Every finding on record at Am Home Health Care, Inc

This visit was for a Federal and State complaint survey of a Home Health Provider. Survey Dates: August 13, 14, 2025 Complaint 2575979 was investigated, with related deficiencies cited. 12 Month Unduplicated Skilled Admissions: 9 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 HHA: Home Health Aide QR 8/18/25 A2

HHA maintains documentation of training CFR(s): 484.80(b)(4) The HHA must maintain documentation that demonstrates that the requirements of this standard have been met. This ELEMENT is not met as evidenced by: Based on personnel file review, policy review, and interview, the home health agency failed to maintain documentation which evidenced HHAs received 75 hours of training prior to providing care for 4 of 4 personnel files reviewed of HHAs hired on or after 5/09/2025 (HHA 1, 2, 3, 4). Findings include: 1. The agency policy “Home Health Aide Service,” dated 2016, indicated HHAs must successfully complete “a basic aide training program totaling at least 75 hours … The Home Health Aide must possess and provide the HHA written evidence of such completion of the training.” 2. A contract between AM Home Health Care and Entity A, a company providing an HHA training program, dated 7/31/2024, indicated Entity A would provide a total of 75 hours of classroom and supervised practical training to all newly hired HHAs. The contract indicated the HHAs “will have received the necessary classroom and clinical instruction from [Entity A] before being authorized to perform patient care.” 3. During the survey Entrance Conference on 8/13/2025 beginning at 9:45 AM, Administrator reported all new HHAs completed a training and competency program through Entity A. 4. HHA 1’s personnel file evidenced a first patient care date of 6/12/2025. The file failed to evidence the aide had completed 75 hours of an aide training program. 5. HHA 2’s personnel file evidenced a first patient care date of 7/06/2025. The file failed to evidence the aide had completed 75 hours of an aide training program. 6. HHA 3’s personnel file evidenced a first patient care date of 5/17/2025. The file failed to evidence the aide had completed 75 hours of an aide training program. 7. HHA 4’s personnel file evidenced a first patient care date of 6/19/2025. The file failed to evidence the aide had completed 75 hours of an aide training program. 8. During an interview on 8/13/2025 beginning at 3:35 PM, Administrator and CM reported they were unsure how Entity A documented new HHAs completed 75 hours of training. The administrative staff stated the personnel files for HHA 1, HHA 2, HHA 3, and HHA 4 did not evidence the number of hours completed for aide training. 9. During an interview on 8/13/2025 beginning at 1:52 PM, Person B, an employee of Entity A, reported all HHAs were to sign an attestation form indicating they completed 75 hours of aide training. Person B reported Entity A provided all training documentation, including the attestation form, to AM Home Health Care. During a follow-up interview on 8/14/2025 beginning at 10:43 AM, Person B reported he/she was unable to find the signed training attestation form for HHA 1 and HHA 2.

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 personnel file review, policy review, and interview, the administrator failed to ensure all training for newly hired employees was provided in a format employees could understand for 3 of 4 personnel files reviewed of HHAs hired on or after 5/09/2025 (HHA 1, 2, 3). Findings include: 1. An agency job description for the title of administrator, dated 2016, indicated Administrator’s responsibilities included but were not limited to “Plan, organize, direct and evaluate operations to ensure the provision of adequate and appropriate care and services … Recruit, employ and retrain qualified personnel … Ensure staff development including orientation ….” 2. A contract between AM Home Health Care and Entity A, a company providing an HHA training program, dated 7/31/2024, indicated Entity A would provide a training and competency evaluation to all newly hired HHAs. 3. During the survey Entrance Conference on 8/13/2025 beginning at 9:45 AM, Administrator reported all new HHAs completed a training and competency program through Entity A. Administrator was unsure how Entity A administered the program to staff who were non-English speaking. 4. HHA 1’s personnel file evidenced a first patient care date of 6/12/2025. Entity A completed the aide’s training and competency evaluation. During an interview on 8/13/2025 beginning at 2:46 PM, HHA 1 requested a Burmese to English translator to conduct the interview. The aide reported she could not “fully understand” spoken English and a translator was not provided during the HHA training and competency program. 5. HHA 2’s personnel file evidenced a first patient care date of 7/06/2025. Entity A completed the aide’s training and competency evaluation. During an interview on 8/13/2025 beginning at 3:15 PM, HHA 2 requested a Burmese to English translator to conduct the interview. The aide reported a translator was not provided during the HHA training and competency program. 6. HHA 3’s personnel file evidenced a first patient care date of 5/17/2025. Entity A completed the aide’s training and competency evaluation. During an interview on 8/14/2025 beginning at 9:52 AM, HHA 3 requested a Burmese to English translator to conduct the interview. HHA 3 reported he had some difficulty understanding spoken English. The aide reported a translator was not provided during the HHA training and competency program. 7. During an interview on 8/13/2025 beginning at 1:52 PM, Person B, an employee of Entity A, reported the entity required all HHAs to understand English to complete the HHA training and competency program. Person B reported Entity A did not provide a translator to non-English speaking aides. 410 IAC 17-12-1(c)(3)

This visit was for a Federal/State complaint survey of a Home Health Provider. Survey Dates: September 26-27, 2024 Complaint: IN109769 with related and unrelated deficiencies cited. 12 Month Unduplicated Skilled Admissions: 100 QR 10/8/24 A2

Classroom and supervised practical training CFR(s): 484.80(b)(1) Home health aide training must include classroom and supervised practical training in a practicum laboratory or other setting in which the trainee demonstrates knowledge while providing services to an individual under the direct supervision of a registered nurse, or a licensed practical nurse who is under the supervision of a registered nurse. Classroom and supervised practical training must total at least 75 hours. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure home health aides (HHA) received the required 75-hour training for 3 of 4 new hired HHA’s since last survey (HHA 21, HHA 23 and HHA 24). Findings include: 1. HHA 21’s personnel file evidenced a hire date of 9/13/24. The personnel file failed to include documentation of the required 75-hour HHA certification course. During an interview on 9/27/24, HHA 21 relayed he attended the hha training class Monday through Friday from 9:00 AM to 5:00 PM and had an hour for lunch. 2. HHA 23’s personnel file evidenced a hire date of 9/24/24. The personnel file failed to include documentation of the required 75-hour HHA certification course. During an interview on 9/27/24, HHA 23 relayed the HHA training course started in the morning and went into the afternoon for about a week. 3. HHA 24’s personnel file evidenced a hire date of 9/24/24. The personnel file failed to include documentation of the required 75-hour HHA certification course. During an interview on 9/27/24, HHA 24 relayed the HHA training was one week for 40 hours. 4. During an interview on 9/27/24, Person 27, instructor for Entity 26, relayed the HHA training course is a week.

