Every finding on record at Advantage Home Health Care Inc

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102. Survey Dates: May 13, 14, 15 and 16, 2025 Active Census: 317 At this Emergency Preparedness survey, [Name of Provider] was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 484.102.

This visit was for a Federal Recertification and State Re-Licensure survey of a Home Health Provider. Survey Dates: May 13, 14, 15 and 16, 2025 12 Month Unduplicated Skilled Admissions: 9 Survey was announced as partially extended on 5/13/25 at 1:21 PM This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Refer to State Form for additional State Findings. Abbreviations CM-Clinical Manager, EP-Emergency Preparedness, HHA-Home Health Aide, LPN-Licensed Practical Nurse, RN-Registered Nurse, OASIS-Outcome and Assessment Information Set, POC-Plan of Care, SN-Skilled Nurse, SOC-Start of Care QR 5/27/25 A2

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure OASIS transmissions were submitted on time for 1 of 1 agency. Findings include: 1. The “OASIS Error Summary by Agency Report” evidenced a 0.46% late submission rate for the period of 1/01/24 to 12/31/24. 2. The “OASIS Error Detail Report” evidenced 1 late submission for the period 1/01/24 to 12/31/24 as follows: On 2/22/24 an OASIS assessment of Patient #16 was completed. This assessment was transmitted on 4/04/24, 42 days later. During an interview on 5/13/25 at 1:58 PM, the Administrator relayed she is responsible for submitting the OASIS and she verified the above late submission error for Patient #16.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to conduct an initial assessment to determine the patient's immediate care and support needs within 48 hours of completed referral for 1 of 1 record reviewed with skilled services SOC in the past six months (Patient #6). Findings include: 1. The agency “Initial Assessment (Admission Assessment) Visit Policy”, last revised 9/17/24, indicated if home care services are not to begin within 48 hours of the time the verbal order is received from the provider to start care, the provider must be notified. 2. Patient #6’s clinical record evidenced an intake was received on 10/24/24, insurance approval was received on 11/19/24 and an initial assessment/SOC visit was conducted on 11/22/24. The record failed to evidence the reason for delay in conducting an initial assessment. 3. During an interview on 5/14/25 at 1:27 PM, RN 4 recalled the reason for delay of the initial assessment and she confirmed the clinical record failed to include documentation of the delay. 410 IAC 17-14-1(a)(1)(A)

5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the start of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the RN failed to conduct a comprehensive assessment within 5 days of SOC for 1 of 1 active record reviewed with SOC in the last 30 days (Patient #5). Findings include: 1. The agency “OASIS/Comprehensive Assessment Data Collections and Submission Policy”, last updated 2/01/23, indicated the Start of care assessment must be completed within 5 calendar days after the start of care. 2. Patient #5’s clinical record evidenced an initial assessment was completed on 4/25/25. The clinical record failed to evidence a comprehensive assessment was completed. 3. During an interview on 5/15/25 at 3:20 PM, RN 7 confirmed she did not perform another assessment after the 4/25/25 initial assessment with Patient #5 after SOC.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the POC goals included patient-specific interventions for 6 of 6 patient records reviewed (Patient #1, 2, 3, 4, 5 and 6). 1.A review of Patient #1’s clinical record evidenced a POC for Patient #1, certification period 5/7/2025 – 7/5/2025. The POC evidenced numerous goals, which included but were not limited to, the patient will remain clean and odor free and dressed appropriately, will be free of signs or symptoms of infection, will be free of signs/ symptoms of skin breakdown, and patient will have no signs or symptoms of adverse reaction to prescribed high- risk medications. The POC lacked interventions to address these goals. During an interview on 5/15/2025 at 11:16 AM, RN 6 failed to identify interventions in the POC for these goals. 2.A review of Patient #2’s clinical record evidenced a POC for Patient #2, certification period 3/21/2025 – 5/19/2025. The POC evidenced numerous goals, which included but were not limited to, patient will remain clean and odor free and dressed appropriately, will be free of signs or symptoms of infection, will be free of signs/ symptoms of skin breakdown, and patient will have a caregiver who can identify his/ her needs and voice when her needs are met when patient cannot. The POC failed to include interventions to address these goals. During an interview on 5/14/2025 at 10:45 AM, RN 5 indicated the interventions were not clearly stated in the POC. 3.A review of Patient #7’s clinical record evidenced a POC certification period 3/21/2025 – 5/19/2025. The POC evidenced numerous goals, which included but were not limited to, patient will have no signs or symptoms of respiratory distress, will have no signs or symptoms of impaired skin integrity, and will have no side effects/ adverse reactions to physician ordered high risk medications and verbalize when to report signs or symptoms. The POC failed to include interventions to address these goals. During an interview on 5/16/2025 at 3:59 PM, RN 9 indicated the interventions were on the aide care plan. RN 9 indicated the aide care plan was not signed by the physician. 410 IAC 17 - 13 - 1(a)1 Findings include: 1. The agency “Care Plan Development and Implementation Policy”, last revised 7/23/24, indicated each nursing diagnosis will have goals (anticipated patient outcome) that are measurable (as evidenced by) and have planned interventions to meet those goals. 4. Patient #3's clinical record included a POC for the certification period 4/18/25 to 6/16/25. The POC failed to include interventions for Patient #3’s goals. During an interview on 5/14/25 at 10:17 AM, the Alternate Clinical Manager verified the POC for Patient #3 did not include any interventions. 5. Patient #5's clinical record included a POC for the certification period 4/28/25 to 6/26/25. The POC failed to include interventions for Patient #5’s goals. During an interview on 5/15/25 at 3:20 PM, RN 7 verified the POC for Patient #5 did not include any interventions. 6. Patient #6's clinical record included a POC for the certification period 3/22/25 to 5/20/25. The POC failed to include interventions for Patient #6’s goals. During an interview on 5/14/25 at 1:27 PM, RN 4 verified the POC for Patient #6 did not include any patient-specific interventions. 410 IAC 17-13-1(a)(1)(xiii)

