Every finding on record at A W Holdings LLC

An Emergency Preparedness Survey was conducted by the Indiana State Department of Health in accordance with 42 CFR 494.62 Survey Dates: 01/06/2026 – 01/12/2026 12-month unduplicated skilled admissions: 2 At this Emergency Preparedness Survey, Homepointe Healthcare was found to be in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 494.62.

This visit was for a Federal Recertification and State Re-Licensure survey of a home health provider. Survey Dates: 01/06/2026 – 01/12/2026 Unduplicated 12-month skilled admissions: 2 This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Refer to State Form for additional State Findings. The Administrator was notified of the partially extended survey on 01/09/2026 at 11:10 AM. Abbreviations used in report: Registered Nurse (RN), Plan of Care (POC), Skilled Nursing (SN), Home Health Aide (HHA), Physical Therapy (PT), Occupational Therapy (OT), Speech Therapy (ST), Start of Care (SOC), and Clinical Manager (CM).

Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to document the existence of a complaint and the resolution of the complaint in 1 of 1 record review of a patient who verbalized a complaint. (Patient 8) Findings include: A revised policy, dated 01/06/2026, titled “ Notice of Rights Including Complaint and Grievance Procedure (C-380)”, indicated that a client or their representative may utilize any form of communication in order to file a complaint or grievance and that the agency will document the existence of all complaints, to include the investigation, actions taken, and resolution/outcome. A clinical record review for Patient 8, evidenced a summary of a telephone conversation, on 07/23/2025, between RN 2 and Patient 8’s representative in which Patient 8’s representative made multiple complaints about RN 1 including her physical abilities and not following through on assigned tasks during her shifts. The agency complaint log failed to evidence a complaint on or around 07/23/2025 to include the phone call, or an acknowledgment, of Patient 8’s representative made any complaint about RN 1. Patient 8 was discharged from the agency on 09/10/2025 due to agency unable to provide staff. The clinical record and complaint log failed to evidence a resolution. During an interview on 01/09/2026 beginning at 12:59 PM, RN 3 indicated that the telephone conversation between RN 2 and Patient 8’s representative on 07/23/2025 should have been documented in the complaint log as a formal complaint, an investigation, and resolution via the agency complaint/grievance process.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to provide an initial assessment within 48 hours of the referral in 2 of 2 active clinical records reviewed with HHA services in a total sample of 6 active clinical records reviewed (Patient #5, 6) The findings include: 1. A clinical record review for Patient #5 evidenced a document titled “Referral Form” which indicated the referral date was 07/26/2023 and the SOC date was 10/03/2023. The clinical record failed to evidence an initial assessment prior to the SOC on 10/03/2023 and failed to evidence documentation as to the reason for the delay in the SOC. On 01/12/2026 at 1:45 PM, the CM indicated after the referral was received, Patient fell had had a fracture requiring an inpatient stay at a rehabilitative hospital prior to the SOC with the agency. The CM indicated there was no documentation of the discharge date from the rehabilitative hospital prior to the SOC. 2. A clinical record review for Patient #6 evidenced a document titled “HHA Referral” which indicated the referral date was 10/09/2024 and the SOC date was 01/22/2025. The referral form indicated the agency was waiting for HHA 2 (also Patient’s family member) to complete HHA training and the holiday season influenced the SOC date. The clinical record failed to evidence an initial assessment prior to the SOC on 01/22/2025. On 01/12/2026 at 4:08 PM, the Administrator indicated there was no initial assessment prior to the SOC on 01/22/2025. On 01/12/2026 at 4:08 PM, the CM indicated there was no documentation the agency offered another HHA while HHA 2 was completing HHA training. 410 IAC 17-14-1(a)(1)(A)

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the following information: (1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment included the physical status of the patient in 3 of 4 active clinical records reviewed with only SN services provided in a total sample of 6 active clinical records reviewed. (Patient #1, 3, 4) The findings include: 1. The clinical record review for Patient #1 evidenced a comprehensive assessment for recertification dated 11/11/2025 which failed to evidence Patient’s height and weight, the assessment of the genitourinary (genital and urinary) systems, the type of feeding tube, type amount of feeding via the feeding tube, and amount of feeding tube flushes, the assessment of the hand grips, social needs, and prognosis. On 01/07/2026 beginning at 3:20 PM, the CM indicated Patient had a urinary catheter which was not included in the comprehensive assessment. The CM indicated the comprehensive assessment should be a complete head-to-toe assessment and should be completed in its entirety but was not. 2. A clinical record review for Patient #3 evidenced a comprehensive assessment dated 12/18/2025 failed to include the assessment of Patient’s weight. On 01/09/2026 at 10:59 AM, the Administrator indicated the assessment did not include the weight. 3. A clinical record review for Patient #4 evidenced a comprehensive assessment dated 01/02/2026 which failed to include the assessment of Patient’s height. On 01/09/2026 at 2:26 PM, RN 4 indicated Patient’s height was not included in the assessment. 410 IAC 17-14-1(a)(1)(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 agency failed to ensure the comprehensive assessment included the review of the medications to include potential drug interactions in 2 of 6 active clinical record reviews. (Patient #3, 6) The findings include: 1. A clinical record review for Patient #3 evidenced an undated document titled “Drug Interaction Report” which indicated 259 potential interactions between 18 medications to include a major drug interaction between ibuprofen (for pain, inflammation) and sodium biphosphate (laxative). The POC for recertification period 10/23/2025-12/21/2025 indicated Patient’s medications included Fleets enema (containing sodium biphosphate) and ibuprofen. The POC indicated there was a significant drug interaction between Fleets enema and ibuprofen. The comprehensive assessment for recertification dated 12/18/2025 failed to include the identification of the drug interactions. On 01/09/2026 at 11:02 AM, the Administrator indicated the comprehensive assessment failed to include the identification of the drug interactions. 2. A clinical record review for Patient #6 evidenced a document titled “Drug Interaction Report” dated 10/28/2025 which indicated 195 potential interactions between 14 medications to include moderate interactions between ergocalciferol (calcium/vitamin D) and Trileptal and insulin (to decrease blood sugar) and Ozempic (to decrease blood sugar). A POC for recertification period 09/20/2025-11/18/2025 indicated Patient’s medications included calcium/vitamin D, Trileptal, Novolog (a type of insulin), and Ozempic. The comprehensive assessment for recertification dated 11/14/2025 failed to include the identification of the drug interactions. On 01/12/2026 at 4:13 PM, the Administrator indicated the drug interactions were not reviewed in the comprehensive assessment. 410 IAC 17-14-1(a)(1)(B)

