Every finding on record at Am - Pm Home Health Services LLC

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 494.62. Survey Dates: 03/11, 03/12, and 03/13/2026 Active Census: 28 At this Emergency Preparedness survey, AM-PM Home Health Services, LLC was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 494.62. QR completed by Area 3 on 3/18/2026.

This visit was for a Federal Recertification and State Re-Licensure survey of a Home Health Provider. Survey Dates: 03/11, 03/12, and 03/13/2026 12-Month Unduplicated Skilled Admissions: 9 Partially Extended on 03/13/2026 at 1:51 PM. This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Refer to State Form for additional State Findings. Abbreviations: HHA - Home Health Aide SN- Skilled Nurse RN- Registered Nurse CM- Clinical Manager POC- Plan of Care SOC- Start of Care DON- Director of Nursing DME- Durable Medical Equipment ADL- Activities of Daily Living QAPI- Quality Assurance Performance Improvement OASIS- Outcome and Assessment Information Set QR completed by Area 3 on 3/18/2026.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure patients were seen within 48 hours of receiving a referral or after an inpatient stay for 3 of 6 active clinical records reviewed. (Patient #2, #3, and #8) Findings Include: #4. Review of Patient #3's active clinical record evidenced a document titled "Assessment Details" dated 01/20/2026 and signed by the Administrator/Clinical Manager. The assessment indicated Patient #3 was hospitalized 01/12/2026 through 01/15/2026. Review of Patient #3's active clinical record evidenced a document titled "Order." The order indicated the services would resume and the SN would perform a ROC. The order was dated 01/16/2026 and signed by the Administrator/Clinical Manager. Review of Patient #3's active clinical record evidenced a document titled "Order." The order indicated services would resume after a hospital stay. The order was dated 03/10/2026 and signed by the Administrator/Clinical Manager. Review of Patient #3's active clinical record evidenced a communication log. The communication note dated 02/25/2026 and signed by the Administrator/Clinical Manager indicated the agency requested resumption of care, orders, and a discharge summary from Entity 1, an acute care hospital. A communication note dated 03/09/2026 and signed by the Administrator/Clinical Manager indicated the agency requested orders to resume services from Entity 1, an acute care hospital. Review of the clinical record for Patient #3 failed to evidence a ROC assessment. The agency failed to ensure a ROC was completed within 48 hours of the patient's discharge from the hospital. During an interview on 03/12/2026 at 12:12 PM, the Administrator/Clinical Manager indicated Patient #3 was hospitalized on 02/24/2026, and discharged on 03/06/2026. The Administrator/Clinical Manager indicated the agency was notified of the discharge on 03/07/2026. During an interview on 03/13/2026 at 2:08 PM, the Administrator/Clinical Manager indicated the agency has 48 hours to complete a ROC. 410 IAC 17-14-1(a)(1)(A) 1. A review of an undated policy titled "Client Reassessment/Update of Comprehensive Assessment" indicated but was not limited to, " … Reassessments must be done at least: … 2. Within forty-eight (48) hours of (or knowledge of) client return home from hospital admission of more than twenty-four (24) hours for any reason other than diagnostic testing. … 3. Within forty-eight (48) hours of (or knowledge of) discharge or transfer) …" 2. A review of Patient #2's active clinical record evidenced a SOC assessment dated 03/02/2026 by RN 2. The assessment revealed the patient was discharged from an inpatient facility on 02/25/2026. The record failed to evidence Patient #2 was seen within 48 hours of the patient's discharge from an inpatient facility. During an interview with RN 2 on 03/13/2026 at 1:21 PM, they indicated they had not seen the patient within the 48 hour window due to the hospital not sending all the information they needed to provide care for Patient #2. They indicated they were not aware they were able to perform an initial evaluation to determine the patient's need for home health care prior to the SOC assessment. 3. A review of Patient #8's active clinical record evidenced a Referral document dated 12/05/2025 by the Administrator/CM. Patient #8's record included a SOC assessment documented 12/31/2025. The agency failed to ensure they saw Patient #8 within a timely manner after receiving the referral. During an interview with the Administrator/CM on 03/13/2026 at 2:05 PM, they indicated the patient should be seen within 48 hours of receiving the referral.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure an individualized plan of care was created for 3 of 6 active clinical records reviewed (Patients #1, 2, and 5). Findings Include: 3. A review of Patient #1's active clinical record on 03/11/2026 failed to evidence a POC for the certification period from 02/28/2026 to 04/28/2026. The POC for the current certification period, for Patient #1, was requested from the Alternate Administrator/Alternate CM on 03/13/2026 at 10:08 AM. A POC, with a SOC date of 03/16/2023 and a certification period from 02/28/2026 to 04/28/2026, was provided on 03/13/2026 at 1:00 PM. The POC was signed by RN 2 on 03/13/2026 at 11:58 AM. During an interview with RN 2 on 03/13/2026 at 1:21 PM, they explained they had not gotten to their POC and had completed the POC on 03/13/2026. The agency failed to ensure a POC was completed for the current certification period in a timely manner. 4. A review of Patient #2's active clinical record on 03/12/2026 failed to evidence a POC for the initial certification from 03/02/2026 to 04/30/2026. The POC for the current certification period, for Patient #2, was requested from the Alternate Administrator/Alternate CM on 03/13/2026 at 10:08 AM. During an interview with RN 2 on 03/13/2026 at 1:21 PM, they explained they had not started Patient #2's initial POC. The agency failed to ensure a POC was completed for the current certification period in a timely manner. 5. During an interview with the Administrator/CM on 03/13/2026 at 1:36 PM, they indicated they were behind on POCs and documents were to be signed and completed within five business days. 410 IAC 17-13-1(a)(1)(D) 1. Review of an undated agency policy titled "Plan of Care" indicated but was not limited to, " … The Plan of Care/485 will be developed following the initial assessment … The plan of care is developed within five (5) working days or as required by agency/state guidelines … The total Plan of Care shall be reviewed … but at least one time every sixty (60) days …" 2. Review of Patient #5's active clinical record on 03/13/2026 at 10:14 AM failed to evidence a POC for the certification period of 02/26/2026 through 04/26/2026. The POC for the current certification period was requested from the Alternate Administrator/Alternate CM on 03/13/2026 at 11:14 AM. On 03/13/2026 at 1:01 PM a POC with a SOC date of 12/28/2025 and a certification period of 02/26/2026 through 04/26/2026 and signed by the Alternate Administrator/Alternate CM was provided. During an interview on 03/13/2026 at 1:38 PM, when queried about the creation of the POC and the POC being sent 03/13/2026, the Alternate Administrator/Alternate CM indicated they forgot to sign the POC and send to the physician. The Alternate Administrator/Alternate CM indicated they could not use their part time work status as an excuse.

