Every finding on record at Adaptive Nursing and Healthcare Services, LLC

Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure patient rights were adhered to and patients received care as ordered by the physician for 1 of 1 closed record reviews. (Patient 10) Findings include: 1. A revised 4/2020 Patient Orientation for Home Health Care was provided by the Alternate Administrator on 3/21/22 at 2:19 p.m. as the current patient rights policy the agency used. The document indicated, but was not limited to, "Section III. Patient Rights and Responsibilities ... treatment or care that is (or fails to be) furnished ... on behalf of Adaptive ... receive all services outlined in the plan of care ..." 2. Reviewed the closed clinical record for Patient 10 on 3/21/2022, SOC (start of care) date 2/25/2019, for the certification period 2/9/2022 to 4/9/2022, with orders for "2/6/2022 HHA to provide 4 hours a day / 7 days per week, not to exceed 28 hours per week throughout the certification period ... Medicaid PA ... RHHA approximately 32 hours per month through Adaptive. ... RN to perform supervisory visits at least every 30 days per state regulations with recertification visits every 56-60 days. RN to perform up to 3 prn visits ... change in condition ... skin condition ..." Patient 10's diagnoses were Guillain Barre (autoimmune disorder), paraplegic (loss of movement to the lower legs), and was confined to a wheelchair and bed. Review of Patient 10's record indicated no HHA (home health aide) visits were made on 2/9, 2/10, 2/13, 2/14, 2/15, 2/16, 2/17, 2/18, 2/20, 2/21, 2/22, 2/23, 2/24, 2/25, 2/27, 2/28, 3/2, 3/4, 3/6, 3/7, and 3/9 of 2022. The agency failed to ensure services were furnished according to the plan of care. Review of Patient 10's RN Narrative note dated 3/10/2022 signed by RN U, of Entity 5, indicated Patient 10's spouse was mentally and physically unable to care for Patient 10. 3. During an interview on 3/21/2022 at 2:02 p.m.. Patient 10 was asked who currently was providing his/her services to which responded "Adaptive." Patient 10 recalled the current Administrator by name. Patient 10 was asked if he/she received a letter about the closure of the agency to which he/she responded "No.".Patient 10 was asked if the agency provided a list of other agencies that he/she could choose to transfer to or discharge. Patient 10 then hung up the phone. 4. During an interview on 3/21/2022 at 2:19 PM, the Alternate Administrator was asked why the discharge summary on the EMR was left blank. The Alternate Administrator provided a discharge summary that included a start of care date of 6/25/2019 and a discharge date of 3/10/2022. The discharge reason indicated the agency was unable to provide adequate staffing and the disposition of the client was left blank. No further information was provided prior to survey exit. 410 IAC 17-13-1(a)

Document efforts to resolve problems CFR(s): 484.50(d)(5)(iv) (iv) Document the problem(s) and efforts made to resolve the problem(s), and enter this documentation into its clinical records; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the resolution was documented for 1 of 1 patient complaints. Findings include: A January 4, 2022 policy titled Complaints and Grievances was provided by the Administrator on 3/21/2022 at 12:48 p.m. The policy indicated, but was not limited to, "iii. Grievances are considered completed when the complainant has been provided with the investigation/resolution of the grievance. This will be used to determine the action to be taken ... iv. A grievance is considered resolved when the client is satisfied with the actions taken on their behalf. ... 7. ... the agency must provide adequate information to address each item stated ..." On 3/14/2022 at 10:00 a.m. the Administrator was asked to provide the complaint log with resolutions for the past 6 months. On 3/21/2022 at 2:19 p.m. the Administrator provided a document titled Grievance Log printed from his/her computer that indicated 1 complaint on 1/4/2022 with a resolution date 1/5/2022. The agency failed to provide adequate information regarding the results of the investigation, what action were taken to resolve the complaint, and if the patient was satisfied with the actions taken.

HHA ceases to operate CFR(s): 484.50(d)(7) The HHA ceases to operate. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to follow agency policy to inform patients about Home Compare that included quality of patient care data to make an informed decision; and failed to provide sufficient notice of its planned cessation to operate and furnish patient care visits under the current license for 1 of 1 home health agency. Findings include: 1. On 3/21/2022 at 2:19 p.m. a document titled "Patient Orientation for Home Health Care" was provided by the Alternate Administrator. The document indicated but was not limited to "...Policies...This book contains general information regarding your rights ... as a patient ... Discharge, Transfer, and Referral ... We will give you, ... at least a fifteen (15) calendar days notice before services are stopped ... all discharges will be documented in the patient chart ... an assessment will be done and instructions provided for any needed ongoing care or treatment ... Discharge Procedure: ... d. Documentation of all communication with the client, including the rationale for discharge, will be kept in the client files with copies sent to the primary physician. ... Discharge Criteria: Name of person or organization assuming responsibility for care. Adaptive will ... discharge the patient from services if: 7. Adaptive ceases to operate ..." 2. A January 9, 2022 policy titled Client Discharge Process was provided by the Administrator on 3/16/2022 at 10:55 a.m. The policy indicated, but was not limited to, " The agency will notify all clients ... 15 calendar days before services are stopped. ... 9. Upon discharge to SNF ... other home health agencies ... will receive in writing information regarding other providers in the area from Home Compare including quality of patient care data in order to assist in making more informed decisions. www.medicare.gov/homehealthcompare/search.html ... 10. Upon discharge to self-care, the client will receive verbal/written information regarding community services, medication use, and any procedures and treatments to be performed, and follow-up visits for physician care. 11. ... documentation include the following: evidence the decision was made unilaterally. The client, family, and physician participated in the decision to discharge client from the agency. d. ... Documentation of all communication with the client, including the rationale for discharge, will be kept in the client file with copies sent to the primary physician. ... j. Services needed be the client are not provided by the agency. 15. The staff will complete a discharge summary that includes the following information: a. Client status at the time of admission to the agency. b. Statement of care and interventions provided and outcomes of care. c. Status at discharge/last visit, current medications, therapies, and continuation of care. d. Name of person or organization assuming responsibility of care. e. Instructions and referrals given to client/family/caregiver. f. Reason for discharge and date of discharge. 16. A copy of the discharge summary is sent to the MD for signature, within 5 business days and the original will be filed in the clients record." 3. During an interview on 3/10/2022 at 9:52 a.m., the Administrator was asked when the agency moved to 1015 Professional Blvd. The Administration indicated the agency moved the week of December 20, 2021, and the former Administrator and Alternate Administrator are no longer here. The Administrator was aware the survey was a post revisit from the December 14, 2021 survey and continued with the entrance conference. The Administrator was asked if he/she had plans to work somewhere else due to the agency closure to which he/she had no answer and all patients and employees were aware of the closure. At 10:35 a.m. the Administrator indicated that the Adaptive agency will no longer be Adaptive on this license and patients and employees all got a letter about the closure. The Administrator was asked why the agency moved to a new building if it was closing. The Administrator indicated the Professional Blvd location was just a temporary location and the agency was waiting on the post revisit survey to be completed. The Administrator was asked what his/her plans were regarding the closure to which he/she was unsure. Asked the Administrator what the current active patient census was to which he/she was unsure. 4. On 3/16/2022 at 11:03 a.m., the Administrator provided an unsigned letter dated January 31, 2022, that indicated Adaptive Nursing and Healthcare Services, LLC Evansville would be closing. The letter indicated that patients would not go without services and would assist the patient in finding a new provider. The letter listed [Entity 5, Entity 11, and Entity 12] as options to choose from. The agency failed to indicate an exact closure date for the agency, when a 15-day notice would occur, and the name of the person sending the letter on the agency's behalf. The agency failed to follow agency policy and ensure patients received in writing information regarding other providers in the area from Home Compare including quality of patient care data in order to assist in making more informed decisions. 5. Review of clinical record 8's Home Health Certification / Recertification Plan of Care start of care date 12/7/2021, for the certification period 2/5/2022 to 4/5/2022, indicated no plans to discharge. A recertification visit dated 2/1/2022 indicated discharge plans were discussed and there was no documentation of plans to discharge. 6. Review of the Patient for clinical record 10's Home Health Certification / Recertification Plan of Care for the certification period 2/9/2022 to 4/9/2022, start of care date 6/25/2019, the verbal start of care date 2/8/2022, indicated no plans to discharge. Review of the Discharge Summary dated 3/10/2022 failed to indicate the disposition of the patient. 7. Phone interviews with patients: During a phone interview on 3/21/2022 at 12:28 p.m., Patient 13 indicated he/she received a letter and a phone call stating the agency was switching to [Entity 5]. Patient 13 indicated he/she never received a list of other agencies to choose from but wanted to stay with the current caregiver who was going with [Entity 5]. During a phone interview on 3/21/2022 at 1:04 p.m. Patient 14 indicated he/she did not receive a letter but received a phone call saying they got bought out and changed their name. Patient 14 indicated his/her family works for the agency. During a phone interview on 3/21/2022 at 1:20 p.m. Patient 15 indicated he/she did not receive a letter about the agency closing and was not provided a list of other agencies to choose from. During a phone interview on 3/21/2022 at 1:25 p.m. Patient 17 indicated he/she never received a letter about the agency closing and was not provided a list of other agencies to choose from. During a phone interview on 3/21/2022 at 12:28 p.m. Patient 12 indicated the agency change their name to [Entity 5]. During a phone interview on 3/21/2022 at 2:02 p.m. Patient 10 indicated the agency that was currently providing services was "Adaptive" and he/she did not receive a letter about the closure of the agency. Patient 10 was asked if the agency sent a letter with a list of agencies to choose from upon transfer or discharge to which he/she hung up the phone. 8. Review of a document titled New Client Agreement 100% in the 2022 QAPI binder indicated patients 13,14,15,16,17 completed a new client agreement, but did not specify any details. 9. During an interview on 3/16/2022 at 12:55 p.m. the Administrator was asked if he/she was aware of or knew what Article 17 of the 410 administrative code was [Indiana administrative code covering home health agency rules,] to which he/she replied "No". 10. During a requested phone interview by the Governing Body with the state Deputy Director on 3/16/2022 at 1:30 p.m. Governing Body B and C asked the state agency about the undetermined closure date and was seeking guidance from the state agency on when to close. The state agency indicated it was not for the state to decide for the agency. The state agency informed Governing Body B and C all patients needed to be discharged from the agency and not delegate oversight of the agency to another licensed Entity without an appropriate discharge. 11. During an interview with the Administrator and Governing Body C (by phone) on 3/17/2022 at 3:10 p.m., the Administrator indicated the agency does not have a target date for closure despite knowing the agency license will expire at the end of March 2022, and still has 144 active patients. The Administrator indicated the agency will renew the license and it will be business as usual. The Administrator indicated the agency had discharged some patients to other agencies and it is being tracked in the system. The Administrator was asked to provide documentation of where patients were being discharged, and he/she replied we do not document where patients go because it was a patient right to go where they choose. At that time, the Administrator and Governing Body C were unable to name where patients were discharged. Governing Body C did not provide any additional information, comments, or questions about the closure date. At that time, the agency failed to clarify if patients were transferred to an affiliated licensed agency instead of an appropriately discharged from the agency to another licensed agency regardless of affiliation. 12. During an interview on 3/21/2022 at 10:00 a.m., the Administrator was asked if the January 31 letter that was sent to patients served as a 15 day discharge notice to which he/she stated "No."

