to the wound bed, cover with a 4x4 gauze, and secure with a Medipore pre-cut dressing. Change daily. 2- Left labia wound: remove old dressing and discard per protocol. Cleanse wound with wound wash and pat dry. Apply wound vac to wound using black foam to wound bed. Suction at 125 mmHg. Agency to change on Monday and Friday.” The orders failed to list who is changing daily when the SN is not performing visits. The section Medications failed to list the subscribed medications, dose, frequency, and route for Patient #1. The POC section titled “Goals/Rehabilitation Potential /Discharge Plans” indicated “Goals: Remain free of injurious falls during care. Remain free of rehospitalization during period of care. Pain will remain manageable and acceptable level for patient. Patient will be knowledgeable or medication regimen and disease management. Patient will not experience any wound complications during period of care. Remain free of hospitalizations related to hypo/hyperglycemia. Rehab potential is fair. Discharge to home under self-supervision and PCP care when goals are met.” The POC failed to evidence education and teaching to the patient/caregiver regarding wound care and infection prevention, skin precautions, caregiver availability, education and teaching regarding nutrition to promote wound healing, call parameters for blood sugar, temperature, pulse, and blood pressure readings, education regarding diabetes and blood sugar control, and a description of the patient’s risk for emergency department visits and hospital readmission, code status, and all necessary interventions to address the underlying risk factors. The POC failed to evidence all required elements, failed to be individualized and patient-specific, with measurable goals and interventions to obtain those specific goals. An agency document titled “Progress Notes” dated 08/08/2025, and signed by the Administrator/RN, indicated Patient #1 did not have any meds in the home due to the patient could not afford the co-pay, and the primary care physician is working on the issue. The Progress note dated 08/12/2025 noted that the Administrator/RN informed Entity 1, the outpatient wound care center, regarding the lack of Patient #1's ability to perform daily wound care due to the unavailability of a caregiver, the absence of necessary medications, and the lack of a glucometer in the home. During an interview on 08/28/2025 at 2:01 PM, when questioned about the location of the interventions, blood sugar parameters, medications, and education regarding wound care to the patient/caregiver doing wound care for Patient #1’s POC, the Administrator/RN stated, “We are doing wound care, and the orders were located in the medication area. The meds and glucometer were not available to the patient, related to funds. We are trying to get samples from resources.” 4. A review of Patient #2's record, SOC date 08/15/2025, contained a POC for the initial certification period 08/15/2025 to 10/14/2025. The POC indicated, but was not limited to, the diagnoses Sacral Cellulitis (a bacterial infection that affects the skin and underlying tissues in the sacral area), Stage III pressure ulcer of coccyx (a wound that has full-thickness skin loss with fat and bone exposed), and Age-related physical debility. The section titled “Orders for Discipline and Treatments” indicated Patient #2 had orders for SN one time a week for 9 weeks, and 3 PRN wound care/education. The section titled “Medications” failed to list oxygen amount, frequency, and route. The POC section titled “Goals/Rehabilitation Potential /Discharge Plans” indicated “Goals: Remain free of injurious falls during care. Remain free of rehospitalization during period of care. Pain will remain manageable and acceptable level for patient. Patient will be knowledgeable or medication regimen and disease management. Patient will not experience any wound complications during period of care. Rehab potential is fair. Discharge to home under self-supervision and Primary Care Physician [PCP]care when goals are met.” The POC failed to evidence education and teaching to the patient/caregiver regarding wound care and infection prevention, skin precautions, pain management, caregiver availability, education and teaching regarding nutrition to promote wound healing, call parameters for temperature, pulse, oxygen saturations, and blood pressure readings, education regarding blood pressure control, and a description of the patient’s risk for emergency department visits and hospital readmission, code status, and all necessary interventions to address the underlying risk factors. The POC failed to evidence all required elements, failed to be individualized and patient-specific, with measurable goals and interventions to obtain those specific goals. An agency document titled “Progress Notes” dated 08/15/2025, and signed by the Clinical Manager/RN, indicated Patient #2, denied pain at the time of visit but then endorsed pain upon wound care treatment. Patient #2 received education on wound care treatment. The patient had shortness of breath on minimal exertion and had prescribed oxygen via nasal cannula at 2 liters continuously. Patient #2 received smoking cessation, deep breathing exercises, diet to promote wound healing, adequate nutritional intake, changing positions to prevent further skin breakdown, proper personal hygiene, hand hygiene, signs and symptoms of infections, and Patient #2 verbalized understanding During an interview on 08/29/2025 at 9:00 AM, when reviewing the POC for Patient #2, the Clinical Manager/RN confirmed the POC should have had call orders, interventions, and individualized specific goals for wound healing and the patient's co-morbidities affecting wound care and healing. 