Update of the comprehensive assessment CFR(s): 484.55(d) Standard: Update of the comprehensive assessment. The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient's condition warrants due to a major decline or improvement in the patient's health status, but not less frequently than- This STANDARD is not met as evidenced by: Based on observation, record review, and interview the agency failed to ensure patient's comprehensive assessment was updated and revised when there was a change in condition in 1 of 5 active clinical records reviewed. (Patient #3) Findings include: On 08-06-2023 at 9:30 AM, during a home visit with Patient #3 and Home Health Aide 1, the aide was observed assisting with showering the patient. The patient undressed and removed a light-colored abdominal binder. Patient was observed washing their own hair, standing upright in the shower while keeping their left hand over a small white dressing, approximately 1 and 1/2 inches high by 4 inches wide, to the left abdomen while using their right hand to lather shampoo into the crown of the head. The patient continued to reach up with the right hand to rinse the hair while agitating vigorously to ensure the hair was free of shampoo. Later, out of the shower, the patient was observed bending at the waist to retrieve an object from the bathroom floor. While getting dressed, the patient required assistance to replace the abdominal binder over the site of the abdominal dressing. Review of undated agency policy received from the Administrator on 08--08-2023 titled, 'CLIENT REASSESSMENT/UPDATE OF COMPREHENSIVE ASSESSMENT C-155' stated, "POLICY A comprehensive assessment will be updated and revised as often as the client's condition warrants ... Reassessments must be done at least ... 4. ... Significant change or new diagnosis ... PURPOSE To identify decline or improvement in health status, modify the Plan of Care and document changes that may affect care ... SPECIAL INSTRUCTIONS ... 2. Clients are assessed when significant changes occur in their condition ... 6. A marked improvement or worsening of a client's condition, which changes the plan of care needed and was not anticipated in the plan of care, would be considered a significant change ... 10. Revisions to the plan of care must be communicated as follows: a. Any revision in a plan of care due to a patient's health status must be communicated to ... ALL physician/allowed non-physician practitioners issuing orders for AM PM Home Health Services plan of care." Review of the clinical record for Patient #3 evidenced a Start of Care date of 07-19-2023 with a Certification period of 07-19-2023 to 09-17-2023 and contained diagnoses which included, but were not limited to: Spondylolysis (cracks or small fractures to the vertebrae of the spine often cause by repetitive stress) of lumbar (lower spine) and cervical (the neck portion of your spinal column) regions, Chronic pain, repeated falls, presence of pain pump (small device, implanted with surgery, that allows direct delivery of medicine to the area needed) and was signed by RN 1. The Plan of Care evidenced the admitting nurse was aware of Patient #3’s upcoming surgery on 08-24-2023 by Doctor 4 to replace the patient's pain pump battery. The clinical record also failed to evidence the registered nurse scheduled or performed a nursing visit after the patient returned home from the 08-24-2023 procedure, failed to perform follow-up assessment, and failed to contact Doctor 4 for subsequent after-care orders or precautions. On 09-08-2023 at 12:34 PM, when queried as to the agency having had foreknowledge of Patient #3's pre-scheduled procedure on 08-24-2023, and what should have transpired afterwards, the Administrator indicated the nurse should have spoken to the physician, and should have obtained post-op orders and precautions. On 09-08-2023 at 2:10 PM, in a telephone interview Person 5, a registered nurse with Doctor 4, verified that Patient #3 had same-day surgery on 08-24-2023 to replace a pain pump battery and was sent home with an abdominal dressing, an abdominal binder, and instructions as to what to do and not to do, for four (4) weeks following the procedure. Person 5 indicated these instructions included but were not limited to: “no bending, lifting, twisting…no elbows above your ears, and reaching up, over, across or down” and, “wearing abdominal binder (except when showering) at all times for the next 30 days”. Person 5 also indicated there had been no communications (no phone calls or faxes) on record from AM PM Home Health Services, LLC. On 09-08-2023 at 2:49 PM, in the telephone interview Person 7 a registered nurse with Doctor 6, the primary care physician for Patient #3, indicated there had been no communications (no phone calls or faxes) on record from AM PM Home Health Services, LLC.. 410 IAC 17-14-1(a)(1)(B)

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 a written competency and a skills competency was completed on 1 of 3 HHA record reviews. (HHA 3) Findings include: A review of of an agency's undated policy received from the administrator on 09/08/2023 titled 'PERSONNEL RECORDS D-180' revealed, "... Competency testing for home health aides and specific competencies per job title. On 09/08/2023 a review of HHA 3 personnel record with a hire date of 05/15/2023, failed to evidence a written and skills competency testing performed by the agency. On 09/08/2023 at 10:40 AM during an interview with human resource 1 indicated they understood if a new hire that just completed the aide training and received their aide certificate the agency wouldn't need to perform a written and skilled competency testing after hire with the agency, they were certain the administrator observed HHA 3 during their check off for their Home Health Aide certification but didn't document it. 410 IAC 17-14-1(1)(A)

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 observation, record review, and interview, the agency failed to ensure the aide care plan was updated after a change in condition of a patient in 1 of 5 active clinical records reviewed. (Patient #3) Findings include: On 09-06-2023 at 9:30 AM, during a home visit with Patient #3 and Home Health Aide (HHA) 1, the aide was observed assisting with showering the patient. The patient undressed and removed a light-colored abdominal binder. Patient was observed washing their own hair, standing upright in the shower while keeping their left hand over a small white dressing, approximately 1 and 1/2 inches high by 4 inches wide, to the left abdomen while using their right hand to lather shampoo into the crown of the head. The patient continued to reach up with the right hand to rinse the hair while agitating vigorously to ensure the hair was free of shampoo. Later, out of the shower, the patient was observed bending at the waist to retrieve an object from the bathroom floor. A review of an agency’s undated policy provided