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure coordination of care with other unaffiliated licensed agencies occurred for 2 of 7 active records reviewed. (Patient 2, 9) Findings include: 1. A revised January 4, 2022 policy titled Coordination of Care was provided by the Alternate Administrator on 3/17/2022 at 10:37 a.m. The policy indicated, but was not limited to, " ... coordinate effectively and support the objectives outlined in the client's plan of care. This may be done through formal care conferences; maintaining complete, current care plans; and written and verbal instructions ... 13. To ensure continuity of care. Procedure: 1. Care conferences may be held as necessary to establish interchange, reporting, and coordinated evaluation between all disciplines involved in the client's care. " 2. During a home visit on 3/14/2021 at 8:00 a.m., Patient 2's Foley catheter bag was completely full. HHA L indicated to Patient 2 the another licensed agency changed the catheter yesterday but did not empty or change the bag. 3. The clinical record for Patient 2, start of care date 10/14/2021, for the certification period 2/11/2022 to 4/11/2022, contained a Plan of Care Service Plan dated 2/14/2022, that indicated the aide was to assist with elimination (toileting) 5 times a week. The note indicated Patient 2 was incontinent at times, wears a brief, and used a urinal. The agency failed to ensure the Plan of Care Service Plan included Patient 2 had a Foley catheter and instruction on emptying the Foley catheter bag. 4. During an interview on 3/16/2022 at 10:25 a.m., the Alternate Administrator was asked why the agency does not change or provide skilled care regarding patient 2's Foley catheter to which he/she replied the agency does not have anything to do with patient 2's Foley catheter and the agency does not document coordination between another licensed entities. 5. The clinical record for Patient 9, start of care date 12/27/2019, for the certification period 2/14/2022 to 4/14/2022, contained a Plan of Care that indicated a separate licensed Entity continued to provide Respite Nursing hours approximately 1-2 days per week and typically on the weekends. POC (plan of care) faxed to them for care coordination. The agency requested copy of their POC in return. The POC indicated "No other companies in patient's home currently." 6. During an interview on 3/17/2022 at 3:30 p.m., the Alternate Administrator indicated the agency sends the plan of care to the other licensed agencies that provide care to the patient and makes a request for the other agency to send them their plan of care. The Alternate Administrator indicated if the agency does not receive anything, the agency does not follow-up or document information the other licensed agency provides or does not provide. 410 IAC 17-2-2(g) 410 IAC 17-14-1(a)(1)(F) 410 IAC 17-14-1(c)(6)

Written instructions to patient include: CFR(s): 484.60(e) Standard: Written information to the patient. The HHA must provide the patient and caregiver with a copy of written instructions outlining: This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure a current plan of care and admission packet was provided to the patient for 2 of 3 home visits with the potential to affect all patients. (Patient 1, 8) Findings include: 1. A policy, copied on 3/16/2022 at 12:00 p.m. from the policy binder provided by the Administrator, titled, "Plan of Care," indicated but was not limited to, "6. The total medical plan of care shall be reviewed by the physician and home health agency personnel as often as the severity of the client's condition requires, but at least once every sixty (60) days." 2. During a home visit on 3/11/2022 at 10:00 a.m. Patient 1's agency home folder was reviewed and evidenced a Patient Orientation for Home Health Care booklet. The Alternate Administrator, who was present on the visit, indicated he/she was going to remove the Patient Orientation for Home Health Care Adaptive Nursing and Healthcare from the home folder and replace it with a "new" Patient Orientation for Home Health Care Adaptive Nursing and Healthcare booklet. The booklet contained a new Admission Consent form which was not explained to the patient at the visit. Patient 1 was asked if he/she was aware of the agency closing and if a letter was sent with a list of other agencies to choose from. Patient 1 indicated the agency letter was received and choose [Entity 5] because he/she wanted to stay with the same caregivers. The Alternate Administrator indicated he/she only works the PA side and that Patient 1 receives services from PA & HHA from Adaptive and Home Health services from SWIRCA. 3. During a home visit on 3/15/2022 at 1:00 p.m. Patient 8's agency home folder was reviewed and had a copy of the plan of care for the certification period of 12/7/2021 to 2/4/2022. The agency failed to ensure a current plan of care was provided to the patient. 4. During an interview on 3/16/2022 at 10:25 a.m., the Alternate Administrator indicated the plan of care was updated in the patient's home folder at each recertification visit. The nurse was to bring the plan of care from the previous recertification. They don't make 2 separate visits so the plan of care in the folder will always be from the previous recertification.

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure a current medication profile was provided to the patient for 1 of 3 home visits. (Patient 8) Findings include: A policy, copied on 3/16/2022 at 12:00 p.m. from the policy binder provided by the Administrator, titled, "Medication Management," indicated but was not limited to, "8. The Medication Profile shall be reviewed by a Registered Nurse on each home visit, every sixty (60) days and updated whenever there is a change or discontinuation in medication. 9. The Registered Nurse shall sign and date the Medication profile upon initiation and, at minimum, every sixty (60) days thereafter." During a home visit on 3/15/2022 at 1:00 p.m. Patient 8’s agency home folder was reviewed and had a copy of the medication profile for the certification period of 12/7/2021 to 2/4/2022. The medication profile indicated a last review date of 12/7/2021. The agency failed to ensure a current medication profile was provided to the patient. During an interview on 3/16/2022 at 10:25 a.m., the Alternate Administrator indicated the medication profile was updated in the patient’s home folder at each recertification visit. The nurse was to bring the medication profile from the previous recertification. They don’t make 2 separate visits so the medication profile will always be from the previous recertification.

Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA's governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA's performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This CONDITION is not met as evidenced by: Based on record review and interview, the agency failed to develop and implement a QAPI (quality assurance and performance improvement) plan that showed measurable data to track and analyze trends related to adverse patient events and infection control concerns to monitor the patient quality of care and improve health outcomes and patient safety (See G642); failed to utilize quality indicator data in its QAPI (quality assurance and performance improvement) plan to monitor the effectiveness, safety, quality of patient care, and identify opportunities for improvement (See G644); and failed to conduct any performance improvement projects (See G658). The cumulative effect of these systemic problems resulted in the home health agency's inability to ensure the provision of safe and quality health care to patients who receive services from this provider for the Condition of Participation 484.60 Quality assessment / performance improvement .

Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to develop and implement an agency-wide QAPI (quality assurance and performance improvement) plan that showed measurable data to track and analyze trends related to adverse patient events and infection control concerns to monitor the patient quality of care and improve health outcomes and patient safety for 1 of 1 agency QAPI reviewed. Findings include: 1. On 3/21/2022 at 2:19 p.m., a document titled "Patient Orientation for Home Health Care" was provided by the Alternate Administrator. The document indicated but was not limited to "...Policies...This book contains general information regarding your rights...as a patient...The home health agency must protect and promote the exercise of these rights as follows ... The patient has the right to receive care of the highest quality." 2. A January 4, 2022 policy titled Quality Assurance Performance Improvement Plan and Program was provided by the Administrator on 3/14/2022 at 1:47 p.m. The policy indicated, but not limited to, " Policy ... be prioritized by the agency's management team ... must measure, analyze, and track quality indicators, including adverse client events ... b. identify opportunities for improvement ... 5. The frequency and detail of the data collection must be approved by the Governing Body. ... 7. To meet state and federal regulatory requirements. ... 8. The QAPI committee will be responsible for coordinating all QAPI activities ... report findings to the Administrator ... who will report to the Governing Body ..." During the entrance conference on 3/10/2022 at 9:55 a.m., the Administrator was asked to provide the agency QAPI program/binder, infection control program, COVID-19 tracking, and vaccination tracking. At that time, the Administrator indicated the agency does not require or mandate vaccinations for employees. On 3/10/2022 at 2:21 p.m., the Administrator provided all Governing Body meeting minutes requested for March, February, January, of 2022, and December 2021. A review of the meeting minutes failed to indicate COVID-19 vaccination requirements, COVID tracking, and failed to address and approve the current QAPI program and the approval of any specific improvement projects. On 3/11/2022 at 12:00 p.m., the Administrator was asked for a 2nd time to provide the QAPI program for the last 2 quarters. The Administrator indicated "we are working on it." During an interview on 3/16/2022 at 9:42 p.m., the Administrator was asked to provide meeting minutes he/she had with Governing Body B and C. The Administrator indicated he/she does not record any meetings between them, but they converse on Zoom (video platform). On 3/14/2022 the Administrator indicated the QAPI program data was kept on a spreadsheet in the computer and its a "live version and we will get it to you." The Administrator indicated he/she oversees the QAPI program. On 3/14/2022 the Administrator indicated a contract nurse tracks the agency's COVID-19 exposures. The administrator emailed the surveyor the COVID tracking list that stopped on February 14, 2022. At that time, the Administrator indicated they had no one test positive for COVID. On 3/14/2022 at 3:13 p.m., the Administrator provided quarter 1 QAPI for 2022 and 2021 QAPI in two separate binders. A review of the QAPI failed to indicate the COVID tracking and vaccination status of employees and tracking of any infections were documented in the program. On 3/21/2022 at 2:19 p.m., the Administrator provided a printed copy of the Fall Incident log listing 3 patients, and a brief explanation of tne adverse event. The agency indicated if the patient called EMS, transferred to ER, injury and treatment by marking a Yes or No next to the event. The agency failed to identify the cause of each fall and identify and implement an appropriate solution to prevent /reduce the risk of future falls. 410 IAC 17-12-2(a)

Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA's governing body. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to utilize quality indicator data in its QAPI (quality assurance and performance improvement) plan to monitor the effectiveness, safety, and quality of patient care, and identify opportunities for improvement for 1 of 1 QAPI reviewed. Findings include: 1. On 3/21/2022 at 2:19 p.m., a document titled "Patient Orientation for Home Health Care," was provided by the Alternate Administrator. The document indicated, but was not limited to, "...Policies...This book contains general information regarding your rights...as a patient...The home health agency must protect and promote the exercise of these rights as follows ... The patient has the right to receive care of the highest quality." 2. A January 4, 2022 policy titled Quality Assurance Performance Improvement Plan and Program was provided by the Administrator on 3/14/2022 at 1:47 p.m. The policy indicated, but not limited to, " Policy ... be prioritized by the agency's management team ... must measure, analyze, and track quality indicators, including adverse client events ... b. identify opportunities for improvement ... 5. The frequency and detail of the data collection must be approved by the Governing Body. ... 7. To meet state and federal regulatory requirements. ... 8. The QAPI committee will be responsible for coordinating all QAPI activities ... report findings to the Administrator ... who will report to the Governing Body ..." 3. During the entrance conference on 3/10/2022 at 9:55 a.m. the Administrator was asked to provide the agency QAPI program, infection control program, COVID tracking and vaccination tracking. At that time, the Administrator indicated the agency does not require or mandate vaccinations for employees. 4. On 3/11/2022 at 12:00 p.m. the Administrator was asked again to provide the QAPI program for the last 2 quarters. The Administrator indicated "we are working on it." 5. Review of the Governing Body meeting minutes dated 2/21/2022, 1/24/2022, 2/8/2022, and 1/1/2022, which were included in the QAPI binder failed to mention the QAPI program or approval of performance improvement projects. The Administrator indicated he/she does not record or document any meetings with the Governing Body. 6. On 3/14/2022 the Administrator indicated the QAPI was kept on a spreadsheet in the computer and its a "live" version and we will get it to you. The Administrator indicated he/she oversees the QAPI program. 7. On 3/14/2022 the Administrator indicated a contract nurse tracks the agency's COVID-19 exposures. The administrator emailed the surveyor the COVID tracking list that stopped on February 14, 2022. At that time, the Administrator indicated they had no one test positive. 8. On 3/14/2022 at 3:13 p.m., the Administrator provided quarter 1 QAPI for 2022 and last year's QAPI in two separate binders. A review of the QAPI failed to indicate COVID tracking and vaccination status for employees was in the program. The QAPI did not show any data pulled from OASIS because the agency had not had any OASIS data to submit. 9. The contents of quarter 1 for 2022, evidenced a document titled "New client agreement (100%)" that listed 24 patients and the date the new client agreements were completed. Dates ranged from 1/24/2022 to 1/25/2022. All agreements were verified by the Administrator. All patients listed were currently on the active census for the agency. 10. The content of quarter 1 QAPI pulled from the Administrators EMR included a "Change of ownership letter," with the same 24 patients listed as the "New client agreement" list. Dates ranged from 1/25/2022 to 2/14/2022. All were verified by the Administrator. 11. The agency failed to use data collected to monitor the effectiveness and safety and quality of care and identify opportunities for improvement. 410 IAC 17-12-2(a)

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to conduct any performance improvement projects for 1 of 1 home health agency. Findings include: A January 4, 2022 policy titled Quality Assurance Performance Improvement Plan and Program was provided by the Administrator on 3/14/2022 at 1:47 p.m. The policy indicated, but not limited to, " Policy ... be prioritized by the agency's management team ... must measure, analyze, and track quality indicators, including adverse client events ... b. identify opportunities for improvement ... 5. The frequency and detail of the data collection must be approved by the Governing Body. ... 7. To meet state and federal regulatory requirements. ... 8. The QAPI committee will be responsible for coordinating all QAPI activities ... report findings to the Administrator ... who will report to the Governing Body ..." On 3/10/2022 and 3/11/2022 the Administrator was unable to provide QAPI program / binder when asked. A review of the Governing Body meeting minutes dated 2/21/2022, 2/8/2022, 1/24/2022, and 1/1/2022, which were included in the QAPE binder failed to mention the QAPI program or any performance improvement projects. The 2/21/2022 meeting minutes address the placement of Governing Body B and C, placement/appointment of new administrative staff, the new organizational chart, and a review of updated policies and procedures, personnel title changes, review of the budget.

Infection prevention and control CFR(s): 484.70 Condition of Participation: Infection prevention and control. The HHA must maintain and document an infection control program which has as its goal the prevention and control of infections and communicable diseases. This CONDITION is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure standard infection control precautions were followed (See G682); failed to ensure an agency wide program was maintained for infectious and communicable disease was an integral part of the QAPI program (See G684); failed to create, maintain, and implement written policies and procedures which were compliant with requirements for CMS (Center for Medicare & Medicaid) vaccine mandate issued on January 14, 2022. (See G687) These failures had the potential effect to place and/or pose a threat to patient health and safety. The failure to create, maintain, and implement agency policy had the potential to affect all 114 agency patients. An Immediate Jeopardy related to the failure of the agency to create, maintain, and implement written policies and procedures was identified and announced to the Administrator n 3/11/2022 at 12:25 p.m. The Immediate Jeopardy remained unremoved upon the survey exit on 3/22/2022, at approximately 12:30 p.m., due to the failure to submit an acceptable Immediacy Removal Plan. The cumulative effect of these systemic problems resulted in the home health agency's inability to ensure the provision of quality health care in a safe environment for patients who received services from this provider for the Condition of Participation 484.70: Infection Prevention & Control. .