Minimum hours of training CFR(s): 484.80(b)(2) A minimum of 16 hours of classroom training must precede a minimum of l6 hours of supervised practical training as part of the 75 hours. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the home health aide training included a minimum of 16 hours of classroom training and 16 hours of practical training for 3 of 4 new hired HHA’s since last survey (HHA 21, HHA 23 and HHA 24). Findings include: 1. HHA 21’s personnel file evidenced a hire date of 9/13/24. The personnel file failed to include documentation of the required classroom and practical training for the HHA certification course. During an interview on 9/27/24, HHA 21 relayed he attended the hha training course class Monday through Friday from 9:00 AM to 5:00 PM, had an hour for lunch and he was shown how to care for the patient during the HHA training course. 2. HHA 23’s personnel file evidenced a hire date of 9/24/24. The personnel file failed to include documentation of the required classroom and practical training for the HHA certification course. During an interview on 9/27/24, HHA 23 relayed the HHA training course started in the morning and went into the afternoon for about a week and the instructor reviewed how to care for the patient, change the bed, clean nails and give a shower during the classroom training. 3. HHA 24’s personnel file evidenced a hire date of 9/24/24. The personnel file failed to include documentation of the required classroom and practical training for the HHA certification course. During an interview on 9/27/24, HHA 24 relayed the HHA training was one week for 40 hours and relayed the instructor showed class attendees how to do care. 4. During an interview on 9/27/24, Person 27, training instructor for Entity 26, relayed the HHA training course consisted of a mixture of power points, in class discussions, labs for skills check off, going over the lecture, watching dementia video and homework to study.

Eligible training/competency evaluation orgs. CFR(s): 484.80(f) A home health aide training program and competency evaluation program may be offered by any organization except by an HHA that, within the previous 2 years: (1) Was out of compliance with the requirements of paragraphs (b), (c), (d), or (e) of this section; or (2) Permitted an individual who does not meet the definition of a "qualified home health aide" as specified in paragraph (a) of this section to furnish home health aide services (with the exception of licensed health professionals and volunteers); or (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 (4) Was assessed a civil monetary penalty of $5,000 or more as an intermediate sanction; or (5) Was found to have compliance deficiencies that endangered the health and safety of the HHA's patients, and had temporary management appointed to oversee the management of the HHA; or (6) Had all or part of its Medicare payments suspended; or (7) Was found under any federal or state law to have: (i) Had its participation in the Medicare program terminated; or (ii) Been assessed a penalty of $5,000 or more for deficiencies in federal or state standards for HHAs; or (iii) Been subjected to a suspension of Medicare payments to which it otherwise would have been entitled; or (iv) Operated under temporary management that was appointed to oversee the operation of the HHA and to ensure the health and safety of the HHA's patients; or (v) Been closed, or had its patients transferred by the state; or (vi) Been excluded from participating in federal health care programs or debarred from participating in any government program. This STANDARD is not met as evidenced by: Based on record review and interview, the home health agency, which was precluded from providing HHA training, failed to ensure the HHA training contractor provided HHA training independently for 1 of 1 agency. Findings include: Findings include: 1. Review of an agency document signed 07/31/2024 and titled “Agreement of Affiliation” evidenced an agreement between the home health agency and Entity 26. The agreement was for Entity 26 to provide supervised classroom and clinical experience for teaching the home health aide course and skills validation. Entity 26 is responsible for providing all theory and practice instruction. 2. During an interview on 09/27/2024 at 11:36 AM, Person 27, an instructor with Entity 26, indicated agency registered nurse (RN) 1 assisted with the practice of skills in the simulated lab. When asked how individuals with limited English proficiency (an individual who does not speak English as their primary language and has a limited ability to read, speak, write, or understand English) understand training instructions being presented, Person 27 indicated agency office clerk, Corporate Person 5, helps with interpretation. When asked how the home health aide skills competency exams are presented to individuals with limited English proficiency, Person 27 indicated Corporate Person 5 will translate questions and multiple-choice answers in the Burmese language as needed. 3. During a tour of the agency home health aide training room, on 09/27/2024 at 12:00 PM, Corporate Person 5 indicated she made copies of the home health aide competency exam for Person 27. 4. HHA 24’s personnel file evidenced a hire date of 9/24/24 and included a certificate issued by AM Home Health Care for a home health aide training course completed on September 1th, 2024. During an interview on 9/27/24 via translator, as requested by HHA 24, HHA 24 relayed the home health agency translator was available to translate when she did not understand the training in English. 5. During an interview on 9/27/24, Person 27, instructor for Entity 26, relayed the HHA training course was held in the AM Home Health Care training classroom and employees of the home health agency assisted with the training and translation.

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102. Survey Dates: 7/1, 7/2, 7/3,7/5/. and 7/8/2024 Active Census: 78 At this Emergency Preparedness survey, AM Home Health Care 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: July 1, 2, 3, 5, 8, 2024 12-Month Unduplicated Skilled Admissions: 28 Survey was announced as fully extended on 7/02/24 at 4:08 PM. During this Federal Recertification Survey, AM Home Health Care was found to be out of compliance with Conditions of Participation §484.60 Condition of participation: Care planning, coordination of services, and quality of care. This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Refer to State Form for additional State Findings. Based on the Condition-level deficiencies during the 7/08/24 survey, your HHA was subject to a partial or extended survey pursuant to section 1891(c)(2)(D) of the Social Security Act on 7/02/24. Therefore, and pursuant to section 1891(a)(3)(D)(iii) of the Act, your agency is precluded from operating a home health aide training, skills competency and/or competency evaluation program for a period of two years beginning July 08, 2024 and continuing through July 07, 2026.