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 evidence the POC was developed in conjunction with the physician and that services were provided as directed in the POC in 6 of 6 active clinical records reviewed. (Patient #1, 2, 3, 4, 5, 6) The findings include: 1. A clinical record review for Patient #1 failed to evidence documentation of communication with the physician regarding the development of the POC for the recertification period 11/13/2025-01/11/2025 which was signed by RN 2. The POC for the recertification period 11/13/2025-01/11/2026 indicated the agency would provide SN services 3 – 5 days a week (not SN respite visits). The clinical record failed to evidence a minimum of 3 visits (not SN respite visits) were provided during the weeks of 11/24/2025 and 12/01/2025. 2. A clinical record review for Patient #2 failed to evidence documentation of communication with the physician regarding the development of the POC for the recertification period 11/09/2025-01/07/2026 which was signed by the CM. 3. A clinical record review for Patient #3 failed to evidence documentation of communication with the physician regarding the development of the POC for the recertification period 12/22/2025-02/19/2026 which was signed by RN 2. The POC for the recertification period 12/22/2025-02/19/2026 indicated the agency was to provide SN services 5-10 hours a day, 2-4 days a week. The clinical record failed to evidence the agency provided SN services 2 times for the week of 12/29/2025 per the POC. On 01/09/2026 at 11:04 AM, the Administrator indicated 2 SN visits were not provided to Patinet since the RN that typically provided SN visits to Patient was on vacation. 4. A clinical record review for Patient #4 failed to evidence documentation of communication with the physician regarding the development of the POC for the recertification periods 11/04/2025-01/02/2026 and 01/03/2026-03/03/2026 which were signed by RN 4. 5. A clinical record review for Patient #5 failed to evidence documentation of communication with the physician regarding the development of the POC for the recertification period 11/12/2025-01/10/2026 which was signed by the CM. The POC for recertification period 11/12/2025-01/10/2026 indicated the agency was to provide SN services 3-6 hours a day, 1-3 days per week. A physician order dated 12/09/2025 indicated to hold SN services, and a physician order dated 12/16/2026 indicated to resume SN services. The record failed to evidence the agency provided SN services since 11/25/2025. On 01/12/2026 at 1:39 PM, the CM indicated the agency had issues providing staffing for Patient and no SN services were provided since 11/25/2025. 6. A clinical record review for Patient #6 failed to evidence documentation of communication with the physician regarding the development of the POC for the recertification period 11/19/2025-01/16/2026 which was signed by RN 6. 7. On 01/07/2026 at 3:27 PM, the Administrator indicated the agency obtained a continuation of care order a couple of weeks prior to the ending of the current certification period and before the start of the next certification period. When queried how the agency developed the POC in conjunction with the physician if no communication with the physician and no order was obtained for the continuation of care after the comprehensive assessment for recertification, the Administrator indicated the agency did not develop the POC with the physician. 8. On 01/09/2026 at 2:28 PM, RN 4 indicated she did not contact the physician after the comprehensive assessment to include the physician in the development of the POC but sent the POC for physician signature after POC has been developed by the RN. 9. On 01/09/2026 at 2:28 PM, RN 2 indicated she did not contact the physician after the comprehensive assessment to include the physician in the development of the POC. 410 IAC 17-13-1(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 record review and interview, the agency failed to ensure the POC included all types and frequency of services provided in 1 of 2 active adult skilled clinical records reviewed with respite nursing services (Patient #4) and in 1 of 1 active clinical record reviewed with attendant care provided (Patient #6) in a total sample of 6 active clinical records reviewed. The findings include: 1. A clinical record review for Patient #4 evidenced a POC for recertification period 11/04/2025-01/02/2026 which indicated Patient had respite skilled nursing services and failed to evidence which agency provided the respite skilled nursing services and the frequency of respite skilled nursing services. On 01/09/2026 at 2:25 PM, RN 4 indicated the agency provided the respite skilled nursing services which was not included on the POC and indicated the POC did not include the frequency of skilled nursing services which were to be used at family’s request. 2. A clinical record review for Patient #6 evidenced a POC for recertification period 11/19/2025-01/16/2026 which indicated Patient had a waiver for attendant care services and failed to evidence which agency provided the attendant care services and the frequency of attendant care services. On 01/12/2026 at 2:53 PM, the Administrator indicated the POC did not identify the agency provided the attendant care servicers and the number of hours to be used per family’s request. 410 IAC 17-13-1(a)(1)(D)(xiii)