COVID-19 Vaccination of Home Health Agency staff CFR(s): 484.70 (d)-(d)(3)(i-x) § 484.70 Condition of Participation: Infection Prevention and Control. (d) Standard: COVID-19 Vaccination of Home Health Agency staff. The home health agency (HHA) must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. For purposes of this section, staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for COVID-19 is defined here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine. (1) Regardless of clinical responsibility or patient contact, the policies and procedures must apply to the following HHA staff, who provide any care, treatment, or other services for the HHA and/or its patients: (i) HHA employees; (ii) Licensed practitioners; (iii) Students, trainees, and volunteers; and (iv) Individuals who provide care, treatment, or other services for the HHA and/or its patients, under contract or by other arrangement. (2) The policies and procedures of this section do not apply to the following HHA staff: (i) Staff who exclusively provide telehealth or telemedicine services outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section; and (ii) Staff who provide support services for the HHA that are performed exclusively outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section. (3) The policies and procedures must include, at a minimum, the following components: (i) A process for ensuring all staff specified in paragraph (d)(1) of this section (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the HHA and/or its patients; (ii) A process for ensuring that all staff specified in paragraph (d)(1) of this section are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations; (iii) A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19; (iv) A process for tracking and securely documenting the COVID-19 vaccination status of all staff specified in paragraph (d)(1) of this section; (v) A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC; (vi) A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law; (vii) A process for tracking and securely documenting information provided by those staff who have requested, and for whom the HHA has granted, an exemption from the staff COVID-19 vaccination requirements; (viii) A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws, and for further ensuring that such documentation contains (A) All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and (B) A statement by the authenticating practitioner recommending that the staff member be exempted from the HHA's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications; (ix) A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and (x) Contingency plans for staff who are not fully vaccinated for COVID-19. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to develop and implement written policies and procedures to ensure all agency staff was in compliance with the Center for Medicare and Medicaid Services COVID-19 vaccination mandate and failed to keep an accurate list of agency employees for tracking of vaccination purposes, for 1 of 1 agency reviewed with the potential to affect all 144 active patients of the home health agency. Findings include: 1. A January 14th, 2022 dated document, the Center for Medicaid and Medicare Services (CMS) issued titled “QSO 22-07-ALL,” that indicated, but was not limited to; “The guidance in this memorandum specifically applies to the following states … Indiana … On November 5, 2021, CMS published an IFC [Interim Final Rule] with comment period (86 FR 61555), entitled “Medicare and Medicaid Programs; Omnibus COVID-19 Health Care Staff Vaccination,” revising the infection control requirements that most Medicare- and Medicaid-certified providers and suppliers must meet to participate in the Medicare and Medicaid programs. These changes are necessary to protect the health and safety of patients and staff during the COVID-19 public health emergency. The COVID-19 vaccination requirements and policies and procedures required by this IFC must comply with applicable federal nondiscrimination and civil rights laws and protections, including providing reasonable accommodations to individuals who are legally entitled to them because they have a disability or sincerely held religious beliefs, practices, or observations that conflict with the vaccination requirement … CMS expects all providers’ and suppliers’ staff to have received the appropriate number of doses by the timeframes specified in the QSO-22-07 unless exempted as required by law, or delayed as recommended by CDC. Facility staff vaccination rates under 100% constitute non-compliance under the rule … Within 30 days after issuance of this memorandum … Policies and procedures are developed and implemented for ensuring all facility staff, regardless of clinical responsibility or patient or resident contact are vaccinated for COVID-19; and 100% of staff have received at least one dose of COVID-19 vaccine, or have a pending request for, or have been granted a qualifying exemption, or identified as having a temporary delay as recommended by the CDC, the facility is compliant under the rule; or Less than 100% of all staff have received at least one dose of COVID-19 vaccine, or have a pending request for, or have been granted a qualifying exemption, or identified as having a temporary delay as recommended by the CDC, the facility is non-compliant under the rule.” 2. A document issued by the Center for Medicaid and Medicare Services (CMS) titled “Attachment G: Home Health Agencies,” indicated, but was not limited to; HHAs [Home Health Agencies] must have a process for ensuring all staff … have received at least a single-dose, or the first dose of a multi-dose COVID-19 vaccine series prior to providing any care, treatment, or other services for the facility and/or its patients. The policy must also ensure those staff who are not yet fully vaccinated, or who have been granted an exemption or accommodation as authorized by law, or who have a temporary delay, adhere to additional precautions that are intended to mitigate the spread of COVID-19 ... From 30-60 days following issuance of this memorandum, the expected minimum threshold for use in these determinations will be 80%. From 60-90 days following issuance of this memorandum, the expected minimum threshold will be 90%. From 90 days on, the expected minimum threshold will be 100%. States should work with their CMS location for cases that exceed these thresholds, yet pose a threat to patient health and safety not otherwise addressed by the criteria below: Immediate Jeopardy: 40% or more of staff remain unvaccinated creating a likelihood of serious harm.” 3. During the entrance conference on 3/10/2022 at 9:50 a.m., the Administrator was asked to provide all COVID-19 policies and procedures related to the new vaccine mandate, a list of all staff and their vaccination status, including the percent of vaccinated staff, and the position or role of each staff member, including staff who are in direct contact with patients, regardless of frequency of contact, and all office staff. The Administrator indicated the agency does not require or mandate COVID-19 vaccinations for all agency employees. The Administrator indicated office staff and field staff are not required to fill out medical or religious exemption forms regarding COVID-19. The Administrator had no documentation regarding the tracking of COVID-19 vaccinations. The Administrator indicated office staff is not required to wear masks at the office. The Administrator indicated being unsure if the agency had any current Covid positive patients. The Administrator was asked to provide the QAPI for review. The Administrator indicated the past and current Governing Body B and Governing Body C made the decision not to comply with federal COVID-19 vaccination regulations based on a supreme court ruling last year. The Administrator was asked to provide the document and policy that documented the Governing Body B and C made their decision to not follow CMS vaccination requirements. The Administrator indicated none of the Adaptive agencies require Covid vaccinations for employees owned by Corporate Entity 1 [Entity 5, Entity 6, Entity 7, Entity 8, Entity 9] that are not a part of the survey. The Administrator indicated the agency was in the process of closing, but with no definite target date. 4. An updated December 28, 2021 document titled “CMS Omnibus COVID-19 Health Care Staff Vaccination Interim Final Rule,” was provided by the Administrator on 3/10/2022 at 12:54 p.m. The document indicated, but was not limited to, “ … Indiana … Medicare and Medicaid-certified providers and suppliers in those states are not required to comply with the Interim Final Rule, and surveyors will not investigate compliance with the rule …” On 3/10/2022 at 1:23 p.m., the Administrator indicated the agency currently employed 127 home health aides, 4 nurses, and 8 office staff. At 1:56 p.m., the Administrator indicated there was no definite date when the provision of services would end for the agency's patients. The agency license expires at the end of March 2022. The agency was unable to provide a policy & procedure in regards to CMS vaccine mandate per QSO 22-09 that outlined vaccination requirements, exemptions, and additional measures/contingency plan to take for staff who don’t qualify for vaccination or exemption. 5. On 3/10/20222 at 1:30 p.m., a review of Board of Directors meeting Minutes dated 12/15/2021, and Governing Body Minutes dated 1/1/2022, 1/21/2022, 1/24/2022, 2/8/2022, and 2/21/2022, failed to evidence any documentation regarding COVID-19 vaccinations or exemptions for employees, or a review or approval of the agency's QAPI program. 6. A December 12/29/2021 policy titled “Covid-19 Guidelines for the Office,” was provided by the Administrator on 3/10/2022 at 2:16 p.m. The policy indicated, but was not limited to, “… Adaptive continues to follow CDC recommendations: … Associates not fully vaccinated should continue to mask and physically distance when in an office unless alone in a private office. Stricter state and local guidelines may supersede these requirements for a given location. Relaxation of masking and physical distance requirements does not apply to staff providing care in the home or other healthcare setting. Managers should ensure adherence to the following policy: … Masks … Individuals should self-identify and mask appropriately. Managers are not expected to monitor proof of vaccination.” 7. On 3/10/2022 at 2:54 p.m., the Administrator indicated Governing Body B and Governing Body C acknowledged the agency was out of compliance regarding the CMS vaccination requirements. 8. A review of Patient #10 clinical record on 3/21/2022, evidenced a document dated 2/8/2022, Home Health Certification/Recertification Plan of Care Order was signed by internal Person B, and a document with the Recertification and Discharge box checked and dated 3/10/2022, was signed by internal Person B. A review of Patient 11's record indicated a signed Plan of Care Service Plan dated 3/14/2022, signed by Person D, at Entity 10, and a Plan of Care Service Plan dated and signed by Person C at Entity 10. 9. When interviewed on 3/21/2022 at 10:45 a.m., the Alternate Administrator indicated when queried why Person B, C, and D, were not on the list of agency employees provided on 3/10/2022, he/she stated they are not here but were hired in when we needed help. The agency failed to provide a complete and accurate employee list and therefore had failed to maintain a process for ensuring the tracking and secure documentation of the vaccination status of staff.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on record review, observation, and interview, the agency failed to ensure patient safety was maintained during patient care for 1 of 3 home visit observations which has the potential to affect all patients that are a fall risk. (Patient 1) (HHA K) Findings include: A revised January 4, 2022 policy titled, "Governing Body," was provided by the Administrator on 3/16/2022 at 11:02 a.m. The policy indicated, but was not limited to, " ... ensure appropriate quality services are provided to patients." An undated HHA (home health aide) Comp (competency) Handout was provided by the Administrator on 3/16/2022 at 11:00 a.m. which failed to indicate stand-by assist instructions or guidance. At that time, the Administrator indicated the agency does not have a policy on stand-by assist. The clinical record for Patient 1 was reviewed on 3/11/2022 and included The Home Health Certification/Recertification Plan of Care Order with a start of care date 5/10/2019, verbal start of care date 2/18/2022, for the certification period 2/23/2022 to 4/23/2022, with orders for HHA to assist with all ADLs such as bathing (shower), hair care, dressing, nail care (no clipping), incontinence care, meal prep. medication reminders, light housekeeping, and transfers. The Plan of Care dated 2/18/22 indicated, but not limited to, "Precautions: HHA to monitor fall risks such as stumbling, shuffling, or unsteady gait ... No other agencies in the home ... Waiver services through [Entity 7] ... 60 day summary: ... was seen in her home on 2/18/22 for her recertification visit ... Discharge Plans: ... no plans to discharge this patient." A review of a Daily Visit Sheet for 3/5/2022 indicated Patient 1 was a Stand-by assist with shower signed by HHA K. A review of Patient 1's Comprehensive Nurse Assessment for the current certification period indicated a MACH (fall risk assessment tool) score of 7 (4 or more is fall risk.) A review of the Plan of Care Service Plan dated 2/18/2022, indicated Patient 1 was a fall risk and required stand-by assist. No specific patient preferences were listed on the Plan of Care Service Plan. During a home visit along with the Alternate Administrator on 3/11/2022 at 10:00 a.m., observed HHA K assist Patient 1 to remove pants and pull-up brief and enter the walk-in shower. Patient 1 bathed self and HHA K left the bathroom and walked to the kitchen to warm up tea leaving Patient 1 unattended during the shower. During the visit, the Alternate Administrator agreed if the patient was a stand-by assist the HHA should have stayed with the patient during the shower. The agency failed to ensure the HHA K performed stand-by assistance (was close by) during patient 1's shower in case he/she lost balance. 410 IAC 177-14-1(a)(1)(H)-RN