OASIS privacy notice CFR(s): 484.50(a)(1)(iii) (iii) An OASIS privacy notice to all patients for whom the OASIS data is collected. This ELEMENT is not met as evidenced by: 416 OASIS Privacy Based on record review and interview, the agency failed to provide patients with the OASIS privacy notice for 1 of 1 agency surveyed. Findings include: A review of the patient admission packet on 7/5/2024 failed to include an OASIS privacy notice. During an interview on 7/5/2024 at 12:45 PM, the Administrator indicated they used to put the OASIS privacy notice in the patient admission folder, but it was missing from the packet.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure an accurate review of all medications for 1 of 3 patients reviewed with home visit observations (Patient #3). Findings include: 1. A review of Patient #3’s clinical record evidenced a start of care (SOC) on 5/09/24 and included a POC and medication profile for the certification period 5/09/24 to 7/07/24. The POC medication profile evidenced the following medications: a) Ibuprofen Oral Suspension 100 milligrams/5 milliliters (mg/ml), 10 ml every 6 hours as needed. The medication profile failed to include an indication for use. b) Magnesium Citrate 1.475 gram (g)/30 ml oral liquid, 150 ml daily as needed. The medication profile failed to include an indication for use. c) Polyethylene Glycol 17 g daily as needed. The medication profile failed to include an indication for use. d) Pseudoeph-Bromphen-Cod 30-2-7.5 mg/ml, 10 ml three times a day as needed. The medication profile failed to include an indication for use. 2. During a home visit observation conducted with Patient #3 and RN 5 on 7/03/24 beginning at 10:51 AM, RN 5 failed to reconcile medications at the comprehensive assessment recertification observation visit. 3. During an interview on 7/03/24 beginning at 11:20 AM, RN 5 relayed they reconcile medication at every visit. 4. During an interview on 7/03/24 beginning at 1:51 PM, the Clinical Manager relayed medications should be reconciled at every visit. 5. During an interview on 7/03/24 beginning at 2:01 PM with the Alternate Clinical Manager and Administrator, the Administrator relayed the POC medication list had not been fully signed-off and has been in-process since SOC on 5/09/24. 410 IAC 17-14-1(a)(1)(B)

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on record review and interview, the home health agency failed to include accurate visit frequency orders on the plan of care (POC) (See G574); failed to ensure services were provided only as ordered by a physician or allowed practitioner (See G580); failed to ensure the POC was reviewed with the physician at start of care (SOC) and/or at recertification (See G588) and failed to notify the physician regarding changes and need to alter the POC (See G590). The cumulative effect of these systemic problems had the potential to impact all 78 active patients which resulted in the agency being found out of compliance with the Condition of Participation 42 CFR 484.60 Care Planning, Coordination of Services and Quality of Care.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the plan of care included accurate visit frequency orders for 1 of 2 active records reviewed with home health aide (HHA) and attendant care services ordered (Patient #2). Findings include: 1. Review of Patient #2’s clinical record included a plan of care (POC) for the certification period 6/07/24 to 8/05/24 which indicated the patient was to receive HHA visits 1 time a week for 1 week and then 5 times a week for 8 weeks. The record evidenced Patient #2 received 2 HHA visits for the week beginning 6/07/24 and received 7 HHA visits a week for the weeks of 6/09/24, 6/16/24, 6/23/24, and 6/30/24. The record failed to evidence physician orders for the above visit frequencies to exceed the POC orders of 1 visit for 1 week and then 5 visits for 8 weeks. 2. During an interview on 7/08/24 beginning at 10:37 AM, the Clinical Manager relayed the patient has a Medicaid prior authorization for HHA visits 7 days per week and the clinical record for Patient #2 did not include a physician order to reflect these frequencies. 410 IAC 17-13-1(a)(1)(C)(iii)

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 4 of 5 active patient records reviewed (Patient #1, 3, 4 and 6). Findings include: 1. The agency policy “Physician’s Plan of Treatment” indicated physician’s orders are established and documented for the health care services the agency provides to those patients who are admitted to service with the agency and also indicated the physician’s plan of care/treatment shall be reviewed by the attending physician not to exceed two (2) months (60 days) for the patient receiving skilled services. 2. The agency policy “Physician Responsibilities” indicated the plan of care for the patient will be developed in consultation with the physician and with the involvement of the patient and appropriate caregivers. 3. Review of Patient #1’s clinical record included a start of care (SOC) on 5/09/16 and a POC for certification period 5/27/24 to 7/25/24 with orders for home health aide (HHA) service frequencies of 6 visits a week for 1 week; 7 visits a week for 7 weeks; and 5 visits a week for 1 week. The record evidenced HHA visits were performed on 5/27/24, 5/28/24, 5/29/24, 5/30/24, 5/31/24, 6/01/24, 6/02/24 and 6/03/24. The clinical record for Patient #1 failed to include a verbal or signed written order for the POC frequencies obtained prior to the above visits performed. During an interview on 7/02/24 beginning at 11:18 AM, RN 3 indicated they did not collaborate with the attending physician for the recertification POC frequency orders for Patient #1 and relayed the recertification POC is faxed to the physician for signature after the Clinical Manager approved it. 4. Review of Patient #3’s clinical record evidenced a SOC on 5/09/24 and included a POC for the certification period 5/09/24 to 7/07/24 with orders for home health aide (HHA) service frequencies of 3 visits a week for 1 week and 6 visits a week for 8 weeks. The record evidenced HHA visits were performed on 5/09/24, 5/10/24, 5/11/24 and 5/12/24. The clinical record for Patient #3 failed to evidence a verbal or signed written order for the POC frequencies was obtained prior to the above visits performed. During an interview on 7/02/24 beginning at 1:51 PM, the Clinical Manager relayed they did not collaborate with the physician for the POC frequencies for Patient #3 and indicated they faxed the POC to the physician for signature. 5. Review of Patient #4’s clinical record evidenced a SOC on 4/23/24 and included a recertification POC for the certification period 6/22/24 to 8/20/24 with orders for home health aide (HHA) service frequencies of 6 visits a week for 8 weeks and 3 visits a week for 1 week. The record evidenced HHA visits were performed on 6/22/24, 6/23/24, and 6/25/24. The clinical record for Patient #4 failed to evidence a verbal or signed written order for the POC frequencies was obtained prior to the above visits performed. During an interview on 7/01/24 beginning at 4:02 PM, RN 1 relayed they only collaborate with the attending physician when there are changes and relayed they did not collaborate with the physician regarding the recertification POC frequencies for Patient #4. 6. Review of Patient #6’s clinical record evidenced a SOC on 6/18/24 and included a POC for the certification period 6/18/24 to 8/16/24 with orders for home health aide (HHA) service frequencies of 5 visits a week for 1 week; 7 visits a week for 7 weeks and 6 visits a week for 1 week. The record evidenced HHA visits were performed on 6/18/24, 6/19/24, 6/20/24, 6/21/24, 6/22/24, 6/23/24, 6/25/24, 6/26/24 and 6/27/24. The clinical record for Patient #6 failed to evidence a verbal or signed written order for the POC frequencies was obtained prior to the above visits performed. Surveyor attempted to contact RN 2 during survey on 7/02/24 at 11:18 AM with no response. A voicemail was left with a callback was requested. The Administrator informed Surveyor at 4:19 PM that RN 2 was on vacation and would be unavailable during the survey. During an interview on 7/02/24 beginning at 4:20 PM, the Administrator indicated the clinical record for Patient #6 failed to include documentation of collaboration with the physician for the POC. 7. During an interview on 7/01/24 beginning at 2:05 PM, the Administrator indicated the RN creating the POC does not collaborate with the physician unless there is a problem and the POC is faxed to the physician for signature. 410 IAC 17-13-1(a)(1)(C)(iii)

Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient's condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the plan of care (POC) was reviewed with the physician at start of care (SOC) and/or at recertification for 4 of 4 active patient records reviewed (Patient #1, 2, 3, and 4). Findings include: 1. The agency policy “Case Management and Assignments” indicated a written plan of treatment and orders will be obtained from the admitting physician and the case manager will obtain and implement physician orders. 2. The agency policy “Physician’s Plan of Treatment” indicated physician’s orders are established and documented for the health care services the agency provides to those patients who are admitted to service with the agency and also indicated the physician’s plan of care/treatment shall be reviewed by the attending physician not to exceed two (2) months (60 days) for the patient receiving skilled services. 3. The agency policy “Physician Responsibilities” indicated the plan of care for the patient will be developed in consultation with the physician and with the involvement of the patient and appropriate caregivers. 4. A Review of Patient #1’s clinical record evidenced a SOC on 5/09/16 and included a recertification POC for the certification period 5/27/24 to 7/25/24. The record failed to evidence documentation of collaboration with the physician for the recertification POC orders. During an interview on 7/02/24 beginning at 11:18 AM, RN 3 indicated they did not collaborate with the attending physician for the recertification POC orders for Patient #1 and relayed the recertification POC is faxed to the physician for signature after the Clinical Manager approves it. 5. Review of Patient #2’s clinical record evidenced a SOC on 7/19/16 and included a recertification POC for the certification period 6/07/24 to 8/05/24. The record failed to evidence documentation of collaboration with the physician for the recertification POC orders. During an interview on 7/02/24 beginning at 1:37 PM, RN 4 relayed they created the recertification POC for Patient #2 and did not collaborate with the attending physician regarding the recertification POC orders and the Clinical Manager faxed the POC to the physician for signature. 6. Review of Patient #3’s clinical record evidenced a SOC on 5/09/24 and included a POC for the certification period 5/09/24 to 7/07/24. The record failed to evidence documentation of collaboration with the physician for the SOC POC orders. During an interview on 7/02/24 beginning at 1:51 PM, the Clinical Manager relayed they did not collaborate with the physician for the POC for Patient #3 and indicated they faxed the POC to the physician for signature. 7. Review of Patient #4’s clinical record evidenced a SOC on 4/23/24 and included a recertification POC for the certification period 6/22/24 to 8/20/24. The record failed to evidence documentation of collaboration with the physician for the recertification POC orders. During an interview on 7/01/24 beginning at 4:02 PM, RN 1 relayed they only collaborate with the attending physician when there are changes and relayed they did not collaborate with the physician regarding the recertification POC for Patient #4. 8. During an interview on 7/01/24 beginning at 2:05 PM, the Administrator indicated the RN creating the POC does not collaborate with the physician unless there is a problem and the POC is faxed to the physician for signature. 410 IAC 17-13-1(a)(2)