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 ensure services were provided only as ordered by a physician in 2 of 2 active adult clinical records reviewed with SN services only in a total sample of 6 active clinical records reviewed. (Patient #1, 4) The findings include: 1. A clinical record review for Patient #1 evidenced hospital discharge instructions from Entity 1 dated 10/13/2025 which indicated Patient had a appendicovesicostomy (a surgical creation of a channel from the bladder to the skin using the appendix to drain urine from the body) performed and had an indwelling catheter (a tube inserted into the bladder and held in place with a balloon). The comprehensive assessment for the resumption of care dated 10/13/2025 indicated the home health agency resumed skilled nursing care, and Patient had an indwelling catheter via the APV. Nineteen skilled nursing visit notes between 11/13/2025 and 12/09/2025 indicated the SN provided indwelling catheter care, and 10 SN visits notes between 12/10/2025-12/12/2025 indicated the SN performed intermittent urinary catheterization (the insertion of a tube into the bladder to drain urine and removing the tube). The clinical record failed to evidence a physician order for the foley care and intermittent urinary catheter. On 01/07/2026 at 3:39 PM, the CM indicated there was not an order for the foley care and intermittent catheter in the clinical record. 2. A clinical record review for Patient #4 failed to evidence an order for home care services to include skilled nursing services after the POC for the recertification period ending on 01/02/2026 and before the POC for the recertification period 01/03/2026003/03/2026 was signed by the physician on 01/05/2026. A skilled nursing visit note dated 01/03/2025 indicated the agency provided skilled nursing services for 15 hours to include gastrostomy (a tube surgically inserted into the stomach) feedings and chest percussion therapy (to loosen thick mucous in the lungs), and the clinical record failed to evidence a physician order for skilled nursing services provided on 01/03/2026. On 01/09/2026 at 2:30 PM, RN 4 indicated there was not an order for the continuation of care for the recertification period before the physician signed the POC on 01/05/2025 for the recertification period beginning 01/03/2026. 410 IAC 17-13-1(a)

Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient's updated comprehensive assessment, and contain information concerning the patient's progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the POC was revised with necessary changes in 2 of 2 active clinical records reviewed with hospitalizations in a total sample of 6 active clinical records reviewed. (Patient #1, 5) The findings include: 1. A clinical record review for Patient #1 evidenced hospital discharge instructions from Entity 1 dated 10/13/2025 which indicated Patient had a appendicovesicostomy (APV, a surgical creation of a channel from the bladder to the skin using the appendix to drain urine from the body) performed and had an indwelling catheter. The comprehensive assessment for the resumption of dated 10/13/2025 indicated the home health agency resumed skilled nursing care, and Patient had an indwelling catheter via the APV. The POC for the certification period 09/14/2025- 11/12/2025 failed to evidence the POC was revised to include the indwelling urinary catheter. On 01/07/2026 at 3:20 PM, the CM indicated Patient had an indwelling urinary catheter via the APV upon resumption of home care services in October, but she forgot to update the POC to include the indwelling catheter. 2. A clinical record review for Patient #5 evidenced discharge paperwork from Entity 8 dated 01/07/2026 which indicated the CPT (chest physiotherapy – to loosen mucous secretions in the lungs) vest treatment was to be completed 3 times a day for 2 -3 days. The POC for the recertification period 11/12/2025-01/10/2026 indicated CPT treatment was twice daily and failed to evidence the POC was revised to reflect the increase to 3 times a day. On 01/12/2026 at 12:50 PM, the CM indicated she did not revised the POC with the increase in CPT treatment to 3 times per day.

Program activities CFR(s): 484.65(c) (1) The HHA's performance improvement activities must— (i) Focus on high risk, high volume, or problem-prone areas; (ii) Consider incidence, prevalence, and severity of problems in those areas; and (iii) Lead to an immediate correction of any identified problem that directly or potentially threaten the health and safety of patients. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the performance improvement activities focused on high risk and problem-prone areas. The findings include: A review of the Quality Assessment and Performance Improvement (QAPI) program meeting notes for the 4th quarter of the fiscal year 2025 indicating both quarters with a patient census of 57. The QAPI program evidenced an increase in patient infections from 13 infections in the 4th quarter of fiscal year 2025 to 21 in the 1st quarter of fiscal year 2026. The QAPI program evidenced an increase in patient hospitalizations from 5 in the 4st quarter of fiscal year 2025 to 13 in the 1st quarter of fiscal year 2026. The QAPI program failed to evidence performance improvement actions to address the increase in the incidence of patient infections and hospitalizations. On 01/12/2026 at 4:22 PM, the Administrator indicated infections and hospitalizations were high risk areas, and there were no performance improvement actions to address either the patient infections or hospitalizations.

HHA maintains documentation of training CFR(s): 484.80(b)(4) The HHA must maintain documentation that demonstrates that the requirements of this standard have been met. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure documentation of the 16 hours of supervised practical training for 5 of 5 training records reviewed HHAs trained by the agency in a total sample of 30 active HHAs. (HHA 3, HHA 4, HHA 5, HHA 6, HHA 7) The findings include: The training record for HHA 3, first patient contact date 06/17/2024, failed to evidence the documentation of the supervised practical hours provided in the HHA training program. The training record for HHA 4, first patient contact date 09/19/2024, failed to evidence the documentation of the supervised practical hours provided in the HHA training program. The training record for HHA 5, first patient contact date 06/26/2024, failed to evidence the documentation of the supervised practical hours provided in the HHA training program. The training record for HHA 6, first patient contact date 12/15/2025, failed to evidence the documentation of the supervised practical hours provided in the HHA training program. The training record for HHA 7, first patient contact date 06/17/2024, failed to evidence the documentation of the supervised practical hours provided in the HHA training program. On 01/08/2026 at 4:38 PM, the Administrator indicated the agency did not have documentation of the 16 supervised practical training hours for the HHA training program.