A qualified HH aide successfully completed: CFR(s): 484.80(a)(1)(i-iv) A qualified home health aide is a person who has successfully completed: (i) A training and competency evaluation program as specified in paragraphs (b) and (c) respectively of this section; or (ii) A competency evaluation program that meets the requirements of paragraph (c) of this section; or (iii) A nurse aide training and competency evaluation program approved by the state as meeting the requirements of §483.151 through §483.154 of this chapter, and is currently listed in good standing on the state nurse aide registry; or (iv) The requirements of a state licensure program that meets the provisions of paragraphs (b) and (c) of this section. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure home health aides completed a home health aide training, skills competency and/or competency evaluation program that was not currently precluded from operating or being the site of a home health training and competency program for 1 of 1 agency which had the potential to affect all home health aides trained on-site. Findings include: 1. A revised January 4, 2022 policy titled Competency Assessment was provided by the Alternate Administrator on 3/21/2022 at 12:45 p.m. The policy indicated, but was not limited to, "Competency Assessment and Competency Follow-up Assessment failed to indicate the following were evaluated after observation of the Home Health Aide performance of the tasks with a client: Reading and recording temperature, pulse, and respiration, safe transfer techniques and ambulation, normal range of motion, and appropriate and safe techniques in personal hygiene and grooming including recognizing, and reporting changes in skin condition, bed bath, sponge, tub, and shower bath, shampoo in (sink, tub, bed), Nail and skin care, oral hygiene, toileting and elimination, and any other task the agency may choose to have the Home Health aide perform. There must be evidence of Home Health Aide orientation to and competency in the delegated tasks not addressed here." 2. Review of the required 1572 form filled out by the Administrator on 3:10 p.m. at 1:23 p.m., indicated the Home Health Agency provided directly a Home Health aide competency evaluation program despite being precluded from operating or being the site of a home health aide training, skills competency and/or competency evaluation program for a period of two years which started on December 14, 2021 to December 13, 2023, for have been found out of compliance with the Conditions of Participation 484.105 Organization and Administration of Services. 3. During an observation of the agency along with the Administrator on 3/16/2022, observed a room located in the home health service part of the building that contained training equipment (wheel chair, inflatable tub, shower, sink, bedside commode). At that time, the Administrator indicated a nurse comes to the agency to "train and comp." the aides in the building. The Administrator indicated contract RN E used to do it but now contract RN F does the training. Contract nurses E and F were not on the current employee roster. 4. Review of HHA J personnel file indicated a hire date of 2/15/2022, was placed on nurse aide registry 2/17/2022, 3 hours competency time and had provided care to a patient unsupervised on 2/18/2022. HHA J had no prior paid work in the health field. 5. During a phone interview on 3/21/2022 at 6:41 p.m., HHA J indicated he/she was provided training on-site at the current agency location by a nurse. HHA J indicated he/she was out in the field as soon as he/she was checked off and on the nurse aide registry. HHA J indicated Adaptive was getting ready to become [Entity 5] and he/she would just transfer over, and this was what they were doing for all the staff and that's how they are getting more clients. 6. During a phone interview on 3/21/2022 at 7:01 p.m., HHA D indicated he/she was provided training by a male nurse in the office at the current agency location and a lady completed the skill competency at the office. HHA D personnel file indicated a hire date of 2/2/2022. 7. A review of HHA H's personnel file indicated a hire date of 3/2/22 (location of hire Jeffersonville), Competency Assessment -HHA completed 3/2/22 and signed by contract RN F, and place on the nurse registry 3/2/22 all onsite at the current agency location. 8. Review of HHA U's personnel file indicated a hire date of 2/22/2022, completed a PCA Skills Checklist 2/16/22, signed by the Alternate Administrator, Completed a Competency Assessment-HHA dated 2/23/22, signed by contract RN E, completed an HHA Skills Competency Follow-up dated 2/23/22, signed by the Administrator, and was placed on the Nurse Aide Registry 2/23/22 all onsite at the current agency location. 9. Review of HHA S's personnel file indicated a hire date of 1/25/2022, received 3 hours of competency time on 1/25/2022, completed a Competency Assessment -HHA on 1/26/2022, signed by contract RN E, completed HHA Skills Competency Follow-up on 1/26/2022, singed by the Administrator, and was placed on nurse aide registry 1/26/2022 all onsite at the current agency location. 10. Review of HHA J, HHA U, HHA D, HHA H, and HHA S's Competency Assessment and Competency Follow-up Assessment failed to indicate the following were evaluated after observation of the Home Health Aide's performance of the tasks with a client: Reading and recording temperature, pulse, and respiration, safe transfer techniques and ambulation, normal range of motion, and appropriate and safe techniques in personal hygiene and grooming including recognizing, and reporting changes in skin condition, bed bath, sponge, tub, and shower bath, shampoo in (sink, tub, bed), Nail and skin care, oral hygiene, toileting and elimination, and any other task the agency may choose to have the Home Health aide perform. The agency failed to follow their own policy. 11. During an interview at 9:40 AM on 3/21/2022, the Administrator and Governing Body C indicated they have the aides demonstrate tasks, but the agency does not teach or train new hires or the aides. The Administrator indicated the aides are not evaluated after observation and performance tasks with a client in the home based on agency policy. Both were unaware the agency continues to be precluded from operating or being the site of a home health aide training, skills competence and/or competency evaluation program for a period of two years based on the December 14, 2021 survey. The Administrator was provided section 1891(c)(2)(D) of the Social Security Act pursuant to section 1891(a)(3)(D)(iii) of the Act information. I410 IAC 17-14-1 (l)(1)(A)

Org. had partial/extended survey CFR(s): 484.80(f)(3) Was subjected to an extended (or partially extended) survey as a result of having been found to have furnished substandard care (or for other reasons as determined by CMS or the state); or This ELEMENT is not met as evidenced by: Based on record review, observation, and interview, the agency failed to comply with CMS COVID-19 vaccination requirements and failed to comply with guidelines of the Social Security Act by not operating or being the site of a home health aide training, skills competency and/or competency evaluation program for a period of two years based on the agency's last survey starting December 14, 2021, for 1 of 1 home health agency. Findings include: 1. During entrance conference on 3/10/2022 at 9:55 a.m., the Administrator indicated the agency does not require or mandate COVID -19 vaccinations for all agency employees. The Administrator indicated office staff and field staff are not required to fill out medical or religious exemptions forms regarding COVID-19. The Administrator had no documentation regarding tracking of COVID-19 vaccinations. The Administrator indicated office staff are not required to wear masks at the office. The Administrator was unsure if the agency had any current Covid positive patients. The Administrator indicated the past and current Governing Body members made the decision not to comply with Federal COVID-19 vaccination regulations based on a supreme court ruling last year. This resulted in an Immediate Jeopardy related to §484.70 (d) Infection Prevention and Control through vaccination of agency staff, or documentation of exemption, was identified and announced on 3/11/2022 at 1:40 p.m. The immediate jeopardy began on February 14th, 2022, when the agency failed to implement CMS-mandated tracking of the vaccination status of agency staff. 2. Review of the required 1572 form filled out by the Administrator at 3:10 p.m. on 1:23 p.m., indicated the Home Health Agency provided directly a Home Health aide competency evaluation program despite being precluded from operating or being the site of a home health aide training, skills competency and/or competency evaluation program for a period of two years starting December 14, 2021 to December 13, 2023 for being out of compliance with Conditions of Participation 484.105 Organization and Administration of Services. 3. During an observation of the agency along with the Administrator on 3/16/2022, observed a room located in the home health service part of the building that contained training equipment (wheelchair, inflatable tub, shower, sink, bedside commode). At that time, the Administrator indicated a nurse comes to the agency to "train and comp." the aides in the building. The Administrator indicated contract RN E used to do it but now contract RN F does the training. Contract nurses E and F were not on the current employee roster. 4. A review of HHA J personnel file indicated a hire date of 2/15/2022, placed on the nurse aide registry 2/17/2022, 3 hours competency time and had provided care to a patient unsupervised on 2/18/2022. HHA J had no prior paid work in the health field. 5. During a phone interview on 3/21/2022 at 6:41 p.m., HHA J indicated he/she was provided training on-site at the current agency location by a nurse. HHA J indicated he/she was out in the field as soon as he/she was checked off and on the nurse aide registry. HHA J indicated Adaptive was getting ready to become [Entity 5] and he/she would just transfer over and was what they are doing to all the staff and that's how they are getting more clients. 6. During a phone interview on 3/21/2022 at 7:01 p.m., HHA D indicated he/she was provided training by a male nurse in the office at the current agency location and a lady completed my skill competency at the office. HHA D personnel file indicated a hire date of 2/2/2022. 7. During an interview on 3/21/2022 at 9:40 a.m., the Administrator and Governing Body C indicated they have the aides demonstrate tasks, but the agency does not teach or train new hires or the aides. Both were unaware the agency continues to be precluded from operating or being the site of a home health aide training, skills competence and/or competency evaluation program for a period of two years based on the December 14, 2021, survey. The Administrator was provided section 1891(c)(2)(D) of the Social Security Act pursuant to section 1891(a)(3)(D)(iii) of the Act information.

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, observation, and interview, the agency failed to ensure home health aide services were consistent with the home health aide training for 2 of 3 home visit observations. (Patients 2, 8) Findings include: 1. A revised 4/2020 Patient Orientation for Home Health Care was provided by the Alternate Administrator on 3/21/22 at 2:19 p.m. as the current patient rights policy the agency used. The document indicated, but was not limited to, "Section III. Patient Rights and Responsibilities ... treatment or care that is (or fails to be) furnished ... on behalf of Adaptive ... receive all services outlined in the plan of care. ..." The handbook indicated, but was not limited to, "Patient Rights and Responsibilities ... The patient has the right to be free from verbal, physical and psychological abuse and to be treated with dignity, and to be free from sexual abuse, neglect, and exploitation." 2. A review of a policy, copied on 3/16/2022 at 12:00 p.m., from the policy binder provided by the Administrator, titled, "Home Health Aide Care Service Plan," indicated but was not limited to, ... "All home health aide staff will follow the identified plan." 3. On 3/14/2022 at 11:46 a.m., the Administrator provided a YouTube link at https://youtu.be/x_goWc-2LB0 titled "Bed Bath Video" that was used to educate staff. A review of the video indicated that staff should only expose the part of the body being washed. 4. During a home visit on 3/14/2022 at 8:00 a.m., observed HHA L pull down patient 2's hospital gown to cover his/her groin area before starting the bed bath leaving Patient 2 cool and unnecessarily exposed. Patient 2's lower extremities were exposed before starting the bed bath as well. HHA L indicated Patient 2 was a very private person. HHA L did not ask patient 2's personal preferences regarding the bed bath. 5. Review of Patient 2's Plan of Care Service Plan did not indicate any personal preferences regarding a bed bath. 6. During an interview on 3/16/2022 at 10:20 a.m., the Alternate Administrator was asked if the expectation of staff was to follow the bed bath training video and if it was appropriate to unnecessarily expose a patient during a bed bath. The Alternate Administrator indicated it would be a patient preference. 7. During a home visit on 3/15/2022 at 1:00 p.m. Patient 8, HHA N was observed to ambulate Patient 8 to the bedroom to sit on the bed after his/her shower. Patient 8 was observed without any clothes on to walk in front of a window with the blinds open facing another apartment while there were other people outside. HHA N shut the blinds after Patient 8 sat down on the bed. 8. A review of Patient 8's Plan of Care Service Plan, effective 2/5/2022 through 4/5/2022, indicated, but was not limited to, ... Please monitor for fall potentials. Make sure the patient is using a cane or walker and standby assist for all mobility ... 9. During an interview on 3/16/2022 at 10:25 a.m., the Administrator indicated they have no policy to close blinds while a patient walked naked through the house, and that would be a patient preference.

Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure qualified personnel reported directly to the Governing Body with no intermediaries for 1 of 1 home health agency. Findings include: 1. An undated Branch Manager job description was provided by the Administrator on 3/10/2022 at 3:21 p.m. The branch manager job description indicated, but was not limited to, "Reports to : Director, Regional Operations ... The Branch Manager under the direct supervision of the Director, Regional Operations ..." 2. Review of the Organizational Structure chart provided by the Administrator on 3/10/2022 at 2:21 p.m., indicated the branch manager and Administrator were the same person. The Administrator was asked why the agency has a "branch" manager if there was no record with the state agency the license had a branch, to which he/she replied the agency wanted to become more unified. A review of The Organizational Chart indicated the following: The left side of the chart indicated a direct line down from the Governing Body down to the Administrator, down to the Alternate Administrator, down to the Nursing Supervisor, down to the Alternate Nursing Supervisor (home office in Terre Haute). The Organization Chart on the left side did not go down to the patient care level. The acting Administrator did not qualify based on federal regulation 484.115 (a)(2). A review of the agency personnel roster failed to indicate the Alternate Nursing Supervisor was a direct employee or contracted employee under this agency license. The Organizational Chart indicated the following: The right side of the chart indicated a direct line from the Administrator over to the Branch Manager, down to the Care Supervisors, down to field staff (RNS, LPNs, HHAs), down to patients. A review of the agency Branch Manager's job description did not meet federal requirements for the survey. The Administrator was asked if the left side of the chart was that of Entity 7 located in the same building to which he/she replied "No." A review of the agency Branch Manager's job description indicated the branch manager reported to the Director of Regional Operations. A review of the agency personnel roster failed to indicate/disclose the name of the Director of Regional Operations who would have responsibilities for the management of the agency. 3. On 3/16/2022 at 9:52 a.m., the Administrator indicated he/she did not have meeting minutes of the weekly meetings with agency staff and did not have meeting minutes he/she communicates with the Governing Body. All meetings were on Zoom (video) remote because we don't work in the same area. The agency failed to ensure the Administrator/Branch Manager reported directly to the Governing Body with no intermediaries. 4. During a phone interview on 3/16/2022 at 1:30 p.m., Governing Body B and C were made aware that Indiana Medicaid follows federal regulations and Medicare standards are applied to Medicaid. the requirements for the home health agencies to qualify to participate in the Indiana Medicaid program was compliance with CMS's Conditions of Participation. 5. During a phone interview with Governing Body C and the Administrator on 3/17/2022 at 3:10 p.m., Governing Body C indicated the organizational chart was correct as well as the lines of authority. Governing Body C did not comment on agency policy or no meeting minute documentation.