by the Administrator on 09-08-2023 titled, ‘SKILLED PROFESSIONAL SERVICES C-200’ revealed, “b. Development and evaluation of the plan of care in partnership with the client … and caregivers …” A review of an agency’s undated policy provided by the Administrator on 09-08-2023 titled, ‘HOME HEALTH AIDE SERVICES C-220’ revealed, “ … 1. The nurse … assesses the need for personal care services … a specific are plan is developed documenting the Aide services to be provided …” A review of an agency’s undated policy provided by the Administrator on 09-08-2023 titled, ‘HOME HEALTH AIDE SUPERVISION C-340’ revealed, “1 … A copy of this written plan … revised periodically, as necessary.” Review of the clinical record for Patient #3 evidenced a Start of Care date of 07-19-2023 with a Certification period of 07-19-2023 to 09-17-2023 and contained diagnoses which included, but were not limited to: Spondylolysis (cracks or small fractures to the vertebrae of the spine often cause by repetitive stress) of lumbar (lower spine) and cervical (the neck portion of your spinal column) regions, Chronic pain, repeated falls, presence of pain pump (small device, implanted with surgery, that allows direct delivery of medicine to the area needed). The Plan of Care evidenced the skilled nurse was aware of Patient #3’s upcoming surgery on 08-24-2023 to replace a pain pump battery. The Aide Care Plan dated 7-19-2023, contained a frequency of home health aide visits 3 (three) times per week for 9 (nine) weeks and indicated the aide was to assist patient with shampooing weekly and showering each visit, “sponge bath up in chair” The Clinical record review failed to evidence a revised aide care plan post patient's surgery on 08-24-2023. The clinical record failed to evidence the registered nurse ensured the aide care plan was updated to reflect revised physician orders post 08-24-2023, change in condition. On 09-08-2023 at 12:34 PM, when queried as to the foreknowledge of Patient #3’s pre-scheduled procedure on 08-24-2023, and what should have transpired afterwards, the Administrator indicated the nurse should have spoken to the physician, should have obtained post-op orders and precautions, and agreed the aide plan of care should have been updated accordingly. On 09-08-2023 at 2:10 PM, in a telephone interview Person 5, a registered nurse with Doctor 4, verified that Patient #3 had same-day surgery on 08-24-2023 to replace a pain pump battery and was sent home with an abdominal dressing and instructions as to what to do and not to do, for four (4) weeks following the procedure. Person 5 indicated these instructions included but were not limited to: “no bending, lifting, twisting…no elbows above your ears, and reaching up, over, across or down” and “wearing abdominal binder (except when showering) at all times for the next 30 days”. Person 5 also indicated that there had been no communications (no phone calls or faxes) on record from AM PM Home Health Services, LLC.. IAC 17-13-2(a)

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment reflected the patient's relevant medical history and current health problems; the patient's psychosocial status, such as ability to participate in care, ability to identify and meet one's needs, and support systems available; and education, knowledge level, and ability to understand and learn for 6 of 6 active patients whose records were reviewed. (Patients #1, 2, 3, 4, 5, and 6) Findings include: 7. A review of the comprehensive assessment for Patient #2, dated 07-13-2023, evidenced diagnoses but not limited to Underweight, Other specified congenital malformations, unspecified intellectual disabilities, blindness, one eye, and unspecified sensorineural hearing loss. The assessment indicated the patient's caregiver able/willing to provide care, but then indicated the caregiver was not able/willing to assist with ADL’s (activities of daily living), failed to Provide Patient weight monitoring, failed to indicate a communication and speech/language barriers, failed to identify nutritional status/needs, failed to identify hearing loss, failed to identify unsteady gait, requires assistance for ambulation/use of assistive device, visual or auditory impairment, and indicated the patient was not a fall risk, On page 3 of 23 of assessment, Patient #2 weight was 92 versus page 12 of 23 indicated Patient’s #2 weight was 130. Under Nursing assessment and Evaluation page 4 of 23, Patient weight Monitoring was not marked. The comprehensive assessment for Patient #2 failed to reflect the patient's relevant medical history and current health problems and support systems available. 8. A review of the comprehensive assessment for Patient #5 dated 07-13-2023, evidenced diagnoses but not limited to Cerebral palsy, autistic disorder, epilepsy, and moderate intellectual disabilities. The assessment indicated communication was left blank, indicated the patient had a surgical incision, but did not indicate where, and ADL's (activities of daily living) functional limitations failed to indicate difficulty with ambulation. The comprehensive assessment for Patient #5 failed to identify communication level and ADL's functional limitations and relevant medical history. 9. A review of the comprehensive assessment for Patient #6 dated 07-12-2023, evidence diagnoses but not limited to cerebral infarction, chronic obstructive pulmonary disease and history of falling. The assessment indicated family was supportive, caregiver not able/willing tp provide care, caregiver not able to receive/follow instructions, caregiver not able/willing to assist with ADL's and needed care, and caregiver is able to safely care for patient, respiratory status indicated lung sounds were diminished, all other respiratory assessments were blank, failed to indicate respiratory Care plan interventions/order skilled nursing assessment, evaluation, and treatment, failed to indicate gastrointestinal status, failed to indicate who prepared their meals, and failed to indicated ability to plan and prepare light meals. The comprehensive assessment failed to identify support systems, medical history and current health problems, and ADL's. 10. On 07-20-2023 at 10:28 AM, during an interview, the administrator indicated they expected a head to toe assessment be completed, all areas on the comprehensive assessment need to be completed. The administrator further indicated they have difficulties with their electronic medical records, trying to figure it all out, and to fix areas they need to fix. 410 IAC 17-14-1(a)(1)(B) 1. A Briggs Healthcare policy was provided by the Administrator on 07-18-2023 at 12:55 PM. The “Comprehensive Client Assessment” Policy No. C-145 indicated but was not limited to, “… Purpose… To determine the appropriate care, treatment, and services to meet client needs and his/her changing needs… Special Instructions… 3… b. Demographic and client history… e. Respiratory status f. supportive assistance… m. Neuro/emotional/behavioral status… 11. Client needs are assessed and care guidelines established based on assessment data…”. 