5. A review of Patient #4's record, SOC date 08/23/2025, contained a POC for the initial certification period 08/23/2025 to 10/21/2025. The POC indicated, but was not limited to, the diagnoses Diabetes Mellitus 2 with Foot Ulcer (a foot wound resulting from prolonged high blood sugar levels damaging blood vessels and nerves, leading to loss of sensation and poor circulation in the feet), and Encounter for Removal or Change of Nonsurgical Dressing. The section titled “Orders for Discipline and Treatments” indicated Patient #4 had orders for SN one time a week for 9 weeks, and 3 PRN. The section titled “Medications” listed the following: 1. Metformin 500 mg-take 1 tablet by mouth once daily. 2. Left plantar foot ulcer: Remove old dressing and discard per protocol. Cleanse the area with saline or wound cleanser. Apply Negative pressure wound therapy (NPWT) (a therapeutic technique using a suction pump, tubing, and a dressing to remove excess wound drainage and to promote healing) using black foam to the wound bed with suction at 125mm/hg pressure. Football dressing to be applied to the foot using 3 rolls of conform gauze, 1 roll of kerlix, and 1 roll of coban. Agency to change on Thursdays. Patient to maintain an open-toe surgical shoe on the left foot with a blue foam sole. Patient to stay off foot as much as possible. The POC section titled “Goals/Rehabilitation Potential /Discharge Plans” indicated “Goals: Remain free of injurious falls during care. Remain free of rehospitalization during period of care. Pain will remain manageable and acceptable level for patient. Patient will be knowledgeable or medication regimen and disease management. Patient will not experience any wound complications during period of care. Patient will have no episodes of hypo/hyperglycemia during period of care. Rehab potential is fair. Discharge to home under self-supervision and PCP care when goals are met.” The POC failed to evidence education and teaching to the patient/caregiver regarding wound care and infection prevention, skin precautions, pain management, caregiver availability, education and teaching regarding nutrition to promote wound healing, wet to dry dressing changes and education to patient/caregiver, call parameters for temperature, pulse, oxygen saturations, blood sugars, and blood pressure readings, education regarding blood sugar control, and a description of the patient’s risk for emergency department visits and hospital readmission, code status, and all necessary interventions to address the underlying risk factors. The POC failed to evidence all required elements, failed to be individualized and patient-specific, with measurable goals and interventions to obtain those specific goals. A review of an agency document titled “Progress Notes” dated 08/26/2025, a late entry for 08/23/2025, and signed by the Administrator/RN, indicated that Patient #4 is not abiding by weight-bearing restrictions to the left foot. Education had been provided to the patient/caregiver on the wet-to-dry dressing process in case of loss of suction with NPWT. Education had been provided regarding wound symptoms and complications. Patient/caregiver voiced understanding. During an interview on 08/29/2025 at 9:00 AM, when reviewing the missing elements on Patient #4’s POC, the Administrator/RN indicated they were unaware they could type in the POC all the necessary interventions they were doing, address the comorbidities, and short- and long-term goals, patient-specific, with call parameters. 6. A review of Patient #5's record, SOC date 07/30/2025, contained a POC for the initial certification period 07/30/2025 to 09/27/2025. The POC indicated, but was not limited to, the diagnoses Cerebrovascular Accident (CVA) (a stroke when blood flow to a part of the brain is interrupted), Open Back Wound, Hypertension, Chronic Back Pain, and Bipolar Disorder. The section titled “Orders for Discipline and Treatments” indicated Patient #4 had orders for SN one time a week for 9 weeks, and 2 PRN for diagnosis management, exacerbation of conditions, or wound complications. The section titled “Medications” listed the following: 1. Lower back wound: Remove old dressing and discard per protocol. Cleanse wound with normal saline. Gently pack saline-moistened gauze to wound depth. Cover with ABD pad and tape. Change dressing daily and PRN soiling/dislodgement. Home health to change once weekly. 2. Carbamazepine (treats seizures, used frequently to treat bipolar disorder, decreasing nerve impulses) 200 mg tablet - take 1 tablet by mouth three times daily - morning, evening, and bedtime - bipolar disorder. 3. Cariprazine (antipsychotic used to treat manic depressive disorder) 3 mg capsule - take 1 capsule by mouth one time daily - bipolar disorder 4. Celebrex 200 mg capsule - take 2 capsules by mouth one time daily - chronic pain. 5. Clopidogrel (prevents clotting formation in the blood) 75 mg tablet - take 1 tablet by mouth one time daily- heart health. 6. Diltiazem CD (treats high blood pressure) 240 mg 24-hour capsule - take 1 capsule by mouth twice daily – hypertension. 7. Losartan-hydrochlorothiazide (treats high blood pressure) 100-12.5 mg tablet - take 1 tablet by mouth daily – hypertension. 8. Nicotine patch 21 mg/24hr - apply 1 patch on skin one time each day at the same time for smoking cessation. 9. Nicotine 2 mg gum - chew one piece as needed for smoking cessation. 10. Oxycodone-acetaminophen 5-325mg tablet - take 1 tablet by mouth every 6 hours as needed for pain. 11. Potassium chloride 20 Milliequivalents (mEq) CR tablet - take 1 tablet one time daily - supplement - do not crush or chew. 12. Pregabalin (treats nerve pain) 75 mg capsule - take 1 capsule by mouth twice daily – neuropathy. 13. Promethazine-DM 6.25-15 mg/5 ml syrup - take 5 ml by mouth four times a day as needed for cough. 14. Rosuvastatin (treats high cholesterol) 40 mg tablet - take 1 tablet by mouth every night – hypertriglyceridemia. 