Competency evaluation CFR(s): 484.80(c)(1)(2)(3) Standard: Competency evaluation. An individual may furnish home health services on behalf of an HHA only after that individual has successfully completed a competency evaluation program as described in this section. (1) The competency evaluation must address each of the subjects listed in paragraph (b)(3) of this section. Subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section must be evaluated by observing an aide's performance of the task with a patient or pseudo-patient. The remaining subject areas may be evaluated through written examination, oral examination, or after observation of a home health aide with a patient, or with a pseudo-patient as part of a simulation. (2) A home health aide competency evaluation program may be offered by any organization, except as specified in paragraph (f) of this section. (3) The competency evaluation must be performed by a registered nurse in consultation with other skilled professionals, as appropriate. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to evidence the HHA demonstrated competency before providing care to a patient in 1 of 5 HHA competencies reviewed. (HHA 6) The findings include: The HHA competency checklist for HHA 6, first patient contact date 12/15/2025, was dated 10/16/2025 and indicated HHA 6 did not meet competency for: reading, writing, and verbal reporting to patients, caregivers, and agency staff; observation, reporting, and documentation of patient status and the care of services furnished; obtaining vital signs; basic elements of body functions; identifying safety hazards in the home; recognizing emergencies, understanding of respect and privacy; oral care; transfers; assisting with ambulation; fluid and nutrition; and recognizing and reporting changes in the skin. Six HHA visit notes dated from 12/29/2025 to 01/06/2025 indicated HHA 6 provided care to Patient #11 to include oral care, checking skin for breakdown, ambulation assistance, and encouraging fluid. On 01/08/2026 at 4:12 PM, the Administrator indicated the competency checklist did not evidence HHA 6 was competent in the tasks provided to Patient.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the RN assigned patient-specific tasks in writing to the HHA in 2 of 2 active clinical records reviewed with HHA services in a total sample of 6 active clinical records reviewed. (Patient #5 and 6) The findings include: 1. A clinical record review for Patient #5 evidenced a HHA Care Plan dated 09/11/2025 which indicated the HHA was to complete exercises per the PT, OT, and ST care plan every visit. The record failed to evidence the PT, OT, and ST care plans were provided to the HHA for direction on the exercises to provide. On 01/12/2026 at 2:10 PM, the CM indicated the agency did not have a copy of the PT, OT, and ST care plan for written direction on the exercises the HHA was to perform with Patient. 2. A clinical record review for Patient #6 evidenced a HHA Care Plan dated 11/14/2025 which indicated the HHA was to obtain Patient’s temperature, pulse, respirations, and blood pressure every visit as needed and failed to include the directions for when obtaining the vital signs was needed. The HHA Care Plan indicated the HHA was to provide exercises as needed per the PT, OT, and ST care plan and failed to evidence the PT, OT, and ST care plans were provided to the HHA for direction on the exercises to provide. On 01/12/2026 at 4:16 PM, the CM indicated there was not a care plan for PT, OT, or ST that was provided to the HHA for direction on exercises to provide Patient. 410 IAC 17-14-1(m)

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 agency failed to ensure the HHA provided services as directed in the HHA care plan in 2 of 2 active clinical records reviewed with HHA services in a total sample of 6 active clinical records reviewed. (Patient #5 and 6) The findings include: 1. A clinical record review for Patient #5 evidenced a HHA Care Plan dated 09/11/2025 which indicated the HHA was to shampoo Patient every visit. The HHA visit notes failed to evidence the HHA shampooed Patient on 29 visits from 12/01/2025-01/08/2026. On 01/12/2026 at 2:04 PM, the CM indicated the HHA did not provide care as directed in the care plan. 2. A clinical record review for Patient #6 evidenced a HHA Care Plan dated 09/17/2025 which indicated the HHA was to assist Patient with a shower weekly. The 19 HHA visit notes failed to evidence the HHA showered the Patient between 10/03/2025-11/14/2025. On 01/12/2026 at 4:15 PM, the Administrator indicated the HHA did not follow the care plan as directed.

HH aide supervision elements CFR(s): 484.80(h)(4)(i-vi) Home health aide supervision must ensure that aides furnish care in a safe and effective manner, including, but not limited to, the following elements: (i) Following the patient's plan of care for completion of tasks assigned to a home health aide by the registered nurse or other appropriate skilled professional; (ii) Maintaining an open communication process with the patient, representative (if any), caregivers, and family; (iii) Demonstrating competency with assigned tasks; (iv) Complying with infection prevention and control policies and procedures; (v) Reporting changes in the patient's condition; and (vi) Honoring patient rights. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the home health aide (HHA) was supervised to ensure the aides furnished care that followed the patient’s plan of care in 2 of 2 active clinical records reviewed with HHA services. (Patient #5, 6) The findings include: 1. A clinical record review for Patient #5 evidenced a HHA Care Plan dated 09/11/2025 which indicated the HHA was to shampoo Patient every visit. The HHA visit notes completed by HHA 1 failed to evidence the HHA shampooed Patient on 29 visits from 12/01/2025-01/08/2026. Review of an agency document titled “Supervisory Visit Information” completed by the CM and dated 01/09/2026 indicated HHA 1 followed the patient’s plan of care. Review failed to evidence the registered nurse provided home health aide supervision to ensure the home health aide followed the aide care plan as directed. On 01/12/2026 at 2:04 PM, the CM indicated the HHA did not provide care as directed in the care plan and no supervision by the RN was provided to the HHA to ensure the care plan was followed. 2. A clinical record review for Patient #6 evidenced a HHA Care Plan dated 09/17/2025 which indicated the HHA was to assist Patient with a shower weekly. The 19 HHA visit notes completed by HHA 2 failed to evidence the HHA showered the Patient between 10/03/2025-11/14/2025. Review of an agency document titled “HHA Supervisory Visit” completed by RN 6 and dated 11/14/2025 indicated HHA 2 provided services as directed in the care plan. Review failed to evidence the registered nurse provided home health aide supervision to ensure the home health aide followed the aide care plan as directed. On 01/12/2026 at 4:16 PM, the Administrator indicated there was no supervision provided to the HHA by the RN to ensure the care plan was followed. 410 IAC 17-14-1(n)