2. On 07-18-2023 at 11:20 AM, Patient #1’s clinical record was reviewed. The clinical record contained a document titled “Assessment Details” and was dated 07-05-2023 and signed by the Administrator. The document evidenced but was not limited to the following diagnoses: Blindness in both eyes, dependence on renal dialysis (a treatment where some of the blood was removed from the body to remove waste. It replaces the non-functioning kidneys), above the knee amputation of the right and left leg, Diabetes Mellitus (a disease where the body was unable to control blood glucose levels) with Diabetic Neuropathy (nerves were damaged because of the disease), Anemia in chronic kidney disease (a disease where the kidneys are unable to produce enough erythropoietin, causing low red blood cell levels), previous occurrence of sepsis (an infection affecting the entire body), and chronic pain. The assessment failed to indicate how the patient communicated and if there was a speech/language barrier. The assessment failed to indicate how pain effects the patient’s activities of daily living. The assessment indicated in integumentary status that there were “no open wounds”, in the section titled “Nutritional Health Screen” they marked “Skin issues: Pressure Ulcers.” The assessment failed to describe the location and the look of the pressure ulcer. The assessment contained a section titled “Respiratory Status” and for the subsection titled “Lung Sounds”, the Administrator marked “Diminished”. The “Lung Sounds” section indicated but was not limited to, “… Diminished… Left: (sic blank), Upper Left: (sic blank), Lower Left: (sic blank), Right: (sic blank), Upper Right: (sic blank), Lower Right: (sic blank) …”. The assessment failed to indicate the patient’s respiratory status. The assessment contained a section titled “Endocrine”, on page 10, it indicated the Blood sugar range was 120-150. The assessment contained a section titled “SN (sic Skilled Nurse) Endocrine Goals”, and it indicated that the blood sugar goals were 100-150. The section titled “Patient/Caregiver Education Provided this visit:” failed to indicate what education was provided to the patient and if they understood the education. The assessment failed to demonstrate an accurate picture of Patient #1’s current health status. 3. On 07-18-2023 at 1:45 PM, Patient #3’s clinical record was reviewed. The clinical record evidenced a document titled “Assessment Details” dated on 07-07-2023 and signed by the Administrator. The document evidenced but was not limited to the following diagnoses: Chronic Obstructive Pulmonary Disease (COPD) (a disease that blocks the airway and caused breathing difficulties), sequelae of cerebral infarction (residual symptoms after a disruption of blood to the brain), age-related physical debility (pain and weakness that come with age), Diabetes Mellitus (a disease where the body was unable to control blood glucose levels) with Diabetic Neuropathy (nerves were damaged because of the disease), and trochanteric bursitis of the right hip (a condition caused by inflammation in the hip). The assessment evidenced in the section titled “Ear/Nose/Throat/Mouth” and subsection titled “Mouth Condition”, the Administrator indicated the mouth condition was normal. The section titled “Nutrition/hydration status” evidenced the patient had dentures. The assessment failed to accurately depict the patient. The assessment contained a section titled “Respiratory Status” and for the subsection titled “Lung Sounds”, the Administrator marked “Diminished”. The “Lung Sounds” section indicated but was not limited to, “… Diminished… Left: (sic blank), Upper Left: (sic blank), Lower Left: (sic blank), Right: (sic blank), Upper Right: (sic blank), Lower Right: (sic blank) …”. The assessment failed to indicate the patient’s respiratory status. The section titled “Patient/Caregiver Education Provided this visit:” failed to indicate what education was provided to the patient and if they understood the education. The assessment failed to evidence the patient’s feet were assessed, the patient had a Diabetic diagnosis. The assessment failed to demonstrate an accurate picture of Patient #3’s current health status. 4. On 07-19-2023 at 12:57 PM, Patient #4’s clinical record was reviewed. The clinical record evidenced a document titled “Assessment Details” dated 07-06-2023 and signed by the Alternate Administrator. The document evidenced but was not limited to the following diagnoses: Fibromyalgia (a disorder that causes pain throughout the body), Orthostatic hypotension (when an individual stands after sitting or lying down and the blood pressure drops), Type 2 Diabetes Mellitus (a disease where the body was unable to control blood glucose levels) with Diabetic Polyneuropathy (the disease effects the nerves in the extremities), Hypertension (high blood pressure), sleep apnea (breathing stops and starts during sleep), chronic fatigue, and Hyperlipidemia (high lipids in the blood). The assessment failed to include blood pressure parameters for when the nurse was to contact the physician or when the patient was to contact the nurse or physician. The assessment failed to include how the patient’s pain effected their activities of daily living. The assessment contained a section titled “Respiratory Status” and for the subsection titled “Lung Sounds”, the Administrator marked “Wheezes”. The “Lung Sounds” section indicated but was not limited to, “… Wheezes… Left: (sic blank), Upper Left: (sic blank), Lower Left: (sic blank), Right: (sic blank), Upper Right: (sic blank), Lower Right: (sic blank) …”. The assessment failed to indicate the patient’s respiratory status. The assessment failed to demonstrate an accurate picture of Patient #4’s current health status. 5. During an interview with the Administrator on 07-18-2023 at 2:55 PM, the Administrator indicated the electronic medical record system would alert the nurse if a section of the assessment was incomplete. The Administrator and Alternate Administrator indicated they were able to fill out goals for each intervention and removed the blank goals. When queried regarding education taught to the patients during the recertification, the Administrator indicated it depended on who the patient was and what their main focus was. The Administrator indicated that their patients were well-versed in their diseases. 6. During an interview with the Administrator, Owner, and Scheduler on 07-19-2023 at 2:45 PM, the Administrator indicated they were working on making the plans of care more specific, and removing the duplicates that are pulled from the assessment from their electronic medical record. The Administrator indicated that if a finding for respiratory was abnormal, they were to indicate why it was abnormal.