15. Venlafaxine XR (treats depression) 75 mg 24-hour capsule - take 1 capsule by mouth once daily - bipolar disorder - do not crush or chew. 16. Wixela (treats airflow obstruction in the lungs) 250/50 mg inhaler - inhale 1 puff daily - asthma - rinse mouth after use. The POC section titled “Goals/Rehabilitation Potential /Discharge Plans” indicated “Goals: Remain free of injurious falls during care. Remain free of rehospitalization during the period of care. Pain will remain at a manageable and acceptable level for the patient. Patient will be knowledgeable or medication regimen and disease management. Patient will not experience any wound complications during period of care. Patient will have no episodes of hypo/hyperglycemia during the period of care. Rehab potential is fair. Discharge to home under self-supervision and PCP care when goals are met.” The POC failed to evidence education and teaching to the patient/caregiver regarding wound care and infection prevention, skin precautions, pain management, caregiver availability, education and teaching regarding nutrition to promote wound healing, wet to dry dressing changes and education to patient/caregiver, call parameters for temperature, pulse, oxygen saturations, and blood pressure readings, education regarding pain, and a description of the patient’s risk for emergency department visits and hospital readmission, code status, and all necessary interventions to address the underlying risk factors. The POC failed to evidence all required elements, failed to be individualized and patient-specific, with measurable goals and interventions to obtain those specific goals. A review of an agency document titled “Progress Notes” dated 07/30/2025, and signed by the Administrator/RN, indicated Patient #5’s lower back wound resulted as a complication of incisional healing post spinal surgery in March of 2025. Patient #5 lives with a family member who provided medication assistance and wound care. The Administrator/RN noted the patient used a walker for ambulation and wore a Holter monitor for heart monitoring. Patient #5’s daughter provided a return demonstration of wound care. During an interview on 08/29/2025 at 9:00 AM, when reviewing the missing elements on Patient #5’s POC, the Administrator/RN indicated they were unaware they could type in the POC all the necessary interventions they were doing, address the comorbidities, and short- and long-term goals, patient-specific, with call parameters. 410 17-13-1(a)(1)(D)(ii, iii, ix, xii, xiii)

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure the RN adhered to standard precautions for preventing the transmission of infections and communicable diseases through proper hand hygiene and gloving for 1 of 2 RN’s providing wound care. (Employee: Administrator/RN) Findings Include: 1. A review of an undated agency policy titled “Hand Hygiene/Hand Washing/Hand Cleansing” indicated, but was not limited to, “ … To prevent transfer of germs and transmission of infections to patients and caregivers … 1. Indications for Hand Hygiene/Hand Washing/ Hand Cleansing are: Before and after direct patient care … Before and after each procedure … After contact with contaminated materials … ” 2. Centers for Disease Control last updated January, 2021. When to Perform Hand Hygiene. Retrieved from cdc.gov/hand hygiene/providers/index.html indicated "Use an Alcohol-Based Hand Sanitizer: Immediately before touching a patient. Before performing an aseptic task [e.g., placing an indwelling device] or handling invasive medical devices. Before moving from work on a soiled body site to a clean body site on the same patient. After touching a patient or the patient's immediate environment. After contact with blood, body fluids or contaminated surfaces. Immediately after glove removal. Wash with Soap and Water: When hands are visibly soiled. ... After known or suspected exposure to spores.... When using alcohol-based hand sanitizer: Put product on hands and rub hands together. Cover all surfaces until hands feel dry. This should take around 20 seconds. ... The CDC Guideline for Hand Hygiene in Healthcare Settings recommends: When cleaning your hands with soap and water, wet your hands first with water, apply the amount of product ... and rub your hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse your hands with water and use disposable towels to dry. Use towel to turn off the faucet. ... Other entities have recommended that cleaning your hands with soap and water should take around 20 seconds. Either time is acceptable. The focus should be on cleaning your hands at the right time. ... When and How to Wear Gloves: Wear gloves ... when ... contact with blood or other potentially infectious materials, mucous membranes, non-intact skin, potentially contaminated skin or contaminated equipment could occur ... Change gloves and perform hand hygiene during patient care, if gloves become damaged, gloves become visibly soiled ... moving from work on a soiled body site to a clean body site on the same patient or in another .... " 3. During a home visit at Patient #1’s residence on 08/29/2025 at 1:30 PM, observed the Administrator/RN provide wound care to Patient #1’s pubis wound. The Administrator performed hand hygiene and donned gloves. Patient #1 pulled their underwear down to show the pubic area, and the Administrator removed the old dressing covering the wound and packing, discarding them in the trash receptacle. The Administrator/RN proceeded using wound cleanser and 4x4 gauzes, cleansing the wound without discarding their gloves, performing hand hygiene, and donning new gloves. During an interview on 08/29/2025 at 2:10 PM, when questioned regarding the need for glove changes and hand hygiene after removing an old dressing, the Administrator/RN stated, “Yes, the gloves should had been discarded, hand hygiene performed, and new gloves donned. I was just thrown by the patient’s comments.” 410 IAC 17-12-1(m)