Every finding on record at Abound Home Health Care, LLC

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR §484.102 Survey Dates: 11/12/2025 - 11/14/2025 Active Census: 9 At this Emergency Preparedness survey, Abound Home Health Care LLC was found to be in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR §484.102. QR Completed on 11/21/2025 by A4.

This visit was for an Initial State Licensure and an Initial Medicaid survey for a Home Health provider. Survey Dates: 11/12/2025-11/14/2025 12 Month Unduplicated Admissions: 17 This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Abbreviations: HHA - Home Health Aide LPN- Licensed Practical Nurse RN- Registered Nurse POC- Plan of Care SOC- Start of Care

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 interviews, the agency failed to have a signed POC or a verbal POC order from the primary Physician before providing services and treatments to patients for 2 of 2 active record reviews with the same Physician (Patients #5, #7) Findings include: 3. A review of Patient #5's record, SOC date 08/15/2025, failed to evidence a POC within the EMR. A Communication Note dated 10/07/2025 indicates that the agency did not have a signed POC. The physician assigned to follow Patient #5's care was no longer practicing. The agency providing skilled nursing services for the following dates: 08/20/2025, 08/27/2025, 09/04/2025, 09/10/2025, 09/17/2025, and 09/24/2025. During an interview on 11/14/2025 at 1:20 PM, the Clinical Manager could not locate a POC for the certification period of 08/15/2025 to 10/13/2025 in Patient #5's record. She indicated the agency contacted the physician's office personnel on 10/07/2025 and requested the physician sign and return the POC. She stated that the patient's physician no longer practiced at that facility. She stated the POC was likely still awaiting a signature. 1. An undated policy titled "Admission Criteria and Process," the agency will submit the POC to the Physician for signature. 2. An undated policy titled "Physician Participation in Plan of Care" indicates the agency will obtain verbal orders to establish the POC; the Physician will sign the POC within 30 days of the agency starting care; the agency will file all original POC in the patient's clinical record; if a change in the patients physician occurs the agency will not continue services until a new written order is obtained from the new Physician assuming the patient's care. 4. A review of Patient #7's record included an OASIS Start of Care dated 08/15/2025, a Communication Note dated 10/07/2025 that indicates the agency did not have a signed POC; The Physician assigned to follow Patient #7's care was no longer practicing. The agency provided skilled nursing services on the following days: 08/20/2025, 08/27/2025, 09/03/2025, 09/10/2025, 09/17/2025, 09/24/2025, and 10/01/2025, with no signed POC and no physician following Patient #7's care. During an interview on 11/14/2025 at 10:29 AM, the Administrator was unable to locate a POC for the certification period dated 08/15/2025 to 10/13/2025 in Patient #7's chart. She indicated the agency attempted to contact the Physician on 10/07/2025 regarding the POC not being signed, and the physician's office indicated the Physician was no longer at that facility. The Administrator confirmed the agency did not have a sign POC for the certification period from 08/15/2025 to 10/13/2025. 410 IAC 17-13-1(a)

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation, record review, and interview, the agency staff failed to follow policy and procedures to prevent the spread of communicable disease on 3 of 3 home visits. (Patient #1, #2, #3) Findings include: 1. An undated policy titled "Hand Hygiene" indicated staff should practice hand hygiene before having direct contact with a patient, after contact with the patient's skin, and after contact with objects in the patient's vicinity.. 2. An undated policy titled "Bag Technique" indicated staff will place the bag on an easy-to-disinfect surface or a water-resistant barrier. 3. During an observation on 11/13/2025 at 10:44 AM, RN 1 did not place a clean barrier between the pink supply bag and the bed; she failed to perform hand hygiene after touching Patient #1's feet and before using the pulse oximeter to collect the patient's oxygen saturation and heart rate. HHA 1 cleaned the pulse oximeter and thermometer, then placed both items on the dirty drape with the nursing bag. The Clinical Manager failed to practice hand hygiene after collecting a dirty drape from the floor and placing it in the trash. 4. During an observation on 11/13/2025 at 11:55 AM, the Clinical Manager failed to perform hand hygiene after touching Patient #2 and before entering the nursing bag, after removing the stethoscope from around the neck and before returning to the computer to document the visit, and after throwing away the dirty barrier drape and before touching the supply bag. 5. During an observation on 11/13/2025 at 1:37 PM, the Clinical Manager failed to perform hand hygiene before entering the nursing bag, after throwing away the dirty drape, and before picking up the nursing bag to exit Patient #3's home. During the home visit, the Clinical Manager cleaned the blood pressure cuff, the oximeter, and the thermometer, then placed them on a dirty drape with a nursing bag. 6. During an interview on 11/14/2025 at 11:48 AM, the Administrator stated the Clinical Manager used alcohol for hand hygiene in her nursing bag when her hands are dirty. 410 IAC 17-12-1(m)

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 document and complete the required HHA subject areas and effectively evaluate HHA competency skills for 1 of 1 HHA record reviews. (HHA 1) Findings include: A review of HHA 1's record with a hire date of 07/11/2025, and first patient contact 07/14/2025, did not include sufficient documentation to show the agency provided education and training or evaluation upon hire or before first patient contact for appropriate and safe techniques in performing personal hygiene and grooming tasks that include, bed bath, sponge, tub, and shower bath, hair shampooing in sink, tub, and bed, nail and skin care, oral hygiene, toileting and elimination, safe transfer techniques and ambulation, normal range of motion and positioning, adequate nutrition and fluid intake, or recognizing and reporting changes in skin condition. During an interview on 11/17/2025 at 2:30 PM, the Administrator could not explain why the agency did not use the forms for on-site demonstration and evaluation of HHA competency skills that require skills and tasks with a patient or pseudo-patient, as required by 484.80 (b)(i), (iii), (ix), (x), and (xi). . 410 IAC 17-14-1(l)(1)(A)

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on the record review and interview, the agency failed to send discharge summaries to the Primary Care Provider (PCP) within five business days of the patient's discharge on 2 of 2 closed records reviewed. (Patient # 10, #11). Findings include: 1. An undated policy titled "Discharge Criteria and Process" indicates that the agency will notify the primary care professional who will be responsible for providing care and services to the patient after discharge. 2. A review of Patient #10's record included a discharge summary that indicated a discharge date of 07/01/2025. RN 1 signed the discharge summary on 10/09/2025. No evidence of notification to PCP of discharge in Patient # 10's chart. 3. During an interview on 11/14/2025 at 10:54 AM, the Administrator reviewed Patient #10's chart; she confirmed that Patient # 10's discharge date was on 07/01/2025, and the RN did not complete the discharge summary until 10/09/2025; she was not able to locate proof that the agency sent the discharge summary to the PCP. 4. A review of Patient #11's record included a discharge summary that indicated a discharge date of 11/05/2025. The chart failed to evidence a notification to PCP of Patient #11's discharge from the agency. 5. During an interview on 11/14/2025 at 11:06 AM, the Administrator reviewed Patient #11's chart; she was not able to locate proof that the agency sent the discharge summary to the PCP. 410 IAC 17-15-1(a)(6)