Communication with all physicians CFR(s): 484.60(d)(1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure the admitting clinician collaborated with the ordering physician after home health admission visits or recertifications were performed, to ensure the plan of care was established with the ordering provider in 4 of 6 active clinical records reviewed. (Patients 1, 2, 4, and 5) Findings include: 4. A review of the comprehensive assessment for Patient #2, dated 07-13-2023, evidenced that care coordination occurred between the skilled nurse and the ordering physician. The POC (Plan of Care) dated 07-15-23 indicated Person 13 of Entity 2 was the ordering physician. The POC for Patient #2, dated 05-19-2023 for the certification period of 05-18-2023 to 07-16-2023 had been signed by Person 11 on 05-22-2023 of Entity 2. During an interview on 07-20-2023 at 1:45 PM with Person 12 of Entity 2 indicated Person 13 left Entity 2 a few months ago, Patient 2 transferred to Person 11 of Entity 2, effective 03-10-2023. Person 12 further indicated that they never receive phone calls from the agency for collaboration and development of the POC, indicated the agency always faxes any documents for the physician’s signature. 5. A review of the Clinical Record for Patient #5 evidenced Person 14 is the ordering physician. During an interview on 07-19-2023 at 1:46 PM with Person 15 of Entity 16 for Person 14, the ordering physician for Patient #5, indicated the agency doesn't phone the physician office for collaboration and development of the POC. 410 IAC 17-14-1(a)(1)(G) 1. A Briggs Healthcare policy was provided by the Administrator on 07-18-2023 at 12:55 PM. The “Clinical Documentation” Policy No. C-680 indicated but was not limited to, “… Purpose… To document conformance with the Plan of Care, modifications to the plan, and interdisciplinary involvement… 4. Telephone or other communication with clients, physicians… or members of the health care team will be documented in clinical progress notes or other interagency communication form…”. 2. On 07-18-2023 at 11:20 AM, Patient #1’s clinical record was reviewed. The clinical record evidenced a plan of care with Person 3 as the signing physician from Entity 2, the physician’s office. 3. On 07-19-2023 at 12:57 PM, Patient #4’s clinical record was reviewed. The clinical record evidenced a plan of care with Person 3 as the signing physician from Entity 2, the physician’s office. During an interview with Person 4, an Intake Coordinator at Entity 2, on 07-20-2023 at 9:49 AM, Person 4 indicated there were no coordination notes from the agency to the physician, Person 3.

Integrate all orders CFR(s): 484.60(d)(2) Integrate orders from all physicians or allowed practitioners involved in the plan of care to assure the coordination of all services and interventions provided to the patient. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure all orders were integrated into the Plan of Care 1 of 6 active record reviews. (Patient #6) Findings Include: 1. A review of an agency's undated policy titled, 'Plan of Care C-580' revealed, "...The plan will be consistently reviewed to ensure client needs are met, and will be updated as necessary...2. The plan of care shall be completed in full to include:...c. Type, frequency, and duration of all visits/services..." 2. A review of clinical record #6 evidenced a Home Health Plan of Care & Certification dated07-12-2023 for the certification period of 07-14-2023 to 09-11-2023 revealed Patient #6 was to received HHA (Home Health Aide) services 7 days a week, 6 hours per day. Further review of the record evidenced an order that was written on 04-11-2023 by the administrator, and signed by the attending physician on 05-11-2023, for HHA services to be decreased to "4 days/week 6 hours a day per pt request". 3. During an interview with the administrator on 07-19-2023 at 11:30 AM, the administrator indicated the order should be on the Plan of Care. 4. A Briggs Healthcare policy was provided by the Administrator on 07-18-2023 at 12:55 PM. The “Clinical Documentation” Policy No. C-680 indicated but was not limited to, “… Purpose… To document conformance with the Plan of Care, modifications to the plan, and interdisciplinary involvement… 4. Telephone or other communication with clients, physicians… or members of the health care team will be documented in clinical progress notes or other interagency communication form…”. 5. On 07-18-2023 at 1:45 PM, Patient #3’s clinical record was reviewed and evidenced a plan of care signed by the Administrator, with a start of care date of 01-10-2023 and a certification period from 07-09-2023 to 09-06-2023. The plan of care indicated Patient #3 was to receive Home Health Aide (HHA) services 6 hours a day, 7 days a week. The plan of care failed to evidence the patient was receiving Attendant care services (ATTC) with the agency and not through Entity 1, the agency’s Personal Service Agency. The agency failed to provide communication notes or a plan of care to the physician that indicated the patient received HHA services and ATTC. 6. During an interview with the Administrator and the Scheduler on 07-19-2023 at 12:15, they indicated Patient #3 received waiver hours through the agency for Attendant Care Services. The Administrator indicated they do not list Attendant Care services on the plan of care because of billing. During an interview with the Scheduler on 07-19-2023 at 12:43 PM, they confirmed Patient #3 received waiver services for Attendant care with the agency, and they were not with the Personal service agency side, Entity 1. 410 IAC 17-12-2(h)

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the HHA's (Home Health Aides) provided services delegated in the home health aide plan of care in 6 (Patients #1, 2, 3, 4, 5, and 6) of 6 patients' whose clinical records were reviewed. The findings include: 6. On 07-18-2023 at 11:20 AM, Patient #1’s clinical record was reviewed. The clinical record evidenced a plan of care with a start of care date of 08-02-2018 and a certification period of 07-07-2023 to 09-04-2023. The plan of care failed to include Home Health Aide frequency and duration. The plan of care indicated but was not limited to, “… Orders and Goals… Home Health Aide Orders… Order: Home Health Aide to provide/assist with personal care and assistance with ADLs (sic Activities of Daily Living) …”. The clinical record contained an Aide Plan of Care dated 07-07-2023 that indicated the frequency and duration for Home Health Aide services for 4 hours a day, 5 days a week. The aide plan of care indicated the patient was to receive for each visit skin care, mouth/denture care, dressing, light laundry, bed made, light housekeeping in the bedroom, bathroom, and kitchen, dusting, sweeping, vacuuming, take out trash, prepare meal, assist with feeding, personal care, sponge bath up in chair, check for pressure points, toileting/hygiene, medications