Must have a written agreement CFR(s): 484.105(e)(2)(i-iv) An HHA must have a written agreement with another agency, with an organization, or with an individual when that entity or individual furnishes services under arrangement to the HHA's patients. The HHA must maintain overall responsibility for the services provided under arrangement, as well as the manner in which they are furnished. The agency, organization, or individual providing services under arrangement may not have been: (i) Denied Medicare or Medicaid enrollment; (ii) Been excluded or terminated from any federal health care program or Medicaid; (iii) Had its Medicare or Medicaid billing privileges revoked; or (iv) Been debarred from participating in any government program. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to take responsibility and ensure a written contract or agreement with other licensed agencies that furnished services to this agency's patients was maintained for 1 of 1 home health agency (Person B, C, D, Alternate Administrator) with the potential to affect all patients. Findings include: 1. A review of the Home Health Agency Landscape form completed by the Administrator on 3/10/2022 at 1:11 p.m. indicated the name of the agency was "Adaptive Nursing", listed services provided as "HHA", with 0 (zero) branches. At a later time, the Administrator was asked to verify the name of the agency and services provided. The Administrator corrected the agency name and indicated the agency does not offer skilled nursing services, but have nurses and added skilled nursing to the form. The CMS 1572 form indicated no contracted staff, but did indicate in entrance conference the agency had contracted nurses for the aide training and competency program. The Administrator indicated all employees are dually employed with 1 personnel file. 2. The following clinical records evidenced Persons not included on the employee roster. No contracts or written agreements were available for review: 3. A review of patient 7's clinical record on 3/21/2022, evidenced documents dated 2/2/2022, titled Home Health Certification/Recertification Plan of Care Order and a Plan of Care Service Plan signed by Person G of Entity 5. The fax had Entity 5's logo and Adaptive Nursing and Healthcare Services with a Washington address. Person B was not listed as an employee based on the current roster nor on the employee terminated roster provided by the Administrator on 3/10/2022 and 3/14/2022. Person B was not contracted by the agency. 4. A review of patient 10's clinical record on 3/21/2022, evidenced a document dated 2/8/2022, Home Health Certification/Recertification Plan of Care Order was signed by internal Person B, and a document with a Recertification and Discharge box both checked and dated 3/10/2022 time in 10:12 am, time out 10:15 am was signed by internal Person B. A review of the electronic medical record for patient 10 indicated a fax sent to [MD name] from Person B dated 3/2/22 due 16.75 hrs under for the week of 2/20/22. The fax had Entity 5's logo and an Adaptive Nursing and Healthcare Services with a Washington address. The electronic medical record notes entry by Person U of Entity 5 indicated on 3/10/2022 at 12:13 p.m. to 12:28 p.m. patient 10 "declined a discharge visit when I came to the home although by phone he was agreeable to the visit and was agreeable to the time." Person B was not listed as an employee based on the current roster provided by the Administrator on 3/10/2022 and 3/14/2022. Person B was not contracted by the agency. 5. A review of patient 11's clinical record indicated a Recertification dated 3/11/22 time in 12:24 PM time out 12:59 PM signed by Person C of Entity 10. The Recertification failed to indicate a certification period. A Plan of Care Service Plan dated 3/14/2022, signed by Person D, at Entity 10 for the certification period of 3/16/2022 to 5/4/2022, and a Plan of Care Service Plan dated and signed by Person C at Entity 10 for the certification period 3/16/2022 to 5/4/2022. Person C and Person D were not listed as employees based on the current roster provided by the Administrator on 3/10/2022 and 3/14/2022. Person C and D were not contracted by the agency. 6. Review of the agency personnel roster provided by the Administrator on 3/16/2022 at 12:27 p.m. failed to indicate the Alternate Clinical Supervisor was listed as an employee of the Adaptive Nursing and Healthcare Service in Evansville. The Administrator indicated Alternate Clinical Supervisor's office was over 2 hours away in Terre Haute and was hired "under Adaptive". Review of the state database indicated there was no "branch" or other locations listed under the agency license for the current survey. The Administrator refused to answer if the office in Terre Haute was a branch or parent and to what licensed Entity. The agency failed to hire or contract the Alternate Clinical Supervisor specific for the Evansville location. 410 IAC 17-12-2(d)

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 record review and interview, the agency failed to ensure skilled nursing services were offered in addition to home health aide services for 1 of 1 home health agency. Findings include: During the entrance conference on 3/10/2022 at 9:55 a.m., the Administrator indicated the agency had skilled nursing services but did not offer skilled nursing services to its patients. During a home visit on 3/14/2022 at 8:00 a.m., the HHA, employee L, indicated another Entity changes Patient 2's foley catheter. On 3/16/2022 at 10:20 a.m., the Alternate Administrator was asked why another licensed agency was providing skilled nursing services to Patient 2 instead of this agency, to which he/she replied this agency has skilled nursing services but we don't offer it to patients.

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 secure computer entry into patient clinical records from persons not employed directly or contracted specifically to this agency, for 1 of 1 home health agency. (Patient 7,10, and 11) Findings include: A review of the revised 10/2014 CMS State Operations Manual, indicated but was not limited to, "Health Facility-Based HHAs (Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) An HHA [home health agency] ... is expected to be an integral but subordinate part of the institution. Administrative and fiscal controls may be exercised over the HHA. However, the HHA's policies, personnel files, and clinical records must be separate and identifiable. During an interview on 3/10/2022 at 10:35 a.m., the Administrator indicated that this Adaptive agency will no longer be Adaptive on its license. Patient and employees all received a letter about the change. The Administrator was asked why the agency moved to a new building if it was closing. The Administrator indicated the Professional Blvd location was just a temporary location and the agency was waiting on the post revisit survey to be completed. The Administrator was asked what his/her plans were regarding the closure to which he/she was unsure. When asked, the Administrator indicated being unsure of the active patient census. During the entrance conference on 3/10/2022, the Administrator was informed the surveyor needed unrestricted access to the current EMR to review records for the survey. The agency gave surveyor access to Matrix EMR (electronic medical record) at 12:00 p.m. At 12:48 p.m., however; unable to access the EMR. The Administrator placed a call to the Governing Body for access again and was instructed to change the surveyor's password to something else and a message displayed that indicated "No read permission," but allowed the surveyor to proceed with clinical record review. The following clinical records evidenced persons not included on the employee roster provided by the Administrator during the survey: A review of Patient 7's clinical record on 3/21/2022, evidenced documents dated 2/2/2022, titled, "Home Health Certification/Recertification Plan of Care Order" and a "Plan of Care Service Plan" signed by Person G of Entity 5. The fax had Entity 5's logo and an Adaptive Nursing and Healthcare Services with a Washington IN address. Person B was not listed as an employee based on the current roster nor on the employee terminated roster provided by the Administrator on 3/10/2022 and 3/14/2022. Person B was not contracted by the agency. A review of Patient 10's clinical record on 3/21/2022, evidenced a document dated 2/8/2022, "Home Health Certification/Recertification Plan of Care Order," which was signed by internal Person B, and a document with a Recertification and Discharge box both checked and dated 3/10/2022, time in 10:12 am, time out 10:15 am, which was signed by internal Person B. A review of the electronic medical record for Patient 10 indicated a fax sent to [MD name] from Person B dated 3/2/22 due 16.75 hrs under for the week of 2/20/22. The fax had Entity 5's logo and an Adaptive Nursing and Healthcare Services with a Washington, IN address. The electronic medical record notes entry by Person U of Entity 5 indicated on 3/10/2022 at 12:13 p.m. to 12:28 p.m., Patient 10 "declined a discharge visit when I came to the home although by phone he/she was agreeable to the visit and was agreeable to the time." Person B was not listed as an employee of this agency based on the current roster provided by the Administrator on 3/10/2022 and 3/14/2022. Person B was not contracted by the agency. A review of Patient 11's clinical record indicated a Recertification dated 3/11/22, time in 12:24 p.m. time out 12:59 p.m., signed by Person C of Entity 10. The Recertification failed to indicate a certification period. A Plan of Care Service Plan dated 3/14/2022, signed by Person D, at Entity 10 for the certification period of 3/16/2022 to 5/4/2022, and a Plan of Care Service Plan dated and signed by Person C at Entity 10 for the certification period of 3/16/2022 to 5/4/2022. Person C and Person D were not listed as employees based on the current roster provided by the Administrator on 3/10/2022 and 3/14/2022. During an interview on 3/21/2022 at 9:40 a.m., the Administrator was asked if the Governing Body provided training for the role of administrator at the agency or if the Administrator was currently being trained since accepting the role. The Administrator indicated "I don't know how to answer that question and I have a checklist in my personnel file that was done by the Governing Body." The Administrator was asked about Entity 5 material found in his/her personnel file and if he/she was currently worked as an Entity 5 employee during the survey. The Administrator indicated "whatever was in that file doesn't pertain to the Adaptive survey and whatever I have in that file I don't have to answer in this survey and this will be escalated to the Governing Body. I talk to both of them and they report back to me and the Governing Body trained me and I completed an administrative checklist." During an interview on 3/21/2022 at 10:45 a.m., the Alternate Administrator indicated when queried why Person B, C, and D were not on the list of agency employees provided on 3/10/2022, he/she stated they are not here but they were hired in when we needed help. The agency failed to secure computer entry into patient records from persons not employed directly or contracted specifically to the agency. 410 IAC 17-15-1(a)(7)

Administrator CFR(s): 484.115(a) Standard: Administrator, home health agency. (1) For individuals that began employment with the HHA prior to January 13, 2018, a person who: (i) Is a licensed physician; (ii) Is a registered nurse; or (iii) Has training and experience in health service administration and at least 1 year of supervisory administrative experience in home health care or a related health care program. (2) For individuals that begin employment with an HHA on or after January 13, 2018, a person who: (i) Is a licensed physician, a registered nurse, or holds an undergraduate degree; and (ii) Has experience in health service administration, with at least 1 year of supervisory or administrative experience in home health care or a related health care program. This STANDARD is not met as evidenced by: Based on record review and interview, the governing body failed to ensure the agency Administrator met current qualifications for 1 of 1 home health agency. Findings include: Review of a revised January 4, 2022 policy titled Governing Body was provided by the Administrator on 3/16/2022 at 11:02 a.m. The policy indicated, but was not limited to, "It is the policy of Adaptive Nursing and Healthcare Services, LLC, and its affiliates that the Governing Body ensures lines ofauthority [sic] are established and to ensure appropriate quality services are provided to patients. Policy: The Governing Body (or designated persons so functioning) assume full legal authority and responsibility for the agency's overall management and operation , the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. Responsibilities: 2. All Governing Body members participate in orientation (including an orientation to the Agency, responsibilities as Governing Body member and role of the Governing Body in Quality Assessment and Performance Improvement). ... c. That clear expectation for client safety are established, implemented and maintained. ... 6. The Agency's scope of services is approved by the Governing Body ... 7. The Governing Body appoints the Administrator or approves the Administrator selected by the corporation or another group ..." Review of a signed 2/8/2022 Administrator Job Description was provided by the Administrator on 3/16/2022 at 11:03 a.m. The job description indicated, but was not limited to, "Qualifications ... Baccalaureate degree in nursing, health service administration, business administration ... College degree required ... Knowledge of the regulatory requirements at the state, federal, and local level." During an interview on 3/10/2022 at 12:33 a.m., the Administrator was asked if he/she holds an undergraduate degree in anything or was a registered nurse to which he/she replied "No." The Administrator indicated the state department director approved her as Administrator for Adaptive Nursing and Healthcare Services. The Administrator was informed the program director acknowledged information such as resume and background check was received, but approval to work in the role of Administrator for the agency had not been granted. RA reviewof the information submitted to the state database for administrative changes indicated the acting Administrators resume with a hire date of 3/2018 to present and failed to evidence a record of the Administrator holding an undergraduate degree. The Governing Body failed to ensure the appointment of a qualified administrator for the agency based on the employment date after January 13, 2018, due to no nursing degree and no undergraduate degree. Review of the Administrator's personnel file that was housed at the internal office and retrieved by the Governing Body indicated a hire date of 3/2018. During an interview on 3/16/2022 at 12:55 p.m. the Administrator was asked if he/she was aware of or knew what Article 17 or the Indiana administrative code was to which he/she replied "no". During an interview on 3/21/2022 at 9:40 a.m. the Administrator was asked if the Governing Body provided training for the role of administrator at the agency or if the Administrator was currently being trained since accepting the role. The Administrator indicated "I don't know how to answer that question and I have a checklist in my personnel file that was done by the Governing Body." The Administrator was asked about Entity 5 material found in his/her personnel file and if he/she was currently working as an Entity 5 employee during the survey. The Administrator indicated "whatever was in that file doesn't pertain to the Adaptive survey and whatever I have in that file I don't have to answer in this survey and this will be escalated to the Governing Body. I talk to both of them and they report back to me and the Governing Body trained me in and I completed an administrative checklist."