Make patient and personnel assignments, CFR(s): 484.105(c)(1) Making patient and personnel assignments, This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the clinical manager provide oversight of personnel assignments in 1 of 1 active clinical record reviewed with a resumption of care for HHA services. (Patient #5) The findings include: A clinical record review for Patient #5 evidenced a Physician Order dated 01/05/2026 which indicated HHA services were on hold due to Patient’s transfer to the hospital. Physician Order dated 01/08/2026 indicated home health services were to resume effective 01/07/2026. The document titled “Consumer Work by Date” indicated HHA 1 provided 8 hours of care on 01/08/2026 and began HHA services at 6:30 AM on 01/09/2026. The clinical record failed to evidence the RN provided a comprehensive assessment for resumption of care before 01/09/2026. On 01/12/2026 at 1:40 PM, the CM indicated she did not conduct a resumption of care visit until 01/09/2026 at 7:45 AM. The CM indicated she was not aware HHA 1 was providing services on 01/08/2026. The CM indicated she spoke with HHA 1 (also Patient’s family member) on 01/08/2026 who notified the CM Patient was back home but the schedule of when to resume services was not discussed.

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure the RN followed current standards of practice in 1 of 1 home visit for the observation of medication administration via a gastrostomy tube (GT, a feeding tube surgically inserted into the stomach). (Patient #3) The findings include: A policy dated August 2002 titled “Administration of Enteral Feedings [feeding through a feeding tube] – Gastrostomy or Jejunostomy Tube [a type of feeding tube]” indicated the clinician should verify placement of the prior to the administration of formula through the GT by withdrawing gastric contents through the GT with a syringe. During an observation of care at the home of Patient #3 on 01/08/2026 at 2:38 PM, RN 5 attached the extension tubing to the gastrostomy button (a type of GT) on Patient’s abdomen, inserted the syringe into the extension tubing, and poured 3 medications identified by RN 5 to be baclofen (for muscle spasms), Keppra (for seizures), and Tripletal (for seizures) individually and flushed in between with water through the GT. RN 5 failed to verify the placement of the feeding tube prior to administration of the medications. On 01/08/2026 at 2:44 PM, RN 5 indicated she usually checks the GT placement prior to administration of the medications but did not this time. On 01/08/2026 at 4:24 PM, the CM indicated the agency’s process for verification of the GT placement prior to medication administration was to check for residual (withdrawing gastric contents through the GT).

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 ensure the clinical record was completed to include the time of visits in 6 of 6 active clinical records reviewed. (Patient #1, 2, 3, 4, 5, 6) The findings include: 1. A policy revised 11/13/2018 titled “Clinical Records and Medical Record Retention Policy” indicated all documentation must be timed. 2. A clinical record review for Patient #1 evidenced comprehensive assessments dated 10/13/2025 and 11/11/2025 which failed to include a time of assessment. 3. A clinical record review for Patient #2 evidenced a comprehensive assessment dated 11/04/2025 which failed to include a time of assessment. 4. A clinical record review for Patient #3 evidenced a comprehensive assessment dated 12/18/2025 which failed to include a time of the assessment. 5. A clinical record review for Patient #4 evidenced a comprehensive assessment dated 01/02/2026 which failed to include a time of the assessment. 5. A clinical record review for Patient #5 evidenced comprehensive assessment dated 11/10/2025 and 01/09/2026 which failed to include a time of the assessment. 6. A clinical record review for Patient #6 evidenced a comprehensive assessment dated 11/14/2025 which failed to include a time of the assessment. 7. On 01/07/2026 at 3:33 PM, the Administrator indicated the comprehensive assessment forms did not include a spot to document the time of the visit but should. 410 IAC 17-15-1(b)

An Emergency Preparedness survey was conducted by the Indiana State Department of Health in accordance with 42 CFR 484.102.Facility ID: IN006663 Survey dates: 10/24/2022 – 10/28/2022, 10/31/2022 At this Emergency Preparedness survey Homepointe Healthcare, was found to be in compliance with 42 CFR 484.102, Emergency Preparedness Requirements for Medicare Participating Providers and Suppliers.

This visit was a Federal Recertification and State Licensure survey of a home health agency.Survey Dates: 10/25/2022 – 10/28/2022, 10/31/2022 Facility ID: IN006663Active Patients: 12 This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Refer to State Form for additional State Findings. Quality Review Completed 11/07/2022