reminder, and reposition in bed. The aide plan of care indicated the patient was to receive weekly shampooing, bed linen change and as needed, and clean equipment. On the aide visit note dated 07-09-2023, Home Health Aide (HHA) 3 indicated the tasks checking pressure points, toileting/hygiene, and medication reminder were not applicable. The aide visit note indicated these tasks were to be performed each visit. On the aide visit note dated 07-11-2023, HHA 4 indicated the tasks reposition in bed, make bed, dust, and vacuum were not completed during the visit. The aide visit note indicated these tasks were to be performed each visit. On the aide visit note dated 07-12-2023, HHA 4 indicated the tasks reposition in bed, light laundry, dust, sweep, vacuum, and check pressure points were not completed during the visit. The aide visit note indicated these tasks were to be performed each visit. On the aide visit note dated 07-13-2023, HHA 4 indicated the tasks reposition in bed and vacuum were not completed during the visit. The aide visit note indicated these tasks were to be performed each visit. On the aide visit note dated 07-14-2023, HHA 4 indicated the tasks reposition in bed and dust were not completed during the visit. The aide visit note indicated these tasks were to be performed each visit. On the aide visit notes dated 07-11, 07-12, 07-13, and 07-14-2023, it failed to evidence Patient #1 received shampoo care. The aide visit note indicated this task was to be performed weekly. On the aide visit note dated 07-17-2023, HHA 3 indicated the tasks sponge bath in chair, wheelchair assistance, checking for pressure points, toileting/hygiene, and medication reminder were not applicable. The aide visit note indicated these tasks were to be performed each visit. On the aide visit note dated 07-18-2023, HHA 3 indicated the tasks wheelchair assistance, assisting with feeding, checking for pressure points, and medication reminder were not applicable. The aide visit note indicated these tasks were to be performed each visit. 7. On 07-18-2023 at 1:45 PM, Patient #3’s clinical record was reviewed. The clinical record evidenced a plan of care with a start of care date of 01-10-2023 and a certification period of 07-09-2023 to 09-06-2023. The plan of care indicated the patient was to receive HHA services 6 hours a day, 7 days a week. The clinical record contained an Aide Plan of Care dated 07-09-2023 that indicated Patient #3 was to receive HHA services 6 hours a day, 7 days a week. The aide plan of care indicated the patient was to receive for each visit hair care, skin care, mouth/denture care, dressing, light laundry, bed made, light housekeeping in the bedroom, bathroom, and kitchen, clean equipment, dusting, sweeping, vacuuming, take out trash, water plants, prepare meal, encourage fluids, personal care, shower, check for pressure points, toileting/hygiene, medications reminder, walker, Home program exercise, and reposition in bed. The aide plan of care indicated the patient was to receive weekly shampooing and bed linen change. On the aide visit note dated 07-08-2023, HHA 5 indicated the tasks reposition in bed and dust were not applicable. The aide visit note indicated these tasks were to be performed each visit. On the aide visit note dated 07-09-2023, HHA 5 indicated the following tasks were completed during the visit: personal care, prepare meals, bed linen change, make bed, light housekeeping: bed/bath/kitchen, sweep, vacuum, take out trash, transport for errands, shopping, and other home activities. The note failed to evidence hands on care. HHA 5 failed to follow the aide plan of care. On the aide visit note dated 07-10-2023, HHA 5 indicated the following tasks were completed during the visit: personal care, prepare meals, bed linen change, make bed, light housekeeping: bed/bath/kitchen, dust, sweep, vacuum, take out trash, transport for errands and other home activities. The note failed to evidence hands on care. HHA 5 failed to follow the aide plan of care. On the aide visit note dated 07-11-2023, HHA 5 indicated the following tasks were completed during the visit: personal care, prepare meals, make bed, light housekeeping: bed/bath/kitchen, sweep, vacuum, take out trash, transport for doctor’s appointment, errands, shopping, and other home activities. The note failed to evidence hands on care. HHA 5 failed to follow the aide plan of care. On the aide visit note dated 07-12-2023, HHA 5 indicated the following tasks were completed during the visit: personal care, prepare meals, bed linen change, make bed, light housekeeping: bed/bath/kitchen, dust, sweep, vacuum, take out trash, transport for doctor’s appointment, errands, shopping, and other home activities. The note failed to evidence hands on care. HHA 5 failed to follow the aide plan of care. On the aide visit note dated 07-13-2023, HHA 5 indicated the following tasks were completed during the visit: personal care, prepare meals, bed linen change, make bed, light housekeeping: bed/bath/kitchen, sweep, vacuum, take out trash, transport for errands, shopping, and other home activities. The note failed to evidence hands on care. HHA 5 failed to follow the aide plan of care. On the aide visit note dated 07-14-2023, HHA5 indicated the following tasks were completed during the visit: personal care, prepare meals, bed linen change, make bed, light housekeeping: bed/bath/kitchen, dust, sweep, vacuum, take out trash, transport for errands, shopping, and other home activities. The note failed to evidence hands on care. HHA 5 failed to follow the aide plan of care. On the aide visit note dated 07-15-2023, HHA 5 indicated the following tasks were completed during the visit: personal care, prepare meals, make bed, light housekeeping: bed/bath/kitchen, sweep, vacuum, take out trash, transport for errands, shopping, and other home activities. The note failed to evidence hands on care. HHA 5 failed to follow the aide plan of care. On the aide visit note dated 07-16-2023, HHA 5 indicated the following tasks were completed during the visit: personal care, prepare meals, make bed, light housekeeping: bed/bath/kitchen, sweep, vacuum, take out trash, transport for errands and other home activities. The note failed to evidence hands on care. HHA 5 failed to follow the aide plan of care. On the aide visit note dated 07-17-2023, HHA 5 indicated the following tasks were completed during the visit: personal care, prepare meals, bed linen change, make bed, light housekeeping: bed/bath/kitchen, dust, sweep, vacuum, take out trash, transport for errands, shopping, and other home activities. The note failed to evidence hands on care. HHA 5 failed to follow the aide plan of care. On the aide visit note dated 07-18-2023, HHA 5 indicated the following tasks were completed during the visit: personal care, prepare meals, bed linen change, make bed, light housekeeping: bed/bath/kitchen, dust, sweep, vacuum, take out trash, transport for errands, shopping, and other home activities. The note failed to evidence hands on care. HHA 5 failed to follow the aide plan of care. During an interview with the Administrator and the Scheduler on 07-19-2023 at 12:15, they indicated Patient #3 received waiver hours through the agency for Attendant Care Services. The Administrator indicated they do not list Attendant Care services on the plan of care. They indicated the notes on the dates from 07-09-2023 to 07-18-2023 were for the Attendant Care services. During an interview with the Scheduler on 07-19-2023 at 12:43 PM, they confirmed Patient #3 received waiver services for Attendant care with the agency, and they were not with the Personal service agency side, Entity 1. 