This visit was for a Federal recertification and State re-licensure survey of a home health agency. Partially Extended survey was announced on 12/9/2021 at 3:25 p.m. Fully Extended survey was announced on 12/14/2021 at 2:52 p.m. Survey Dates: December 8, 9, 10, 13, and 14 of 2021. These deficiencies reflect State Findings cited in accordance with 410 IAC 17. Refer to State Form for additional State findings. Adaptive Nursing and Healthcare Services is precluded from conducting a home health aide training or competency evaluation program for a period of two years starting December 14, 2021 to December 13, 2023 for being out of compliance with Conditions of Participation 484.105 Organization and Administration of Services. QR Completed 1/6/2022 A4

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 provide home health aide services as ordered on the plan of care for 2 of 6 records reviewed. (Patient 1, 4) Findings include: 1. A revised policy dated August 26, 2021 titled Plan of Care was provided by the Administrator on 12/9/2021 at 11:01 a.m. The policy indicated, but was not limited to, "Policy: ... agency staff to ensure that care provided is appropriately and planned to meet each client's assessment needs. ... 2. Clients shall be accepted for care based on a reasonable expectation that the client's health needs can be adequately met by the home health agency in the client's place of residence. 3. Medical care shall follow a written medical plan of care. ..." 2. The complete clinical record for patient 1 was reviewed on 12/8/2021 and included a plan of care for the certification period 10/14/2021 to 12/12/2021, SOC (start of care) date 10/14/2021, with orders to provide home health aide services 7 hours a day/5 days per week. The agency failed to provide home health aide services as indicated on the plan of care as follows: Review of the Daily Visit Sheet dated 10/15/2021 indicated the HHA (home health aide) visit was from 8:00 a.m. to 11:40 a.m. The aide did not indicate on the sheet that any tasks were completed, and all tasks assigned listed on the Daily Visit Sheet for the 10/15/2021 visit were left blank. The agency failed to meet the service hours and tasks assigned as indicated of the plan of care. Review of the Daily Visit Sheet for the week of 10/24/2021 to 10/30/2021 indicated an HHA visit on 10/29/2021 was from 8:00 a.m. to 1:28 p.m. The Administrator provided a Confidential fax to the physician that indicated the HHA missed 4 hours due to the patient refused alternate staff. Patient 1's electronic medical record failed to indicate any other HHA visits for that week. The agency failed to meet the services hours as indicated on the plan of care. Review of the Daily Visit Sheet for the week of 10/31/2021 to 11/6/2021 indicated an HHA visit on 11/3/2021 was from 7:36 a.m. to 10:00 a.m. The Administrator provided a Confidential fax to the physician that indicated the HHA missed 8 hours due to the patient refused alternate staff on 11/1/2021. Patient 1's electronic medical record failed to indicate any other HHA visits for that week. The agency failed to meet the service hours as indicated on the plan of care. Review of the Daily Visit Sheets for the week of 11/7/2021 to 11/13/2021 indicated an HHA visit on11/8/2021 was from 7:42 a.m. to 10:08 a.m. and from 1:03 p.m. to 3:03 p.m. The Daily Visit Sheet on 11/10/2021 was from 7:39 a.m. to 9:54 a.m. Review of the Daily Visit Sheets for the week of 11/21/2021 to 11/27/2021 indicated an HHA visit on 11/24/2021 was from 7:57 a.m. to 10:02 a.m. and from 12:02 to 2:11 p.m. The Daily Visit Sheet on 11/26/2021 was from 7:59 a.m. to 10:01 a.m. and from 12:04 p.m. to 2:03 p.m. An HHA visit was conducted on 11/23/2021. Patient 1's electronic medical record failed to indicate any other HHA visits for that week. The agency failed to meet the service hours as indicated on the plan of care Review of the Daily Visit Sheets for the week of 11/28/2021 to 12/4/2021 indicated an HHA visit on 11/29/2021 was from 7:58 a.m. to 10:00 a.m. and from 12:02 p.m. to 2:00 p.m. The Daily Visit Sheet on 12/1/2021 was from 8:00 a.m. to 10:00 a.m. and from 12:00 p.m. to 1:30 p.m. An HHA visit was conducted on 11/30/2021. Patient 1's electronic medical record failed to indicate any other HHA visits for the week. The agency failed to meet the service hours as indicated on the plan of care During an interview on 12/9/2021 at 2:41 p.m. the Administrator indicated patient 1 received dialysis on Monday, Wednesday, Friday, and that was the reason for shortened visits. The Administrator indicated that transportation for dialysis was another reason for the shortened visits. 3. The complete clinical record for patient 4 was reviewed on 12/8//2021 and included a plan of care for the certification period 10/9/2021 to 12/7/2021, SOC date 4/12/2021, with orders to provide home health aide services 3 hours a day/ 3 days per week. The agency failed to provide home health aide services as indicated on the plan of care as follows: Review of the Daily Visit Sheets for the week of 10/10/2021 to 10/16/2021 indicated an HHA visit on 10/15/2021 with combined hours for HHA / Attendant Care of 12:30 p.m. to 4:59 p.m. The agency failed to delineate Attendant Care hours, from a separate licensed agency, from the HHA hours. An HHA visit was conducted on 10/13/2021. Patient 4's electronic medical record failed to indicate any other visits for that week. The agency failed to meet the service hours as indicated on the plan of care Review of the Daily Visit Sheets for the week of 10/17/2021 to 1023/2021 indicated an HHA visit on 10/18/2021 was from 8:03 a.m. to 10:02 a.m. The Daily Visit Sheet for 10/21/2021 was from 8:00 a.m. to 10:00 a.m. The Daily Visit Sheet on 10/22/2021 was from 8:00 a.m. to 10:02 a.m. The agency failed to meet the service hours as indicated on the plan of care. Review of the Daily Visit Sheets for the week of 10/24/2021 to 10/30/2021 indicated an HHA visit on 10/25/2021 was from 7:59 a.m. to 10:02 a.m. The Daily Visit Sheet for 10/27/2021 was from 8:00 a.m. to 10:00 a.m. The Daily Visit Sheet for 10/29/2021 was for 8:00 a.m. to 10:00 a.m. The agency failed to meet the service hours as indicated on the plan of care. Review of the Daily Visit Sheets for the week of 10/31/2021 to 11/6/2021 indicated an HHA visit on 11/1/2021 was from 8:00 a.m. to 10:19 a.m. The Daily Visit Sheet for 11/3/2021 was from 8:00 a.m. to 10:00 a.m. The Daily Visit Sheet on 11/5/2021 was from 8:00 a.m. to 10:00 a.m. The agency failed to meet the service hours as indicated on the plan of care. Review of the Daily Visit Sheets for the week of 11/7/2021 to 11/13/2021 indicated an HHA visit on 11/8/2021 was from 7:58 a.m. to 10:40 a.m. The Daily Visit Sheet for 11/10/2021 was from 8:00 a.m. to 10:00 a.m. The Daily Visit Sheet on 11/12/2021 was from 7:58 a.m. to 10:01 a.m. The agency failed to meet the service hours as indicated on the plan of care. Review of the Daily Visit Sheets for the week of 11/14/2021 to 11/20/2021 indicated an HHA visit on 11/15/2021 was from 9:27 a.m. to 10:00 a.m. The Daily Visit Sheet on 11/17/2021 was from 7:59 a.m. to 10:02 a.m. Patient 4's electronic medical record failed to indicate any other visits for the week. The agency failed to meet the services hours as indicated on the plan of care. Review of the Daily Visit Sheets for the week of 11/21/2021 to 11/27/2021 indicated an HHA visit on 11/22/2021 was from 7:59 a.m. to 10:02 a.m. The Daily Visit Sheet for 11/23/2021 was for 7:56 a.m. to 10:15 a.m. The Daily Visit Sheet on 11/24/2021 was for 8:38 a.m. to 10:07 a.m. The agency failed to meet the services as indicated on the plan of care. 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 failed to follow infection control standards of practice for 1 of 4 home visit observations. (Patient 1) Findings include: 1. A revised August 26, 2021 policy titled Infection Prevention and Control Plan was provided by the Administrator on 12/9/2021 at 11:01 a.m. The policy indicated, but was not limited to, “Policy: The agency has developed and implemented infection control practices that conform to OSHA regulations, CDC guidelines, state and local regulations and currently accepted standards of practice…”. 2. An undated procedure or training protocol for Home Health Aides on 11:16 a.m. The procedure/training protocol indicated, but was not limited to, Vital Signs…Hand Washing Infection Control-Ask the HHA to wash their hands for you and observe they are doing it correctly…” 3. During a home visit on 12/9/2021 at 8:00 a.m. HHA F was observed giving a bed bath to patient 1. The home health aide is supposed to change gloves each time dirty water is changed for new. HHA F failed to change gloves according to the procedure/training protocol of the Aide’s competency checks. During the bed bath, HHA F assisted in rolling patient 1 onto the left side while in bed. After washing, rinsing and patting dry the patient’s neck and back the patient was returned to supine position for the Aide to get wipes to clean a bowel movement. The patient was again rolled onto the left side, then HHA F used wipes to proceed in cleaning the buttocks of the bowel movement. Each dirty wipe was placed on the soiled paper chux (incontinence pad) and when the patient had been cleaned of the bowel movement, the dirty chux was rolled up with all dirty materials in the chux and pushed it as far under the patient as possible to be pulled out on the other side. HHA F completed washing, rinsing and drying buttocks. HHA F returned the patient to the supine position once again and moved to the other side of the bed to pull the dirty chux out from underneath the patient, then disposed of it in the waste can. However, the Aide did not remove the gloves that were on and dispose of them with the dirty chux. HHA F proceeded to get a clean gown to put on the patient and then began cleaning up the water basins, washcloths, and towels. After HHA F completed cleaning the patient’s bowel movement, the cloth chux that was under the soiled paper chux was not removed and replaced. HHA F failed to prevent cross-contamination by not removing both gloves after cleaning the patient’s bowel movement appropriately or replacing the soiled linen with fresh clean linen. 4. During an interview on 12/9/2020 at 9:10 a.m. the RNCM G indicated the home health aide should have changed the gloves after the bowel movement was cleaned. The RNCM G also indicated HHA F should have changed the cloth chux underneath the patient. 5. During an interview on 12/9/21 at 11:16 a.m. the Alternate Administrator (AA) C indicated when a bed bath is given all linens should be changed. 17-12-1(m)

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to verify visitors self-screened for Covid-19 prior to entering the home health agency during a pandemic for 5 of 5 survey days. Findings include: A revised August 26, 2021, policy titled Infection Prevention and Control Plan was provided by the Alternate Administrator on 12/13/2021 at 3:06 p.m. The policy indicated, but was not limited to, "The agency has developed and implemented infection control practices that conform to OSHA regulations, CDC guidelines, state and local regulations and currently accepted standards of practice." On 12/8/2021, 12/9/2021, 12/10/2021, 12/13/2021, and 12/14/2021 the agency failed to screen state surveyors and other visitors for Covid-19 by verifying if visitors saw the "Stop before you enter ..." sign and confirming a self-screen was done before entering the agency during a pandemic. During an interview on 12/13/2021 at 1:05 p.m. the Administrator indicated the agency no longer screens visitors for Covid-19. At that time, the Administrator provided an email from Regional Vice President of [Entity F] dated 5/4/2021 that indicated, "Here is the new flyer that should be posted near your front entrance regarding the new protocols around Covid. We will NO LONGER be doing temp checks at our front doors!" 17-12-1(m)

Information to the state survey agency CFR(s): 484.100(a) Standard: The HHA also must disclose the following information to the state survey agency at the time of the HHA's initial request for certification, for each survey, and at the time of any change in ownership or management: This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to notify the State agency of a change in management / ownership for Adaptive Nursing and Healthcare Services, LLC., for 1 of 1 home health agency. Findings include: A revised policy dated August 2021 titled Governing Body was provided by the Administrator on 12/9/2021 at 11:01 a.m. The policy indicated, but was not limited to, "It is the policy of [Entity F] and its affiliates that the Governing Body ensures lines of authority are established and to ensure appropriate quality services are provided to patients. Policy: The Governing Body (or designated persons so functioning) assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program." Review of the state database indicated a letter dated 2/3/21 with notice that effective 12/24/20, a stock transfer occurred as well as a legal name change from "Adaptive Nursing and Healthcare Services, INC." to "Adaptive Nursing and Healthcare Services, LLC." The state database indicated Entity J, a separate license agency, was located at the same address. Review of the State database information indicated Person G under ownership information for "Adaptive". During entrance conference on 12/8/2021 at 9:41 a.m. the Administrator indicated Governing Body member K was the only Governing Body member and that Person G left this year and was no longer a part of Adaptive Nursing and Healthcare Services, LLC. Review of the Amended & Restated Limited Liability Company Agreement of Adaptive Nursing and Healthcare Services, LLC, was provided by the Operations Manager G on 12/14/2021 at 12:45 p.m. The agreement indicated, but was not limited to, “This Amended & Restated Limited Liability Company (this “Agreement”) of Adaptive Nursing and Healthcare, LLC (the “Company”) is entered into as of the 26th day of February, 2021, by HAH Group Holding Company LL, a Delaware limited liability company, as the sole member (the “Sole Member”). WHEREAS, effective as of December 9, 2020, the Company was duly formed pursuant of the provisions of the Indiana Business Flexibility Act … WHEREAS, on December 8, 2020, the Company entered into the operating agreement with its prior sole member, Adaptive Group Holdings, LLC (the “First Operating Agreement”) … the Sole Member now desires to amend and restate the First Operating Agreement in its entirety … Section 2. Sole Member. The name and the business, residence or mailing addresses of the Sole Member is as follows: Name HAH Group Holding Company LLC Address 33 S. St., Fifth Floor Chicago, IL 60603 … Section 6. … Agents. … The Sole Member hereby appoints the below-listed as officers of the Company: [Chief Executive Officer L, Chief Financial Officer M, President K, Vice President N]” The agency failed to disclose a change in management / ownership to the state agency. During an interview on 12/14/2021 at 2:30 p.m. the Administrator indicated that Person G left Adaptive in May 2021. 17-10-1(d)