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 patients received the home health services which were written in an individualized plan of care that identified patient-specific measurable outcomes and goals in 4 of 6 clinical records reviewed. (#1, #3, #4, #6) The findings include: 1. Review of an agency policy titled “Client Plan of Care,” revised 4/14/2020, stated, “ … Each client must receive the home health services that are written in the individualized Plan of Care….” 2. Clinical record review for patient #1, start of care 12/15/2009, evidenced an agency plan of care for certification period 8/13/2022 – 10/11/2022. This plan of care evidenced orders to monitor the patient’s blood pressure every morning. Clinical record review of agency documents titled “Homepointe HealthCare Nursing Flow Sheet” dated 8/13/2022, 9/4/2022, 9/11/2022, 9/18/2022, 10/2/2022, and 10/9/2022, failed to evidence the patient’s blood pressure was taken as ordered on the plan of care. During an interview on 10/31/2022 at 11:39 AM, the clinical manager indicated the blood pressure should have been taken by the RN (Registered Nurse) as ordered in the plan of care. 3. Clinical record review for patient #3, start of care 12/15/2009, evidenced an agency plan of care for certification period 8/9/2022 – 10/7/2022. This plan of care evidenced orders for tracheostomy (a surgically created hole in the windpipe that provided an alternative airway) care twice a day. Clinical record review of agency documents titled “Homepointe HealthCare Nursing Flow Sheet” dated 8/15/2022 – 8/16/2022, 8/16/2022 - 8/17/2022, 8/17/2022 – 8/18/2022, 8/18/2022 – 8/19/2022, 8/19/2022 – 8/20/2022, 8/22/2022 – 8/23/2022, 8/29/2022 – 8/30/2022, 8/30/2022 – 8/31/2022, 8/31/2022 – 9/1/2022, 9/2/2022 – 9/3/2022, 9/4/2022 – 9/5/2022, 9/5/2022 – 9/6/2022, 9/6/2022 – 9/7/2022, 9/7/2022 – 9/8/2022, 9/8/2022 – 9/9/2022, 9/11/2022 – 9/12/2022, 9/12/2022 – 9/13/2022, 9/13/2022 – 9/14/2022, 9/14/2022 – 9/15/2022, 9/15/2022 – 9/16/2022, 9/16/2022 – 9/17/2022, 9/17/2022 – 9/18/2022, 9/19/2022 – 9/20/2022, 9/20/2022 –9/21/2022, 9/22/2022 – 9/23/2022, 9/23/2022 – 9/24/2022, 9/24/2022 – 9/25/2022, 9/27/2022 –9/28/2022, 9/28/2022 – 9/29/2022, 9/29/2022 – 9/30/2022, 9/30/2022 – 10/1/2022, 10/2/2022 –10/3/2022, 10/3/2022 –10/4/2022, 10/4/2022 – 10/5/2022, 10/5/2022 – 10/6/2022, and 10/6/2022 –10/7/2022, failed to evidence tracheostomy care was done twice per day as ordered on the plan of care. During an interview on 10/31/2022 at 10:15 AM, the clinical manager indicated if there was a nurse in the evening then the tracheostomy care should have been done by the nurse. 4. Clinical record review for patient #4, start of care 5/22/2018, evidenced an agency plan of care for certification period 8/18/2022 – 10/16/2022. This plan of care stated “ … Home Heath Aide Discipline (HHA services currently on hold) To offer and provide assistance, as accepted, with ADL’s [activities of daily living], may provide light housekeeping for health and safety, temperature to be taken per mom request or if patient is ill – to call Clinical Care Manager/Nurse if temperature is greater than 101 or less than 97….” Review of patient #4’s clinical record failed to evidence any home health aide visits. During an interview on 10/26/2022 at 10:03 AM, RN #2 indicated the family was very particular about who can come out to the home, and currently the agency does not have a home health aide. 5. Clinical record review for patient #6, start of care 4/8/2009, evidenced an agency plan of care for certification period 5/31/2022 – 7/29/2022. This plan of care indicated patient #6 was to have his blood pressure taken monthly. Review of the clinical record failed to evidence the patient’s blood pressure was taken monthly. During an interview on 10/31/2022 at 10:27 AM, the clinical manager indicated the patient's blood pressure should have been taken as ordered. 410 IAC 17-13-1(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 record review and interview, the home health agency failed to ensure the plan of care was individualized and complete to include all indications and doses for medications in 3 of 5 active clinical records reviewed. (#1, #2, #4) The findings include: 1. Review of an agency policy titled “Client Plan of Care,” revised 4/14/2020, stated “The individualized Plan of Care must specify the care and services necessary to meet the client specific needs as identified on the comprehensive assessment … The Plan of Care shall be completed in full to include: … All medications and treatments….” 2. Clinical record review for patient #1, start of care 12/15/2009, evidenced an agency plan of care for certification period 8/13/2002 – 10/11/2022. This plan of care indicated the patent was taking the following medications: Magic bullet suppository (for constipation) 5 mg (1/2 suppository) to 10 mg (1 suppository) daily in the morning per mom’s discretion, Desonate Cream (for itching) small amount topically three times a day until rash was resolved, expectorant syrup 200 mg - 400 mg four times a day as needed per mom’s discretion depending on severity of symptoms. The plan of care failed to evidence indications and route for all medications. 3. Clinical record review for patient #2, start of care 10/18/2021, evidenced an agency plan of care for certification period 8/13/2002 – 10/11/2022. This plan of care indicated the patent was taking the following medications: bacitracin (for infection) small amount topically to gastrostomy [feeding tube inserted into the stomach] button site twice a day as needed until healed for redness or irritation per parent discretion, bacitracin quantity sufficient topically to reddened skin twice a day as needed until healed. The home health agency failed to ensure there were no duplicate medications on the plan of care. 4. Clinical record review for patient #4, start of care 5/22/2018, evidenced an agency plan of care for certification period 8/18/2022 – 10/16/2022. This plan of care stated, “ … Cortisone 1% cream quality sufficient topical to affected area TID [three times a day] PRN [as needed for skin rash]….” This plan of care failed to indicate where to apply the cream. During an interview on 10/31/2022 at 10:02 AM, the clinical manager indicated the order was there for wherever the patient may need the cream. 410 IAC 17-13-(a)(1)(D)(ix)