8. On 07-19-2023 at 12:57 PM, Patient #4’s clinical record was reviewed. The clinical record evidenced a plan of care with a start of care date of 07-23-2023 and a certification period of 07-08-2023. The plan of care evidenced orders for the patient to have received HHA services 6 hours a day, 7 days a week. The clinical record evidenced an Aide Plan of Care dated 07-08-2023, it indicated the patient was to receive HHA services 6 hours a day, 7 days a week. The aide plan of care indicated the patient was to receive for each visit hair care, skin care, dressing, light laundry, bed linen change, bed made, light housekeeping in the bedroom, bathroom, and kitchen, clean equipment, sweeping, vacuuming, take out trash, prepare meal, encourage fluids, assist with feeding, personal care, shower, toileting/hygiene, medications reminder, and assistance with cane. The aide plan of care indicated the patient was to receive weekly shampooing, foot care, nail care, dusting, tub bath with an indication that the patient was able to determine if they wanted a bath or shower. On the aide visit note dated 07-07-2023, HHA 6 indicated personal care, cleaning equipment, vacuuming, taking out the trash, toileting/hygiene were not applicable during the home visit. The aide visit note indicated these tasks were to be performed each visit. On the aide visit note dated 07-10-2023, HHA 6 indicated personal care, bed linen change, making the bed, cleaning equipment, vacuuming, taking out the trash, and toileting/hygiene were not applicable during the home visit. The aide visit note indicated these tasks were to be performed each visit. On the aide visit note dated 07-11-2023, HHA 6 indicated personal care, bed linen change, making the bed, cleaning equipment, vacuuming, taking out the trash, and toileting/hygiene were not applicable during the home visit. The aide visit note indicated these tasks were to be performed each visit. On the aide visit note dated 07-12-2023, HHA 6 indicated personal care, bed linen change, making the bed, cleaning the equipment, vacuuming, taking out the trash, and toileting/hygiene were not applicable during the home visit. The aide visit note indicated these tasks were to be performed each visit. On the aide visit note dated 07-13-2023, HHA 6 indicated personal care, bed linen change, making the bed, cleaning the equipment, vacuuming, taking out the trash, and toileting/hygiene were not applicable during the home visit. The aide visit note indicated these tasks were to be performed each visit. On the aide visit note dated 07-14-2023, HHA 6 indicated personal care, bed linen change, making the bed, cleaning the equipment, vacuuming, taking out the trash, and toileting/hygiene were not applicable during the home visit. The aide visit note indicated these tasks were to be performed each visit. On the aide visit note dated 07-16-2023, HHA 7 indicated they did not complete light laundry for the patient. The aide visit note indicated this task was to be performed each visit. On the aide visit note dated 07-17-2023, HHA 6 indicated personal care, bed linen change, making the bed, cleaning the equipment, vacuuming, taking out the trash, and toileting/hygiene were not applicable during the home visit. The aide visit note indicated these tasks were to be performed each visit. On the aide visit note dated 07-18-2023, HHA 6 indicated personal care, bed linen change, making the bed, cleaning the equipment, sweeping, vacuuming, taking out the trash, and toileting/hygiene were not applicable during the home visit. The aide visit note indicated these tasks were to be performed each visit. On the aide visit note dated 07-19-2023, HHA 6 indicated personal care, bed linen change, making the bed, cleaning the equipment, vacuuming, taking out the trash, and toileting/hygiene were not applicable during the home visit. The aide visit note indicated these tasks were to be performed each visit. 9. During an interview with the Administrator on 07-20-2023 at 2:33 PM, when queried regarding if there was to be a description for why an aide did not complete a task, the Administrator indicated the aides are to indicate why the task was not performed. The Administrator indicated that if an aide was performing a weekly task every day for the patient, they were to inform the Administrator or the Alternate Administrator, and they would inform the physician of increased needs. 1. A review of an agency's undated policy titled, 'HOME HEALTH AIDE: DOCUMENTATION C-800' revealed, "POLICY...Home Health Aides will document care/services provided on the home health aide charting form. Care/services provided should be in accordance with direction provided in the Home Health Aide Care Plan...3. The designated Registered Nurse...is responsible for reviewing the Home Health Aide's charting before it is placed in the chart..." 2. On 07-18-2023 a Clinical Record Review of Patient #2 evidenced a 'AIDE Plan of Care' dated 07-17-2023 which revealed the following tasks for the HHA to perform each visit: skin care, mouth/denture care, nail care, dressing, make bed, light housekeeping, sweep, vacuum, take out trash, prepare meal, encourage fluids, assist with medication reminders, personal care, shower, check for pressure points, toileting/hygiene, and assist with ambulation, provide supervision. Further record review revealed the following HHA visit notes: on 07-10-2023 failed to evidence: a shower, encourage fluid intake, and medication reminder was completed and a note indicating why tasks were not completed; on 07-11-2023 failed to evidence a shower, encourage fluid intake, and medication reminder was completed and a note indicating why tasks were not completed; on 07-12-2023 failed to evidence a shower, light housekeeping, sweep, vacuum, and medication reminder was completed and a note indicating why tasks were not completed; on 07-14-2023 failed to evidence: a shower, encourage fluid intake, light housekeeping, sweep, vacuum, and medication reminder was completed and a note indicating why tasks were not completed; on 07-15-2023 failed to evidence, a shower, encourage fluid intake, light housekeeping, and medication reminder was completed