Officer, a director, agent, managing employee CFR(s): 484.100(a)(2) The name and address of each person who is an officer, a director, an agent, or a managing employee of the HHA as defined in §420.20l, §420.202, and §420.206 of this chapter. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to disclose the name of each person who is an officer, director, an agent, or a managing employee for Adaptive Nursing and Healthcare Services LLC., the legal name of the agency for 1 of 1 home health agency. Findings include: A policy titled Governing Body was provided by the Administrator on 12/9/2021 at 11:01 a.m. The policy indicated, but was not limited to, "It is the policy of [Entity F] and its affiliates that the Governing Body ensures lines of authority are established and to ensure appropriate quality services are provided to patient. The Governing Body (or designated persons so functioning) assume full legal authority and responsibility for the agency’s overall management and operation, the provision of all home health services … 8. Additional activities of the Governing Body: … Establishing or approving written policies and procedures governing operations … Provision of services." Review of the state agency database indicated RN E was the Alternate Clinical Supervisor. During entrance conference on 12/8/2021 at 9:41 a.m. the Administrator indicated RN (registered nurse) C was the Alternate Clinical Supervisor and that RN E left the agency. Review of the Governing Body meeting minutes dated 6/3/2019 indicated former RN N was the Alternate Clinical Supervisor. Reviewed the Governing Body minutes dated 3/8/2021, 2/12/2021, and 1/3/2020 which did not indicate a change in the Alternate Clinical Supervisor position. During an interview on 12/13/2021 at 10:05 the Administrator was asked to provide the appointment letter for the Alternate Clinical Supervisor. At that time, the Administrator was unable to provide the appointment letter and a confirmation letter from the state agency regarding the change. The agency failed to appoint and inform the state agency of a managing employee change. 17-10-1(d)(2)

Responsible for the management of the HHA CFR(s): 484.100(a)(3) The name and business address of the corporation, association, or other company that is responsible for the management of the HHA, and the names and addresses of the chief executive officer and the chairperson of the board of directors of that corporation, association, or other company responsible for the management of the HHA. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to notify the state agency of the name and address of the current governing body or other responsible person for the management of the HHA since the transfer of agency stocks for 1 of 1 home health agency. Findings include: During entrance conference on 12/8/2021 at 9:41 a.m. the Administrator indicated the agency was going through an acquisition and that Governing Body member K, who was Person 0 of Entity F as well, was who he/she reported to. During an interview on 12/13/2021 at 10:05 a.m. the Administrator was asked to provide a written document indicating who the Governing Body members(s) were for verification due to the recent transfer of agency stocks. Review of the Amended & Restated Limited Liability Company Agreement of Adaptive Nursing and Healthcare Services, LLC, was provided by the Operations Manager G on 12/14/2021 at 12:45 p.m. The agreement indicated, but was not limited to, “This Amended & Restated Limited Liability Company (this “Agreement”) of Adaptive Nursing and Healthcare, LLC (the “Company”) is entered into as of the 26th day of February, 2021, by HAH Group Holding Company LL, a Delaware limited liability company, as the sole member (the “Sole Member”). … the Sole Member now desires to amend and restate the First Operating Agreement in its entirety … Section 2. Sole Member. The name and the business, residence or mailing addresses of the Sole Member is as follows: Name HAH Group Holding Company LLC Address 33 S. St., Fifth Floor Chicago, IL 60603 … Section 6. … Agents. … The Sole Member hereby appoints the below-listed as officers of the Company: [Chief Executive Officer L, Chief Financial Officer M, President K, Vice President N]” The agency failed to notify the state agency of the names and address of the current officers of the Company. During an interview on 12/14/2021 at 2:30 p.m. the Administrator indicated that Entity F bought Adaptive, and Person G and Governing Body member K, have part ownership of Entity F. The Administrator indicated he/she had no documentation to provide after reaching out to Governing Body member K for verification of the current Governing Body members. 17-10-1(d)(3)

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: Based on record review and interview, the agency administrator failed to ensure Adaptive Nursing and Healthcare Services LLC., - Evansville administrative and supervisory responsibilities were not delegated to other Entities on an ongoing basis for 1 of 1 quality assessment and performance improvement program review; and failed to clearly set forth in writing, administrative control, and lines of authority for the delegation of responsibility down to the patient care level (See G940); the governing body failed to exercise its responsibility for the agency's management by having failed to adopt policies in the legal name of the agency, Adaptive Nursing and Health Care Services, LLC., d/b/a Adaptive Nursing and Healthcare Services and failed to maintain separate personnel files specific to Adaptive Nursing and Health Care Services (See G942); failed to demonstrate distinct boundaries of the Medicaid-certified program in relation to any other programs the larger organization has to offer (See G944); failed to ensure the administrator reported directly to the Governing Body without the use of intermediaries (See G946); the administrator failed to ensure the agency met all rules and regulations for recertification and failed to ensure the responsibility for all day-to-day operations of the parent agency (See G948); and failed to disclose a merge of a branch location to the state agency (Indiana Department of Health) and failed to ensure if the Centers for Medicare and Medicaid Services (CMS) was notified and approved the merge prior to moving all patients to the parent location (See G972). The cumulative effect of this systemic problem resulted in the agency being out of compliance with §484.105 Condition of participation: Organization and administration of services. In regard to G940: Findings Include: 1. A revised August 26,2021 policy titled Quality Assurance Performance Improvement Plan and Program was provided by the Administrator on 12/14/2021 at 9:50 a.m. The policy indicated, but was not limited to, "4. The QAPI committee will be responsible for coordinating all QAPI activities, reviewing collection data, analyzing data, assisting staff in developing improvement activities, planning actions, collecting data and analyzing the effectiveness of action and implementing effective actions. 5. The QAPI committee will meet on a regular basis and will report findings to the Administrator/Director of Clinical Services, who will report to the Governing Body. 6. Results will also be communicated by the QAPI committee to staff, including contract staff." 2. A revised August 2021 policy titled Governing Body was provided by the Administrator on 12/9/2021 at 11:01 a.m. The policy indicated, but was not limited to, "It is the policy of [name of Entity F] and its affiliates that the Governing Body ensures lines of authority are established and to ensure appropriate quality services are provided to patients. ... a. That an ongoing program for Quality Assessment/Performance Improvement and client safety is defined, implemented and maintained." 3. Review of the Evansville License QAPI meeting Q3/2021 dated 12/3/2021 indicated Person C, corporate Quality Assurance Supervisor, was present at the meeting. Review of the Evansville QAPI meeting dated 5/6/2020 indicated Person P of Jeffersonville was present at the meeting. 4. During an interview on 12/8/2021 at 12:35 p.m. the undated Organizational Chart for the "Evansville Parent License" was reviewed along with the Administrator. The Administrator indicated he/she reported to a Person B, a Clinical Director, Person C, a Quality Assurance Supervisor, and Person D, an Area Manager. The Administrator indicated they were all corporate people that are not directly employed at the agency. The Administrator indicated corporate Person M at a different location oversees the QAPI, and Person C reviews patient charts and advises on what corrections need to be made. Persons B and D of the Jeffersonville office provides guidance and advises on clinical issues at the agency. The agency failed to ensure the quality assessment and performance improvement program responsibilities were not delegated to corporate or other licensed Entities. 5. Review of the state database indicated a letter dated 2/3/21 with notice that effective 12/24/20, an indirect stock transfer occurred as well as a legal name change from "Adaptive Nursing and Healthcare Services, INC." to "Adaptive Nursing and Healthcare Services, LLC." The state database indicated Entity J, a separate license agency, was located at the same address. During entrance conference on 12/8/2021 at 9:41 a.m. the Administrator was asked about how the agency delineated services from Entity J to which he/she replied there was no clear delineation and its ran under one license. On 12/8/2021 at 11:25 a.m. the undated "Evansville Parent License" organizational chart was reviewed. The chart indicated a line between the Supervising Nurse and On-Call Staffing and then to patients. The agency failed to indicate a direct line of authority for the delegation of responsibility between RN's/LPN's/HHA's down to the patient care level. The Administrator agreed there should be a direct line between Agency Staff RN's/LPN's/HHA's down to the patient care level. During an interview on 12/8/2021 at 12:35 p.m. the undated Organizational Chart for the "Evansville Parent License" was reviewed along with the Administrator. The Administrator indicated he/she reported to a Person B, a Clinical Director, Person C, a Quality Assurance Supervisor, and Person D, an Area Manager. The Administrator indicated they were all corporate people and not directly employed at the agency. The Administrator indicated corporate Person M at a different location oversees the QAPI, and Person C reviews patient charts and advises on what corrections need to be made. Persons B and D of the Jeffersonville office provides guidance and advises on clinical issues at the agency. 17-12-1(a)(1) 17-12-1(a)(2)