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the physician or allowed practitioner was promptly notified of the need to alter the plan of care (POC) related to the start of care (SOC) date for 4 of 4 patient records reviewed with mock SOC and POC dates (Patient #3, 4, 5 and 6). Findings include: 1. The agency policy “Care Plan” indicated a regular review of the health needs/problems, plan and goals will be reviewed with the patient, family, physician and others involved in the care of the patient. 2. The agency policy “Case Management and Assignments” indicated a written plan of treatment and orders will be obtained from the admitting physician and the case manager will obtain and implement physician orders. 3. The agency policy “Physician’s Plan of Treatment” indicated physician’s orders are established and documented for the health care services the agency provides to those patients who are admitted to service with the agency and also indicated the physician’s plan of care/treatment shall be reviewed by the attending physician not to exceed two (2) months (60 days) for the patient receiving skilled services. 4. The agency policy “Physician Responsibilities” indicated the plan of care for the patient will be developed in consultation with the physician and with the involvement of the patient and appropriate caregivers. 5. Review of Patient #3’s clinical record evidenced a referral received on 4/12/24 with a SOC on 4/12/24 and a mock POC was created for the certification period 4/12/24 to 6/10/24. Patient #3’s actual SOC was on 5/09/24 and included a POC for the certification period 5/09/24 to 7/07/24. The record failed to include documentation of collaboration with the physician regarding the SOC date and POC certification period dates needing to be altered due to pending insurance authorization. During an interview on 7/02/24 beginning at 1:51 PM, the Clinical Manager relayed they did not collaborate with the physician for the actual POC frequencies on 5/09/24 for Patient #3 and indicated they faxed the new POC to the physician for signature. 6. Review of Patient #4’s clinical record evidenced a referral received on 2/16/24 with a SOC on 2/16/24 and a mock POC was created for the certification period 2/26/24 to 4/25/24. Patient #4’s actual SOC was 4/23/24 and included an initial POC for the certification period 4/23/24 to 6/21/24. The record failed to include documentation of collaboration with the physician regarding the SOC date and POC certification period dates needing to be altered due to pending insurance authorization. During an interview on 7/01/24 beginning at 4:02 PM, RN 1 relayed they only collaborate with the attending physician when there are changes and relayed they did not collaborate with the physician regarding the initial POC frequencies for Patient #4 during the 4/23/24 SOC visit. 7. Review of Patient #5’s clinical record evidenced a referral received on 4/12/24 and a mock POC was created for the certification period 4/29/24 to 6/27/24. Patient #4 was listed on the active census report provided to Surveyor on 7/01/24. The electronic medical record failed to include documentation of Patient #5 being an active patient and failed to include documentation of collaboration with the physician regarding the mock SOC date and POC certification period dates not being accurate due to still pending insurance authorization. During an interview on 7/01/24 beginning at 4:35 PM, the Administrator relayed Patient #5 is not an active patient and is still pending insurance authorization. 8. Review of Patient #6’s clinical record evidenced a referral received on 5/20/24 with SOC on 5/21/24 and a mock POC was created for the certification period 5/27/24 to 7/25/24. Patient #6’s actual SOC was 6/18/24 and included a POC for the certification period 6/18/24 to 8/16/24. The record failed to include documentation of collaboration with the physician regarding the SOC date and POC certification period dates needing to be altered due to pending insurance authorization. Surveyor attempted to contact RN 2 during survey on 7/02/24 at 11:18 AM with no response. A voicemail was left with a call back was requested. The Administrator informed Surveyor at 4:19 PM that RN 2 was on vacation and would be unavailable during survey. During an interview on 7/02/24 beginning at 4:20 PM, the Administrator indicated the clinical record for Patient #6 failed to include documentation of collaboration with the physician for the actual POC on 6/18/24. 9. During an interview on 7/02/24 beginning at 2:05 PM, the Administrator relayed the home health agency created a mock POC that was sent to the physician for signature. The relayed once insurance approval was received, the patient was admitted to home health. A new actual SOC visit and POC was created after insurance approval was received for the above patients. 10. During an interview on 7/03/24 beginning at 4:45 PM, the Administrator relayed the physician and/or attending practitioner is made aware of the mock POC via the fax cover sheet. Surveyor requested copies of these fax cover sheets and the Administrator relayed they were unable to locate any of the fax cover sheets for the above patients. 410 IAC 17-13-1(a)(2)

Improvements are sustained CFR(s): 484.65(c)(3) The HHA must take actions aimed at performance improvement, and, after implementing those actions, the HHA must measure its success and track performance to ensure that improvements are sustained. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to document improvement actions and evaluate the success of the actions on quality improvement activities for 1 of 1 agency surveyed. Findings include: The agency quality assessment and performance improvement (QAPI) committee minutes for 9/21/2023 indicated a performance improvement plan (PIP) to reduce hospitalizations and emergency room visits for non – emergent care. The minutes for the 12/21/2023 meeting included monthly data which included the number of hospitalizations and emergency room use. The minutes for the 6/27/20234 meeting indicated the PIP for hospitalizations continued. The minutes failed to document actions taken to reduce hospitalization /emergency room usage. During an interview on 7/3/2024 at 2:30 PM, the Administrator indicated they provided patients with a symptom list with what to do and a “Call me first” sign to encourage patients to call the agency before going to the emergency room. The Administrator could not identify when they started that campaign or the effect on the hospitalization/ emergency room rates. 410 IAC 17 – 12 – 2(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 ensure employees followed standards of practice for hand hygiene and bag technique to reduce the spread of infections for 3 of 3 home visit observations (Patients #1, 2, and 3). Findings include: 5. During a home visit observation conducted with Patient #3 and RN 5 on 7/03/24 beginning at 10:51 AM, RN 5 was observed wearing gloves while performing an assessment of Patient #3. RN 5 removed their gloves and failed to perform hand hygiene. During an interview on 7/03/24 beginning at 11:20 AM, RN 5 relayed hand hygiene should be performed before touching the patient and before the next patient. 6. During an interview on 7/03/24 beginning at 1:51 PM, the Clinical Manager indicated hand hygiene should be performed before an assessment, before and after gloves, before and after you touch the patient, before and after med refills and when you leave the patient home. 410 IAC 17–12–1(m) 1. The agency bag technique policy indicated the supply bag was to be placed on an impermeable barrier, required hand hygiene before the removal of supplies, and the bag should be kept closed after removing the supplies. 2. The Centers for Disease Control and Prevention (CDC) hand hygiene for healthcare workers, retrieved from https:// www.cdc.gov/ clean- hands/hcp/ clinical-safety /index.html, identified standard hand hygiene practice as the use of hand washing or use of alcohol – based hand rub before touching a patient or their surroundings, moving from a dirty site to a clean site, after removing gloves, and before switching tasks. 3. During a home visit observation on 7/1/2024 at 12:08 PM, registered nurse (RN) 3 completed an assessment on Patient #1. The assessment included tasks that required the nurse to touch the patient with gloved hands. The last part of the assessment involved the nurse touching the patient’s feet with gloved hands. Following the assessment, RN 3 filled Patient #1’s medication tray with medications, in which they removed the pills from a bottle and placed them into the pill tray. RN 3 failed to remove gloves and perform hand hygiene after touching the patient’s feet and before touching the medication. During an interview on 7/3/2024 at 2:34 PM, RN 3 indicated they did not remove gloves and perform hand hygiene before touching the patient’s medication. RN 3 indicated they should have performed hand hygiene before touching medication. 4. During a home visit observation on 7/1/2024 at 1:30 PM, RN 4 placed the nursing bag on the couch with no barrier underneath it. After completing all tasks, RN 4 retrieved a small trash bag from the nursing bag and gathered up the trash. During an interview immediately after the visit, RN 4 indicated they normally placed the empty trash bag on the couch, as a barrier for the nursing bag. When asked, RN 4 indicated they forgot to use the barrier today.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the registered nurse (RN) supervised the home health aide (HHA) every 14 days for 1 of 2 active clinical records reviewed of patients receiving skilled nurse (SN) and HHA services (Patient #2). Findings include: 1. Review of Patient #2’s clinical record included a plan of care (POC) for the certification period 6/07/24 to 8/05/24 and included orders for skilled nursing (SN) and home health aide (HHA) services. The record evidenced the registered nurse performed HHA supervisory visits on 6/03/24 and 6/19/24. The clinical record failed to evidence RN 4 performed HHA supervisory visits every 14 days. 2. During an interview on 7/02/24 beginning at 1:37 PM, RN 4 indicated HHA supervisory visits should be performed every 14 days and relayed the HHA supervisory visit for Patient #2 was not done on time. 3. During an interview on 7/02/24 beginning at 2:05 PM, the Administrator indicated HHA supervisory visits should be done every 14 days. 4. During an interview on 7/03/24 beginning at 1:51 PM, the Clinical Manager indicated HHA supervisory visits should be completed every 14 days. 410 IAC 17-14-1(n)