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure services were provided only as ordered by a physician or allowed practitioner for 1 of 1 active patient record reviewed with SOC in the last 30 days (Patient #5). Findings include: 1. Patient #5’s clinical record included a POC for certification period 4/28/25 to 6/26/25 with orders for HHA visit frequencies of one to three hours a day, one to three days a week for 60 days. The record evidenced HHA visits were performed on 4/28/25 and 4/30/25. The POC was signed by Physician B on 4/30/25. The clinical record for Patient #5 failed to include a verbal or signed written order for the HHA frequencies was obtained prior to the above visits performed. 2. During an interview on 5/15/25 at 3:20 PM, RN 7 relayed she did not collaborate with the physician at SOC and she faxed the POC for signature. 410 IAC 17-13-1(a)

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to document a valid verbal order for 2 of 3 patients with a start of care in the past 6 months (Patients #6, and 7). Findings include: 1. A review of the agency verbal order policy, dated 9/17/1014, indicated the verbal order “… will include the date and time, the name of the provider giving the verbal order, and the name of the provider’s staff member relaying the verbal order.” 2. A review of the clinical record for Patient #7 evidenced a “Start of Care Summary” which included a section titled “Admission Assessment/ Verbal Order to start care.” The form has a date of 2/26/25 and time of 9:05 AM. The form included Physician A’s name and RN 9’s signature. A document titled “60 Day Review” included a section that stated, “Verbal orders to continue care as ordered on 485 [POC] from [Physician A] on 4/25/2025.” RN 9 documented the time as 2:15 PM and included RN 9’s signature. During an interview on 5/16/2025 at 9:50 AM, the Administrator indicated the verbal orders were not documented correctly and were insufficient to support a verbal order. 410 IAC 17 – 14 – 1(a)(H) 2. Patient #6’s clinical record evidenced a “Start of Care Summary” which included a section titled “Admission Assessment/Verbal Order to start care” was received on 11/22/24 at 9:05 AM. The clinical record failed to evidence this verbal order was sent to the physician for signature. During an interview on 5/14/25 at 1:27 PM, RN 4 relayed the Start of Care Summary was not faxed to the physician for signature. During an interview on 5/15/25 at 10:55 AM, the Administrator relayed the Start of Care Summary form is an in-house form and it is not sent to the physician for signature.