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure all orders were recorded on the plan of care in 1 of 5 active clinical records reviewed. (#1) The findings include: Review of an agency policy titled “Physician Orders,” revised 3/4/2019 stated, “Medications, services, and treatments are administered only as ordered by a physician. The orders may be initiated via telephone, verbally, or in writing … All client care orders, including verbal orders, must be recorded in the plan of care….” Clinical record review for patient #1, start of care 12/15/2009, evidenced an agency document titled “Physician Order,” dated 8/15/2022, which stated “1. Discontinue Gas-X Drops (Simethicone 20 mg [milligram] /0.3mg) 75 mg1mL [milliliter] JT jejunostomy [feeding tube inserted through the abdomen into the small intestines] TID [three times daily] 2. Start Gas-X gel caps [capsule] (simethicone 125 mg/gel cap JT TID (dissolve in water before administering via JT)." Clinical record review evidenced a plan of care for certification period 8/13/2022 – 10/11/2022. This plan of care evidenced the following medication order: “Gas-X Drops (Simethicone 20 mg/0.3mg) 75 mg/ 1mL JT jejunostomy TID….” This plan of care failed to evidence the new medication orders were recorded on the plan of care. Clinical record review evidenced an agency plan of care for certification period 10/12/2022 – 12/10/2022. This plan of care evidenced the following medication orders: Dilantin [for seizures] 75 mg/3 mL once daily at 8 AM, Dilantin 100 mg/4ml twice a day at 3 PM, and 10 PM. The agency failed to ensure the plan of care was updated with the most current Dilantin orders. An agency document titled “Physician Order,” dated 10/9/2022, stated “DC [discontinue] existing Dilantin order. Give Dilantin 100 mg/4ml at 8 AM, and 3 PM, and 125 mg/5ml at 10 PM, Recheck Dilantin level in 10 days." During an interview on 10/31/2022 at 11:42 AM, the clinical manager indicated orders are written on the physician order form and incorporated into the patient’s clinical record and a copy was taken to the home. The plan of care would then be updated at the time of recertification.

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 home health agency failed to administer treatments only as ordered by the physician in 1 of 5 active clinical records. (#2) The findings include: Review of an agency policy titled “Client Plan of Care,” revised 4/14/2020, stated “All client care orders, including verbal/telephone orders. must be obtained by the physician….” Clinical record review for patient #2, start of care 10/18/2021, evidenced an agency document titled “Homepointe HealthCare Nursing Flow Sheet,” dated 10/5/2022. This document indicated the patient had an open blister on the right heel and a band-aid was applied per parent request. Review of the patient’s clinical record failed to evidence an order for treatment to the blister on the right heel. During an interview on 10/31/2022 at 10:05 AM, the clinical manager indicated the note should have been clearer, it was the parent that was applying the band-aid so an order was not needed.

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 home health agency failed to promptly alert the physician of changes in the patient’s status in 4 of 5 active clinical records reviewed. (#1, #2, #3. #4) The findings Include: 1. Review of an agency policy titled “Skilled Nursing Services,” revised 1/18/2011, stated, “ … The Registered Nurse: Informs the physician and other medical personnel of changes in the client's condition and needs….” 2. Clinical record review for patient #1, start of care 12/15/2009, evidenced an agency plan of care for certification period 8/13/2002 – 10/11/2022. This plan of care evidenced orders to monitor the patient’s blood pressure every morning. Clinical record review evidenced agency documents titled “Homepointe HealthCare Nursing Flow Sheet” which indicated the patient’s blood pressure was 140/102 (a normal blood pressure reading is 120/80) on 8/16/2022, 142/102 on 8/22/2022, 150/108 on 9/2/2022, 166/116 on 9/6/2022, 157/109 on 9/8/2022, 129/100 on 9/13/2022, 159/105 on 9/19/2022, 154/110 on 9/21/2022, 137/103 on 9/28/2022, and 135/100 on 9/29/2022. These documents failed to evidence the physician was notified of the elevated blood pressure. During an interview on 10/31/2022 at 11:41 PM, RN [registered nurse] #2 indicated the physician was aware of the patient’s increased blood pressure and the staff was to recheck the blood pressure if it was high. RN #2 indicated she should have added this to the patient’s plan of care. 3. Clinical record review for patient #2, start of care 10/18/2021, evidenced agency documents titled “Homepointe HealthCare Nursing Flow Sheet,” which indicated a rash to her upper arm on 9/1/2022, bruising noted to left side of the abdominal area and dragging her right foot on 9/16/2022, an abrasion 1 cm (centimeter) by 0.8 cm noted on 9/25/2022, right ankle open area 1 cm by 0.8 cm noted on 9/30/2022, abrasions to feet and an area noted on the left pinky toe on 10/3/2022. Review of these documents failed to evidence the physician was notified of the rash, bruising, and wounds. During an interview on 10/31/2022, at 10:20 AM, the clinical manager indicated the family thought the rash could have been from the pool float. She also indicated the patient’s skin was very sensitive, so they do not call or notify the physician for tiny abrasions and bruises. 4. Clinical record review for patient #3, start of care 4/28/2008, evidenced agency documents titled “Homepointe HealthCare Nursing Flow Sheet,” which indicated on 9/14/2022, patient #3 had a creamy yellow discharge to his right eye, on 9/15/2022, the patient’s right eye was reddened, on 9/25/2022, the patient complained of belly spasms but refused medication because he didn’t like the way it made him feel, and on 9/29/2022, he complained of spasms again and refused medication. The document indicated the patient would speak with his doctor at his appointment in November. These documents failed to evidence the physician was notified of the eye drainage, redness and the stomach spasms. During an interview on 10/31/2022 at 10:22 PM, the clinical manager indicated the patient was going to speak with his doctor, so they did not call the physician. 5. Clinical record review for patient #4, start of care 5/22/2018, evidenced agency documents titled “Homepointe HealthCare Nursing Flow Sheet,” which indicated on 9/28/2022, the patient had a moist cough, on 9/30/2022, the patient had a cough and stridor (high pitched whistling sound when taking a breath), on 10/3/2022, the document indicated the patient had a nonproductive cough, and on 10/5/2022, the patient had a cough and rhonchi (abnormal breath sounds). These documents failed to evidence the physician was notified of the change in the patient’s condition. During an interview on 10/31/2022 at 10:03 AM, the clinical manager indicated the physician should have been notified of the respiratory changes the patient was experiencing. 410 IAC 17-13-1(a)(2)

Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient's updated comprehensive assessment, and contain information concerning the patient's progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This ELEMENT is not met as evidenced by: Based on observation, record review and interview, the home health agency failed to ensure the plan of care was revised to reflect the patient’s current medications in 4 of 6 clinical records reviewed (#1, #2, #5, #6) The findings include: 1. Review of an agency policy titled “Client Plan of Care,” revised 4/14/2020, stated “ … The Plan of Care will be updated as necessary, but no less than every 55 to 60 days….” 2. Clinical record review for patient #1 evidenced an agency document titled “Medication Profile,” dated 10/2/2022, which indicated patient #1 was taking the medications: Sterapred (steroid) 30 mg [milligram] twice a day for five days as needed for respiratory distress per mom’s discretion (start date 10/26/2020), Tobramycin (antibiotic) 0.3 mg eye solution instill one drop into affected eye four times a day for ten days as needed (start date 7/11/2017), Acetic Acid 2% solution (ear cleaner) to 5 drops to affected ear three times a day for 7 days for drainage, redness, or foul odor per mom’s discretion (start date 11/1/2018), Neomycin-polymyxin (antibiotic) 4 drops into the affected ear twice a day for seven days as needed for signs and symptoms of infection per mom’s discretion (start date 12/5/2018), Ofloxacin 0.3% drops (antibiotic) instill 5 drops into the affected ear twice a day for seven days as needed for symptoms of ear infection per mom’s discretion (start date 6/1/2019). Tobi Inhalation solution (for infection) 300 mg/5ml nebulizer twice a day for ten days (start 7/10/22 and end 7/19/2022, Tobramycin (antibiotic) 0.3% eye solution instill one drop into affected eye four times a day for ten days (start 7/10/2022 and end 7/19/2002). Clinical record review for patient #1, start of care 12/15/2009, evidenced an agency plan of care for certification period 8/13/2002 – 10/11/2022. This plan of care indicated the patent was taking the following medications: Tobramycin 0.3 mg eye solution instill one drop into the affected eye four times a day for ten days as needed, Tobi Inhalation solution 300 mg/5ml nebulizer twice a day for ten days (start 7/10/22 and end 7/19/2022), Tobramycin 0.3% eye solution instill one drop into affected eye four times a day for ten days (start 7/10/2022 and end 7/19/2002). The agency failed to revise the plan of care to reflect the patient’s current medication usage. 3. Clinical record review for patient #2, start of care 10/18/2021, evidenced an agency plan of care for certification period 8/13/2002 – 10/11/2022. This plan of care indicated the patent was taking the following medications: Vicodin (narcotic pain reliever) 7.5 mg 325 mg one tablet every six hours as needed for moderate pain, Pulmicort (for breathing) 0.25 mg/1 vial via nebulizer twice a day as needed for wheezing, Flonase (for allergies) 100 mcg (micrograms) one spray in each nostril as needed for allergy symptoms. The agency failed to ensure the plan of care was revised to include the patient’s current medication usage. During a home visit on 10/27/2022, at 11:45 AM, medications were observed in the patient’s home. Observation failed to evidence the patient had Vicodin, Flonase, and Pulmicort in the home. Clinical record review evidenced an agency document titled “Medication Profile,” dated 9/16/2022, which indicated an order for Tizanidine (muscle relaxer) 2 mg one tablet three times a day. Clinical record review of the agency’s plan of care for patient #2, for certification period 8/13/2022 – 10/11/2022, failed to evidence the order for Tizanidine. During an interview on 10/27/2022 at 11:48 AM, RN [registered nurse] #4 indicated patient #2 had not used Vicodin, Pulmicort, or Flonase in a few years and the medications were not present in the home. During an interview on 10/31/2022 at 10:43 AM, the clinical manager indicated orders are written on the physician order form and incorporated into the patient’s clinical record and a copy was taken to the home. The order would be updated on the plan of care on the next recertification. 4. Clinical record review for patient #5, start of care 10/7/2021, evidenced an agency document titled “Physician Order.” This document indicated the patient was to receive five to nine hours a day (skilled nursing services) for five to seven days a week. Clinical record review evidenced an agency plan of care for certification period 10/7/2002 – 12/5/2022. This plan of care indicated patient #5 was to receive skilled nursing services seven to nine hours a day for six to seven days. The plan of care failed to evidence the revised hours and days for skilled nursing services. During an interview on 10/31/2022 at 10:01 AM, the clinical manager indicated the order was updated in the patient’s clinical record and the plan of care would be updated on the next recertification. 5. During an interview on 10/31/2022 at 10:54 AM, the clinical manager was queried about patient #6’s wound care to the back of the head. The clinical manager indicated the patient’s wound had healed but his mask would sometimes rub on the back of his head causing a new wound. Clinical record review for patient #6, start of care 4/8/2009, evidenced an agency plan of care for certification period 5/31/2022 – 7/29/2022. This plan of care evidenced an order to “Clean the area on the back of the head with betadine where the skin is broken/open/swollen. Apply PRN [as needed] Neosporin triple antibiotic ointment (quantity sufficient) topically to the area. Then apply dry dressing daily….” The agency failed to revise the plan of care when the patient's wound healed.