This visit was for a Federal home health Recertification and State Re-licensure survey Survey Dates: August 2, 3, 4, 5, and 6, 2021 Partially Extended on August 5, 2021 at 1:15 PM Facility number: 013209 Provider number: 15K124 Current Census: 134 Unduplicated Census last 12 months: 148 This deficiency reflects State and Federal findings cited in accordance with 410 IAC 17. Quality review completed 8/19/21 by Area 2

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 patients' plan of care included (but not limited to) all pertinent diagnoses, all medications and treatments, and measurable outcomes for 5 of 7 records reviewed (#1, 2, 3, 4, 5). Findings include: 1. Review of an agency policy dated 2016, titled "2.8 Care Plan" stated " ... steps to be taken in developing the care plan ... collection of baseline data including all pertinent diagnoses ... establishment ... provision of services which lists ... medication ... based upon the goals to be achieved, what actions must be taken to achieve them ... determination of the goals to be achieved ...." 2. Review of an agency job description dated 2016, titled "Title of Position: Registered Nurse" stated " ... responsibilities ... participates in the development and periodic revision of the physician's Plan of Treatment and processes change orders as needed ...." 3. Clinical record review was completed on 8/2/2021 for patient #1, start of care 4/30/2019, certification period 6/18/2021 - 8/16/2021, with a primary diagnosis of essential hypertension (high blood pressure). An agency document titled "Home Health Plan of Care & Certification" dated 6/14/2021 by RN D and dated 6/16/2021 by MD (physician) A. This agency document stated " ... goal ... patient's pain will be within acceptable levels for patient within cert [certification] period ...." The plan of care failed to evidence a measurable goal. During an interview on 8/3/2021 at 9:35 AM, assistant director of nursing, RN C indicated the acceptable level for pain for patient is found in the certification note and visit note (not on the plan of care). 4. Clinical record review was completed on 8/2/2021 for patient #2, start of care 10/18/2019, certification period 6/9/2021 - 8/7/2021, with a primary diagnosis of essential hypertension, and other diagnoses (but not limited to) asthma, gastro-esophageal reflux disease (heartburn), vitamin D deficiency, constipation, and mixed hyperlipidemia (high cholesterol). An agency document titled "Home Health Plan of Care & Certification" dated 6/4/2021 by RN D and dated 6/8/2021 by MD A. This agency document stated " ... medications ... Tradjenta oral tablet [diabetic medication] ... ER/Hospitalization Re-Admission Risk Factors and Interventions ... DM [diabetes] type 2 ... skilled nursing orders ... prn BS [blood sugar] checks for signs/symptoms of hypo/hyperglycemia [low or high blood sugar] ... goal ... patient will notify home health company immediately of blood sugar > [greater than] 350 or < [less than] 70 ...." The plan of care failed to evidence the pertinent diagnosis of diabetes. During an interview on 8/3/2021 at 1:00 PM, director of nursing, RN B indicated diabetes should be included as a pertinent diagnosis in the plan of care. 5. Clinical record review was completed on 8/4/2021 for patient #3, start of care 12/17/2018, certification period 4/5/2021 - 6/3/2021, with a primary diagnosis essential hypertension and other diagnoses (but not limited to) monoplegia of lower limb (paralysis of one leg), osteoporosis (bones become brittle), gastro-esophageal reflux disease, vitamin D deficiency and joint pain. An agency document titled "Home Health Plan of Care & Certification" dated 3/31/2021 by RN O and dated 4/6/2021 by MD A. This agency document stated " ... medications ... Tradjenta oral tablet [diabetic medication] Supplies ... glucometer [measures blood sugar] ... ER/Hospitalization Re-Admission Risk Factors and Interventions ... DM [diabetes] ... skilled nursing orders ... prn BS [blood sugar] checks for signs/symptoms of hypo/hyperglycemia [low or high blood sugar] ...." The document also stated " ... goal ... patient's pain will be within acceptable levels for patient within cert period ...." The plan of care failed to evidence the pertinent diagnosis of diabetes and failed to evidence a measurable goal. 6. Clinical record review was completed on 8/3/2021 for patient #4, start of care 9/18/2017, certification period 6/29/2021 - 8/27/2021, with a primary diagnosis anxiety disorder and other diagnoses (but not limited to) auditory hallucinations (hearing voices), major depressive disorder, essential hypertension, chronic kidney disease and osteoarthritis (joint pain). An agency document titled "Home Health Plan of Care & Certification" dated 7/26/2021 by RN P and dated 6/29/2021 by MD A. This agency document stated " ... medications ... Januvia oral tablet ... diabetic agent ... safety measures ... diabetic precautions ... ER/Hospitalization Re-Admission Risk Factors and Interventions ... DM [diabetes] ...." The document also stated " ... goal ... patient will have better coping behavior evidenced by verbalization and ability to maintain within cert [certification] period ...." The plan of care failed to evidence the pertinent diagnosis of diabetes and failed to evidence a measurable goal. 7. Clinical record review was completed on 8/4/2021 for patient #5, start of care 3/18/2014, certification period 6/9/2021 - 8/7/2021, with a primary diagnosis fracture of neck of right femur (hip fracture). A document titled "After Visit Summary" dated 6/20/2021 by Hospital B stated " ... your medications have changed ... start taking ... prednisone [decreases inflammation] 20 mg tablet ... take 2 tablets by mouth daily for 5 days ...." An agency document titled Patient Communication Log dated 6/21/2021 by director of nursing, RN B stated " ... paperwork from Hospital stated DX [diagnosis] was strain of right ankle ... new orders given for Prednisone ...." An agency document titled "Skilled Nursing Visit Note" dated 6/22/2021 by RN G stated " ... pain management intervention ... prednisone helps ...." The plan of care failed to evidence the new diagnosis of strain of right ankle and failed to evidence the medication prednisone. During an interview on 8/4/2021 at 3:00 PM, director of nursing, RN B indicated the medication should be in the medication profile and diagnosis should be documented in orders. 17-13-1 (a)(1)(C) 17-13-1 (a)(1)(D)(ix)