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on record review and interview, the governing body failed to exercise its responsibility for the agency's management by having failed to adopt policies in the legal name of the agency, Adaptive Nursing and Health Care Services, LLC., d/b/a Adaptive Nursing and Healthcare Services for 1 of 1 governing body; and failed to maintain separate personnel files specific to Adaptive Nursing and Health Care Services for 7 of 7 personnel file reviews. (Employee B, C, D, E, F, G, H) Findings include: 1. The revised 10/2014 CMS State Operations Manual, indicated but was not limited to, "Health Facility-Based HHAs (Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) An HHA based to a hospital, SNF, hospice, or rehabilitation facility is expected to be an integral but subordinate part of the institution. Administrative and fiscal controls may be exercised over the HHA. However, the HHA's policies, personnel files, and clinical records must be separate and identifiable. 2. Review of the state database indicated Adaptive Nursing and Healthcare Services LLC., provided Skilled Nursing Services and Home Health Aide Services. Review of the state database indicated a separate licensed Entity J that provides attendant care, homemaker, and companion services is located at the same address. Review of the state database indicated a February 3, 2021 letter that stated "Effective, December 24, 2020, Adaptive Groups Holdings, LLC sold 100% of the stock in Adaptive to HAH Group Holding Company, LLC. The tax id for Adaptive remains the same and this is NOT a Change of Ownership ... legal business name changes from Adaptive Nursing and Healthcare Services, Inc to Adaptive Nursing and Healthcare Services, LLC. This is simply a legal business name change." The letter was signed by the President of Adaptive Nursing and Healthcare Services. 3. A revised 4/8/19 signed Administrator Job Description was provided by the Administrator on 12/9/2021 at 11:01 a.m. The policy indicated, but was not limited to, "5. Provides direction in formulating the programs and policies." 4. Governing body meeting minutes dated 2/12/2021 failed to indicate policies and procedures of Entity F were adopted by the governing body, for Adaptive Nursing and Health Care Services LLC. 5. Governing body meeting minutes dated 1/3/2021 failed to indicate policies and procedures of Entity F were adopted by the governing body, for Adaptive Nursing and Health Care Services LLC. 6. Governing body meeting minutes dated 1/28/2019 failed to indicate policies and procedures of Entity F were adopted by the governing body, for Adaptive Nursing and Health Care Services LLC. 7. The following policies & procedures and job descriptions presented throughout the survey failed to ensure the information was specific to Adaptive Nursing and Healthcare Services LLC., d/b/a Adaptive Nursing and Healthcare Services and not that of Entity F, including, but not limited to: Governing Body Plan of Care Incident Reporting Orientation of Personnel Client Rights Administrator: Defined Administrator Job Description Client Discharge Process Advance Directive Client Transfer Job Description for Personnel Specialist (reports to Operation Manager) Job Description: HHA Job Description: LPN/RN (Homecare) Bathing and stand-by assist procedure Quality Assurance Performance Improvement Plan and Program 8. Review of the Client Agreement provided by the Alternate Administrator on 12/8/2021 at 11:20 a.m. indicated "Financial Responsibility ... I agree to pay late fees of an additional $100 and interest of 5% each week after 60 days. In the event [Entity J INC.] is required to take action to collect any amounts ... I agree to pay Adaptive Nursing and Healthcare Services Inc. ... I agree to Jurisdiction in the State of Indiana and the Venue in the Court in Clark County, Indiana." The agency failed to delineate two separate licenses on the Client Agreement form. 9. A review of personnel file B indicated an August 23, 2021 offer letter and Job Description for Entity F signed by the Administrator and Person L, Administrator for Entity F. The letter logo indicated Entity F and Entity R. A job description for a Territory Clinical Manager signed and dated 2/12/2021 with Entity F and Entity R logos on the top of the page and an address for Chicago listed at the bottom. The signed Background Check Consent Form dated 7/27/2021 and 3/22/2017 indicated Entity J, K, and Q’s logos at the top of the page. A dated 4/3/2017 signed Tuberculosis Screening Consent form for Adaptive Nursing and Healthcare Services and Entity J. A signed Health Assessment/Work Release dated 8/24/2021 for Entity F. A signed 4/3/2017 Authorization for a Confidential Reference for both Adaptive Nursing and Healthcare Services and Entity J. The agency failed to separate and identify the personnel file for Adaptive Nursing and Healthcare Services LLC., d/b/a Adaptive Nursing and Healthcare Services from other licensed Entities. 10. A review of personnel file C indicated a 4/6/2021 signed Registered Nurse Case Manager job description for Entity F. A signed Hepatitis B Vaccination dated 5/4/20 and a signed Health Assessment/Work Release for contained logos for Entities J and K. The agency failed to separate and identify the personnel file for Adaptive Nursing and Healthcare Services LLC., d/b/a Adaptive Nursing and Healthcare Services from other licensed Entities. 11. A review of personnel file D indicated a dated 9/30/19 signed Senior Program Manager job description for [Entity J] / Adaptive Nursing and Healthcare Services and a dated 3/15/18 Program Manager job description for [Entity J] / Adaptive Nursing and Healthcare Service. The agency failed to separate and identify the personnel file for Adaptive Nursing and Healthcare Services LLC., d/b/a Adaptive Nursing and Healthcare Services from other licensed Entities. 12. A review of personnel file E indicated a dated 9/13/2021 enrollment letter for Entity F, a signed Background Check Consent Form dated 8/27/2021 with Entities J, K, and Q’s logos listed at the top of the page. A signed Program Manager job description dated 09/13/2021 for [Entity J] / Adaptive Nursing and Healthcare Service and a case E Verify document dated 9/4/2021 with company name of [Entity F]. The agency failed to separate and identify the personnel file for Adaptive Nursing and Healthcare Services LLC., d/b/a Adaptive Nursing and Healthcare Services from other licensed Entities. 13. A review of personnel file F indicated a dated 11/3/2021 signed Background Check Consent Form with Entities J, K, and Q’s logos listed at the top of the page and an E Verify document dated 11/11/2021 with company name of [Entity F]. The agency failed to separate and identify the personnel file for Adaptive Nursing and Healthcare Services LLC., d/b/a Adaptive Nursing and Healthcare Services from other licensed Entities. 14. A review of personnel file G indicated a dated 8/30/2021 signed Case Manager job description for Adaptive Nursing and Healthcare Services along with Entity F's logo listed at the top of the page. A signed Acknowledgement of the Insurance Offer dated 8/30/2021 for Entity F. The agency failed to separate and identify the personnel file for Adaptive Nursing and Healthcare Services LLC., d/b/a Adaptive Nursing and Healthcare Services from other licensed Entities. 15. A review of personnel file H indicated a dated 3/15/2021 Program Manager job description for [Entity J] / Adaptive Nursing and Healthcare Service. A signed Background Check Consent Form dated 3/4/2021 with Entities J, K, and Q’s logos listed at the top of the page. A signed Hepatitis B Vaccination form dated 3/15/2021 with Entities J, K, and Q's logos listed at the top of the page. The agency failed to separate and identify the personnel file for Adaptive Nursing and Healthcare Services LLC., d/b/a Adaptive Nursing and Healthcare Services from other licensed Entities. 15. During the entrance conference interview on 12/8/2021 at 9:41 a.m. the Administrator indicated Adaptive Nursing and Healthcare Services LLC., has one personnel file for two separate licenses located within the building and that there was no clear delineation between the two licenses. 16. During an interview on 12/9/2021 at 3:35 p.m. the Administrator indicated the Governing Body got together to discuss the policies between the two merged agencies. The Administrator was unable to provide a written document stating Adaptive adopted another Entity's policies and procedures. On 12/13/2021, the Administrator confirmed the personnel files contained other licensed Entity information. The Administrator indicated the August 23, 2021 offer letter for TCM for Entity F was considered the same as the Administrator. 17-12-1(b)

Administrator must: CFR(s): 484.105(b)(1) Standard: Administrator. The administrator must: This STANDARD is not met as evidenced by: Based on record review and interview the administrator failed to demonstrate distinct boundaries of the Medicaid-certified program in relation to any other programs the larger organization has to offer in 1 of 1 home health agencies. Findings include: 1. A revised 10/2014 CMS State Operation Manual, indicated but was not limited to, "Operation of the HHA (Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) 2183.1 ... other programs should be separate and distinct from the HHA. Ensure that the HHA has: Separate policies and procedures for admission to the HHA, including separate consent forms; ... Personnel Records ... Time sheets or other records to demonstrate distinct assignment of personnel to the HHA; and separate budgets." 2. A review of personnel file B indicated an August 23, 2021 offer letter and Job Description for Entity F signed by the Administrator and Person L, Administrator for Entity F. The letter logo indicated Entity F and Entity R. A job description for a Territory Clinical Manager signed and dated 2/12/2021 with Entity F and Entity R logos on the top of the page and an address for Chicago listed at the bottom. The signed Background Check Consent Form dated 7/27/2021 and 3/22/2017 indicated Entity J, K, and Q’s logos at the top of the page. A dated 4/3/2017 signed Tuberculosis Screening Consent form for Adaptive Nursing and Healthcare Services and Entity J. A signed Health Assessment/Work Release dated 8/24/2021 for Entity F. A signed 4/3/2017 Authorization for a Confidential Reference for both Adaptive Nursing and Healthcare Services and Entity J. The agency failed to separate and identify the personnel file for Adaptive Nursing and Healthcare Services LLC., d/b/a Adaptive Nursing and Healthcare Services from other licensed Entities. 3. A review of personnel file C indicated a 4/6/2021 signed Registered Nurse Case Manager job description for Entity F. A signed Hepatitis B Vaccination dated 5/4/20 and a signed Health Assessment/Work Release for contained logos for Entities J and K. The agency failed to separate and identify the personnel file for Adaptive Nursing and Healthcare Services LLC., d/b/a Adaptive Nursing and Healthcare Services from other licensed Entities. 4. A review of personnel file D indicated a dated 9/30/19 signed Senior Program Manager job description for [Entity J] / Adaptive Nursing and Healthcare Services and a dated 3/15/18 Program Manager job description for [Entity J] / Adaptive Nursing and Healthcare Service. The agency failed to separate and identify the personnel file for Adaptive Nursing and Healthcare Services LLC., d/b/a Adaptive Nursing and Healthcare Services from other licensed Entities. 5. A review of personnel file E indicated a dated 9/13/2021 enrollment letter for Entity F, a signed Background Check Consent Form dated 8/27/2021 with Entities J, K, and Q’s logos listed at the top of the page. A signed Program Manager job description dated 09/13/2021 for [Entity J] / Adaptive Nursing and Healthcare Service and a case E Verify document dated 9/4/2021 with company name of [Entity F]. The agency failed to separate and identify the personnel file for Adaptive Nursing and Healthcare Services LLC., d/b/a Adaptive Nursing and Healthcare Services from other licensed Entities. 6. A review of personnel file F indicated a dated 11/3/2021 signed Background Check Consent Form with Entities J, K, and Q’s logos listed at the top of the page and an E Verify document dated 11/11/2021 with company name of [Entity F]. The agency failed to separate and identify the personnel file for Adaptive Nursing and Healthcare Services LLC., d/b/a Adaptive Nursing and Healthcare Services from other licensed Entities. 7. A review of personnel file G indicated a dated 8/30/2021 signed Case Manager job description for Adaptive Nursing and Healthcare Services along with Entity F's logo listed at the top of the page. A signed Acknowledgement of the Insurance Offer dated 8/30/2021 for Entity F. The agency failed to separate and identify the personnel file for Adaptive Nursing and Healthcare Services LLC., d/b/a Adaptive Nursing and Healthcare Services from other licensed Entities. 8. A review of personnel file H indicated a dated 3/15/2021 Program Manager job description for [Entity J] / Adaptive Nursing and Healthcare Service. A signed Background Check Consent Form dated 3/4/2021 with Entities J, K, and Q’s logos listed at the top of the page. A signed Hepatitis B Vaccination form dated 3/15/2021 with Entities J, K, and Q's logos listed at the top of the page. The agency failed to separate and identify the personnel file for Adaptive Nursing and Healthcare Services LLC., d/b/a Adaptive Nursing and Healthcare Services from other licensed Entities. 9. During the entrance conference interview on 12/8/2021 at 9:41 a.m. the Administrator indicated Adaptive Nursing and Healthcare Services LLC., has one personnel file for two separate licenses located within the building and that there was no clear delineation between the two licenses. 10. During an interview on 12/9/2021 at 3:35 p.m. the Administrator indicated the Governing Body got together to discuss the policies between the two merged agencies. The Administrator was unable to provide a written document stating Adaptive adopted another Entity's policies and procedures. On 12/13/2021, the Administrator confirmed the personnel files contained other licensed Entity information. The Administrator indicated the August 23, 2021 offer letter for TCM for Entity F was considered the same as the Administrator.

Administrator appointed by governing body CFR(s): 484.105(b)(1)(i) (i) Be appointed by and report to the governing body; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the administrator reported directly to the Governing Body without the use of intermediaries for 1 of 1 home health agency. Findings include: A revised August 2021 policy titled Governing Body was provided by the Administrator on 12/9/2021 at 11:01 a.m. The policy indicated, but was not limited to, "It is the policy of [name of Entity F] and its affiliates that the Governing Body ensures lines of authority are established and to ensure appropriate quality services are provided to patients. ... a. That an ongoing program for Quality Assessment/Performance Improvement and client safety is defined, implemented and maintained." During an interview on 12/8/2021 at 12:35 p.m. the undated Organizational Chart for the "Evansville Parent License” was reviewed along with the Administrator. The Administrator indicated he/she reported to a Person B, a Clinical Director, Person C, a Quality Assurance Supervisor, and Person D, an Area Manager. The Administrator indicated they were all corporate people and not directly employed at the agency. The Administrator indicated corporate Person M at a different location oversees the QAPI, and Person C reviews patient charts and advises on what corrections need to be made. Persons B and D of the Jeffersonville office provide guidance and advise on clinical issues at the agency. 17-12-1(b)(1)

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on record review and interview, the administrator failed to ensure the agency met all rules and regulations for recertification and failed to ensure the responsibility for all day-to-day operations of the parent agency for 1 of 1 home health agency. Findings include: The Administrator failed to ensure Adaptive Nursing and Healthcare Services LLC., - Evansville administrative and supervisory responsibilities were not delegated to other Entities on an ongoing basis and failed to clearly set forth in writing administrative control and lines of authority for the delegation of responsibility down to the patient care level. (See G940) The Administrator failed to ensure its responsibility for the agency's management by having failed to adopt policies in the legal name of the agency, Adaptive Nursing and Health Care Services, LLC., d/b/a Adaptive Nursing and Healthcare Services; and failed to maintain separate personnel files specific to Adaptive Nursing and Health Care Services. (See G942) The Administrator failed to report directly to the Governing Body without the use of intermediaries. (See G946) The Administrator failed to disclose a merge of a branch location for the parent Evansville agency to the state agency (Indiana Department of Health) and failed to ensure the Centers for Medicare and Medicaid Services (CMS) was notified and approved the merge prior to moving all patients to the parent location. (See G972) 17-12-1(b)(3) 17-12-1(c)(1)

Report all branch locations to SA CFR(s): 484.105(d)(1) The parent HHA is responsible for reporting all branch locations of the HHA to the state survey agency at the time of the HHA's request for initial certification, at each survey, and at the time the parent proposes to add or delete a branch. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to disclose a merge of a branch location for 1 of 1 home health location, to the state agency (Indiana Department of Health) and failed to ensure if the Centers for Medicare and Medicaid Services (CMS) was notified and approved the merge prior to moving all patients to the parent location. Findings include: A revised 4/8/19 signed Administrator Job Description was provided by the Administrator on 12/9/2021 at 11:01 a.m. The policy indicated, but was not limited to, "Knowledge of the regulatory requirements at the state, federal, and local levels." During entrance conference on 12/8/2021 at 9:41 a.m. the Administrator indicated the Newburgh branch closed earlier this year and was not sure if the state agency was notified. The Administrator indicated all patients from the Newburgh branch were transferred to the Evansville parent location. A review of the Governing Body meeting minutes dated 2/12/2021 indicated "Discussed plan to merge Newburgh branch back in to parent". The agency failed to notify the state agency and CMS of the branch merge and closure of the Newburgh location under the agency license.