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on record review and interview, the SN failed to perform a pain assessment for 2 of 3 SN only patient records reviewed (Patient #3 and 6). Findings include: 1. The agency policy “Skilled Nursing Documentation”, last revised 12/01/18, indicated a head to toe assessment of the client is to be performed each shift. 2. Patient #3’s clinical record evidenced a SOC on 2/20/13 and included an RN Supervisory visit/60-day review completed on 4/16/25 by RN 1. The supervisory visit form failed to evidence RN 1 assessed Patient #3’s pain during the assessment. During an interview on 5/16/25 at 2:53 PM, RN 1 relayed pain should be assessed on every visit and she confirmed the supervisory visit failed to include documentation of a pain assessment for Patient #3. 3. Patient #6’s clinical record evidenced a SOC on 11/22/24 and POC for the certification period of 3/22/25 to 5/20/25. The record included SN visits completed by LPN 3 on 3/27/25, 4/01/25, 4/02/25, 4/03/25, 4/04/25, 4/08/25, 4/09/25, 4/10/25, 4/11/25, 4/12/25, 4/16/25, 4/17/25, 4/18/25, 4/19/25, 4/22/25, 4/23/25, 4/24/25, 4/25/25, 4/29/25, 4/30/25, 5/01/25, 5/02/25, 5/06/25, 5/07/25, 5/08/25 and 5/09/25 with Not Applicable (N/A) marked in the pain assessment section of the SN visit note. The LPN visit notes failed to evidence LPN 3 assessed Patient #6’s pain during the above SN visits. A RN Supervisory visit/60-day review was completed on 4/20/25 by RN 4. The supervisory visit form failed to evidence RN 4 assessed Patient #6’s pain during the assessment. During an interview on 5/15/25 at 10:28 AM, LPN 3 relayed Patient #6 was nonverbal and she does not document on pain for Patient #6. During an interview on 5/16/25 at 8:53 AM, RN 4 relayed pain should be assessed during the SOC visit and if pain is a problem or they are taking pain meds, they assess for effectiveness. She confirmed she does not document a pain assessment for Patient #6 4. During an interview on 5/ 15/25 at 10:55 AM, the Administrator relayed pain should be assessed on every SOC and recertification visit. 410 IAC 17-14-1(a)(1)(B)

Contact information for the patient CFR(s): 484.110(a)(4) Contact information for the patient, the patient's representative (if any), and the patient's primary caregiver(s); This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the agency failed to identify a patient’s correct address for 1 of 3 home visits (Patient #2). Findings include: On 5/13/2025 at 3 PM, the Administrator provided Patient #2’s POC document, which included the address of Patient, for a home visit scheduled for 5/14/2025 at 8:30 AM. On 5/14/2025 the surveyor arrived at the address listed on the POC. at 8:15 AM. At 8:38 AM, the surveyor called the agency branch to enquire about the nurse’s estimated time of arrival. When the surveyor gave the address, administrative employee 8 indicated this was the patient’s old address and provided the correct address. During Patient #2’s chart review on 5/14/2025 beginning at 10:30 AM, RN 5 provided a copy of Patient #2’s Emergency Preparedness Plan. The plan indicated the old address of Patient #2. During an interview on 5/14/2025 at 10:40 AM, RN 5 indicated the patient moved a few weeks ago and the agency should have updated the address on the emergency plan. 410 IAC 17 - 15 -1(a)(1)

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to submit the discharge summary to the physician within 5 days of discharge for 2 of 2 discharge records reviewed (Patient #8 and 9). A review of the discharge record for Patient #9, evidenced a discharge summary for 2/17/2025. The discharge summary indicated the discharge was “Pt [patient] unwilling to abide by guidelines set forth by agency.” During an interview on 5/13/2025 at 12:49 PM, the Administrator indicated they did not send the discharge summary to the physician. The Administrator indicated the physician knew of the issues with Patient #9 and was aware of the discharge. Findings include: 1. Patient #8’s clinical record evidenced a discharge date on 2/25/25 and included a discharge summary completed on 2/25/25. The clinical record failed to evidence the discharge summary was sent to the physician within 5 days of discharge. 2. During an interview on 5/13/25 at 12:49 PM, the Administrator relayed the home health agency did not fax the discharge summary to the physician when Patient #8 was discharged.

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 home health agency failed to ensure all entries in the clinical record were appropriately authenticated, dated and timed for 2 of 3 active patient records reviewed with SOC in the past six months (Patient #5 and 6). Findings include: 1. Patient #5's clinical record evidenced initial assessment documentation and signed consents dated 4/25/25 and included an OASIS comprehensive assessment dated 4/28/25 completed by RN 7. The comprehensive assessment visit note failed to evidence the patient signature confirming the visit. During an interview on 5/15/25 at 3:41 PM, RN 7 stated she completed the initial assessment on 4/25/25 and did not return to Patient #7’s home on 4/28/25. She relayed she completed the OASIS comprehensive assessment on 4/28/25 based on the information she received during the 4/25/25 visit. 2. Patient #6's clinical record included an original POC with a SOC date of 11/20/24 for the certification period 11/20/24 to 1/18/25 signed by the physician on 11/13/24. The POC was revised to reflect the actual SOC date of 11/22/24 and the certification period of 11/22/24 to 1/20/25. The clinical record failed to evidence documentation of the reason the SOC date was changed and the POC was revised. During an interview on 5/14/25 at 2:30 PM, RN 4 relayed the SOC date was adjusted to accommodate the payor source approval date and confirmed the clinical record for Patient #6 did not include any documentation of this. During an interview on 5/15/25 at 11:55 AM, Admin 5 reviewed the original paperwork that was submitted for insurance prior authorization. She relayed the prior authorization had to be redone to reflect the correct SOC date of 11/22/24.