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation, record review and interview, the agency failed to ensure all staff followed standard precautions and infection control for 3 of 3 home visits observed (#1, 2, 4). Findings include: 1. Review of an undated agency policy titled "2.79 Bag Technique" stated " ... inside of nursing bag ... never enter without washing/sanitizing hands ...." 2. Review of an undated agency document titled "Bag Technique" stated " ... remove the supplies from bag and place them on a clean dry surface or a surface barrier as needed ... do not reenter the bag with gloves on ... remove the gloves if worn, perform hand hygiene, and then reenter the bag ...." 3. Review of an agency policy dated 2016, titled "2.80 Hand Washing Policy - In Patient's Homes" stated " ... alcohol-based hand sanitizer is preferred ... before and after caring for clients ... between tasks on the same client ... after removing gloves ... after touching objects that are potentially contaminated ...." 4. A home observation visit was conducted with RN D on 8/2/2021 at 12:15 PM, with patient #1. RN D was observed applying hand sanitizer and gloves, checked vital signs, hand grasps, and palpated (examined by touch) bilateral pedal (right and left top of foot) pulses, and refilled medication box. RN D failed to remove soiled gloves, perform hand hygiene (wash hands with soap and water or with hand sanitizer) and apply clean gloves prior to filling medication box. 5. A home observation visit was conducted with RN G on 8/3/2021 at 10:55 AM, with patient #4. RN G was observed wearing gloves when exiting car and entering home of patient #4. RN G removed papers from folder and filled medication box, then removed soiled gloves having worn since exiting car. Removed thermometer and blood pressure cuff from nursing bag and placed on coffee table. Applied clean gloves, checked blood pressure and oxygen level. RN D failed to remove soiled gloves upon entering home, perform hand hygiene and apply clean gloves prior to filling medication box. RN G failed to perform hand hygiene prior to entering nurse bag and failed to place equipment on a barrier. 6. A home observation visit was conducted with RN I on 8/3/2021 at 11:55 AM, with patient #2. RN I was observed wearing gloves when exiting car and entering home of patient #2. RN I removed scale from nursing bag and weighed patient, placed sanitizing wipe on scale, placed scale in plastic bag, and placed plastic bag into nursing bag. RN I removed soiled gloves, applied clean gloves, and completed physical assessment of patient #2. RN I failed to remove soiled gloves upon entering home, perform hand hygiene and apply clean gloves prior to removing scale from nursing bag. RN I failed to clean scale before placing in plastic bag and placing in nursing bag and failed to perform hand hygiene after removing soiled gloves and before applying clean gloves. 7. During an interview on 8/3/2021 at 1:00 PM, when asked if the agency would expect a glove change and hand hygiene after physical assessment of patient and before filling a medication box, administrator A indicated yes. 8. During an interview on 8/4/2021 at 3:00 pm, when asked if the agency would expect an employee to wear gloves from their cars into a patient home and perform physical assessment without removing soiled gloves, administrator A indicated no. When asked if the agency would expect an employee to remove soiled gloves, apply hand sanitizer and apply clean gloves after performing physical assessment and before refilling medication box, administrator A indicated yes. 17-12-1(m)

Competency evaluation CFR(s): 484.80(c)(1)(2)(3) Standard: Competency evaluation. An individual may furnish home health services on behalf of an HHA only after that individual has successfully completed a competency evaluation program as described in this section. (1) The competency evaluation must address each of the subjects listed in paragraph (b)(3) of this section. Subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section must be evaluated by observing an aide's performance of the task with a patient or pseudo-patient. The remaining subject areas may be evaluated through written examination, oral examination, or after observation of a home health aide with a patient, or with a pseudo-patient as part of a simulation. (2) A home health aide competency evaluation program may be offered by any organization, except as specified in paragraph (f) of this section. (3) The competency evaluation must be performed by a registered nurse in consultation with other skilled professionals, as appropriate. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the home health aide competency included the subject area of recognizing and reporting changes in skin condition for 4 of 4 employee files reviewed (Home Health Aide J, K, M, N). Findings include: 1. Review of an agency document dated 12/29/2017 titled "Home Health Aide Competency Checklist" which is used for home health aide competency checkoffs, failed to evidence the subject area, recognizing and reporting changes in skin condition. 2. Review of agency document dated 3/20/2020 titled "Home Health Aide Competency" completed for HHA (home health aide) N, failed to evidence the subject area, recognizing and reporting changes in skin condition. Review of agency document dated 4/27/2020 titled "Home Health Aide Competency" completed for HHA M, failed to evidence the subject area, recognizing and reporting changes in skin condition. 3. Review of agency document dated 9/4/2020 titled "Home Health Aide Competency" completed for HHA J, failed to evidence the subject area, recognizing and reporting changes in skin condition. 4. Review of agency document dated 11/17/2020 titled "Home Health Aide Competency" completed for HHA K, failed to evidence the subject area, recognizing and reporting changes in skin condition. 5. During an interview on 8/6/2021 at 11:05 AM, when queried if the Home Health Aide Competency form included the subject area, recognizing and reporting changes in skin condition, the administrator A indicated it did not.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the home health aide care plan was specific to the needs of the patient for 1 of 5 records reviewed who received home health aide services (#1). Findings include: 1. Review of an agency policy dated 2016, titled "2.52 Home Health Aide Service" stated " ... professional staff responsibilities ... coordinating nurse ... is responsible ... determining individual patient needs ... providing direction ... to the Aide [home health aide] ...." 2. Clinical record review was completed on 8/2/2021 for patient #1, start of care 4/30/2019, certification period 6/18/2021 - 8/16/2021, with a primary diagnosis of essential hypertension (high blood pressure). An agency document titled "Home Health Plan of Care & Certification" dated 6/14/2021 and signed by RN D, dated 6/16/2021 and signed by MD A. This agency document stated " ... order ... home health aides ... are to call the office and speak with the nurse if their patient is diabetic and states sugars are high or low or have a general complaint of headache, dizziness, warm flushes, sweating without exertion, or other s/sx [signs/symptoms] of high or low blood sugars ...." Clinical record review evidenced a document titled "Aide Plan of Care" dated 6/18/2021, signed by RN D. The document, stated "parameters to notify case manager [register nurse] ... other: blood sugar >350 or <70 ...." The home health aide care plan failed to indicate specific instructions of signs and symptoms of high and low blood sugar the home health aide is to report to a nurse. During an interview on 8/3/2021 at 9:35 AM, when queried how the home health aide knew the signs and symptoms of low and high blood sugar to call to a nurse, administrator A indicated blood sugar information is included in the home health aide training. Queried whether this information would be found in the home health aide plan of care, administrator A indicated it was not. 17-13-2 (a)

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the home health aide followed the plan of care for 5 of 5 records reviewed that were assigned home health aides (#1, 4, 5, 6, 7). Findings include: 1. Review of an agency policy dated 2016, titled "2.52 Home Health Aide Service" stated " ... an aide never decides which patient care procedures ... she/he will perform ... an aide performs only those activities which have been assigned by a nurse ...." 2. Clinical record review was completed on 8/2/2021 for patient #1, start of care 4/30/2019, certification period 6/18/2021 - 8/16/2021, with a primary diagnosis of essential hypertension (high blood pressure). An agency document titled "Aide Plan of Care" dated 6/18/2021, signed by RN D. The document stated " ... bathing ... shower ... each visit ...." Clinical record review evidenced agency documents titled "HHA [home health aide] Weekly Visit Record" dated 6/21/2021 - 7/31/2021 for 30 visits, signed by HHA Q. The agency documents stated " ... bathing ... tub bath/shower ...." The HHA documentation identified the completed task as tub bath/shower. The home health aide documentation failed to identify the specific bathing task provided. 3. Clinical record review was completed on 8/3/2021 for patient #4, start of care 9/18/2017, certification period 6/29/2021 - 8/27/2021, with a primary diagnosis anxiety disorder. An agency document titled "Aide Plan of Care" dated 7/9/2021, signed by administrator A. This document stated " ... bathing ... shower ... each visit ...." Clinical record review evidenced agency documents titles "HHA Weekly Visit Record" dated 7/12/2021 - 7/24/2021 for 10 visits, signed by HHA K. These agency documents stated " ... bathing ... tub bath/shower ...." The HHA documentation identified the completed task as tub bath/shower. The home health aide documentation failed to identify the specific bathing task provided. 4. Clinical record review was completed on 8/4/2021 for patient #5, start of care 3/18/2014, certification period 6/9/2021 - 8/7/2021, with a primary diagnosis of fracture neck of right femur (hip fracture). An agency document titled "Aide Plan of Care" dated 6/8/2021, signed by RN I. This document stated " ... bathing ... shower ... each visit ...." Clinical record review evidenced agency documents titled "HHA Weekly Visit Record" dated 6/20/2021 - 7/24/2021 for 28 visits, signed by HHA R. These agency documents stated " ... bathing ... tub bath/shower ...." The HHA documentation identified the completed task as tub bath/shower. The home health aide documentation failed to identify the specific bathing task provided. 5. Clinical record review was completed on 8/4/2021 for patient #6, start of care 6/11/2016, certification period 7/15/2021 - 9/12/2021, with a primary diagnosis of chronic obstructive pulmonary disease. An agency document titled "Aide Plan of Care" dated 7/13/2021, signed by RN O. This document stated " ... bathing ... shower ... each visit ...." Clinical record review evidenced agency documents titled "HHA Weekly Visit Record" dated 7/12/2021 - 7/30/2021 for 15 visits, signed by HHA S. These agency documents stated " ... bathing ... tub bath/shower ...." The HHA documentation identified the completed task as tub bath/shower. The home health aide documentation failed to identify the specific bathing task provided. 6. Clinical record review was completed on 8/5/2021 for patient #7, start of care 6/8/2018, certification periods 3/24/2021 - 5/22/2021 and 5/23/2021 - 7/21/2021, with a primary diagnosis diabetes. An agency document titled "Aide Plan of Care" dated 5/18/2021, signed by RN O. This document stated " ... bathing ... shower ... each visit ... or tub bath per pt [patient] request ...." Clinical record review evidenced agency documents titled "HHA Weekly Visit Record" dated 3/24/2021 - 5/14/2021 for 35 visits, signed by HHA T. These agency documents stated " ... bathing ... tub bath/shower ...." The HHA documentation identified the completed task as tub bath/shower. The home health aide documentation failed to identify the specific bathing task provided. 7. During an interview on 8/5/2021 at 9:00 AM, when asked if documentation should identify the type of bath provided, administrator A indicated yes, it should have.