and a note indicating why tasks were not completed; on 07-16-2023 failed to evidence: a shower, encourage fluid intake, sweep, vacuum, and medication reminder was completed and a note indicating why tasks were not completed; and on 07-17-2023 failed to evidence a shower, encourage fluid intake, assistance with feeding, light housekeeping, vacuum, and medication reminder was completed and a note indicating why tasks were not completed. The HHA failed to follow the Aide Plan of Care. 3. On 07-18-2023 a Clinical Record Review of Patient #5 evidenced a 'AIDE Plan of Care' dated 07-13-2023 which revealed the following tasks for the HHA to perform each visit: hair care, skin care, mouth/denture care, foot care, nail care, dressing, light laundry, make bed, light housekeeping, sweep, prepare meal, encourage fluids, assist with feeding, personal care, shower, check for pressure points, toileting/hygiene, and medication reminders. Further record review revealed the following HHA visit notes: on 07-07-2023 failed to evidence light laundry was completed and a note indicating why the task was not completed; on 07-08-2023 failed to evidence light laundry was completed and a note indicating why the task was not completed; on 07-10-2023 failed to evidence light laundry was completed and a note indicating why the task was not completed; on 07-11-2023 failed to evidence light laundry was completed and a note indicating why the task was not completed; on 07-13-2023 failed to evidence light laundry was completed and a note indicating why the task was not completed; on 07-14-2023 failed to evidence light laundry was provided and a note indicating why the task was not completed; on 07-15-2023 failed to evidence light laundry was completed and a note indicating why the task was not completed; and on 07-17-2023 failed to evidence light laundry was completed and a note indicating why the task was not completed. The HHA failed to follow the Aide Plan of Care. 4. On 07-18-2023 a Clinical Record Review of Patient #6 evidenced a 'AIDE Plan of Care' dated 07-14-2023 which revealed the following tasks for the HHA to perform each visit: skin care, mouth/denture care, dressing, prepare meal, personal care, check for pressure points, medications reminder, and assist with ambulation with use of walker/cane. Further record review revealed the following HHA visit notes: on 07-07-2023 failed to evidence mouth/denture care, check for pressure points was completed and a note indicating why tasks were not completed; on 07-11-2023 failed to evidence mouth/denture care and check for pressure points was completed and a note indicating why tasks were not completed ; on 07-12-2023 failed to evidence mouth/denture care was completed and a note indicating why tasks were not completed , on 07-13-2023 failed to evidence mouth/denture care was completed and a note indicating why tasks were not completed ; on 07-14-2023 failed to evidence mouth/denture care and check for pressure points was completed and a note indicating why tasks were not completed ; on 07-18-2023 failed to evidence mouth/denture care and check for pressure points was completed and a note indicating why tasks were not completed; and on 07-19-2023 failed to evidence mouth/denture care and check for pressure points was completed and a note indicating why tasks were not completed . The HHA failed to follow the Aide Plan of Care. 5. On 07-20-2023 at 10:18 AM, the administrator indicated education had been completed with the home health aides, they are to document on the aide visit notes why they are not performing tasks as ordered, and are to notify the office so nursing could either talk to the patient and physician, and/or make changes to the Aide Plan of Care.

HH aide supervision elements CFR(s): 484.80(h)(4)(i-vi) Home health aide supervision must ensure that aides furnish care in a safe and effective manner, including, but not limited to, the following elements: (i) Following the patient's plan of care for completion of tasks assigned to a home health aide by the registered nurse or other appropriate skilled professional; (ii) Maintaining an open communication process with the patient, representative (if any), caregivers, and family; (iii) Demonstrating competency with assigned tasks; (iv) Complying with infection prevention and control policies and procedures; (v) Reporting changes in the patient's condition; and (vi) Honoring patient rights. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the accuracy of supervisor visits for HHA's (Home Health Aides) providing services according to the plan of care for 6 of 6 active clinical records reviewed. (Patients 1, 2, 3, 4, 5, and 6) Findings include: 5. On 07-18-2023 at 11:20 AM, Patient #1’s clinical record was reviewed. The clinical record evidenced a plan of care with a start of care date of 08-02-2018 and a certification period of 07-07-2023 to 09-04-2023. The plan of care failed to include Home Health Aide frequency and duration. The plan of care indicated but was not limited to, “… Orders and Goals… Home Health Aide Orders… Order: Home Health Aide to provide/assist with personal care and assistance with ADLs (sic Activities of Daily Living) …”. The clinical record contained an Aide Plan of Care dated 07-07-2023 that indicated the frequency and duration for Home Health Aide services for 4 hours a day, 5 days a week. The aide plan of care indicated the patient was to receive for each visit skin care, mouth/denture care, dressing, light laundry, bed made, light housekeeping in the bedroom, bathroom, and kitchen, dusting, sweeping, vacuuming, take out trash, prepare meal, assist with feeding, personal care, sponge bath up in chair, check for pressure points, toileting/hygiene, medications reminder, and reposition in bed. The aide plan of care indicated the patient was to receive weekly shampooing, bed linen change and as needed, and clean equipment. On the aide visit note dated 07-09-2023, Home Health Aide (HHA) 3 indicated the tasks checking pressure points, toileting/hygiene, and medication reminder were not applicable. The aide visit note indicated these tasks were to be performed each visit. On the aide visit note dated 07-11-2023, HHA 4 indicated the tasks reposition in bed, make bed, dust, and vacuum were not completed during the visit. The aide visit note indicated these tasks were to be performed each visit. On the aide visit note dated 07-12-2023, HHA 4 indicated the tasks reposition in bed, light laundry, dust, sweep, vacuum, and check pressure points were not completed during the visit. The aide visit note indicated these tasks were to be performed each visit. On the aide visit note dated 07-13-2023, HHA 4 indicated the tasks reposition in bed and vacuum were not completed during the visit. The aide visit note indicated these tasks were to be performed each visit. On the aide visit note dated 07-14-2023, HHA 4 indicated the tasks reposition in bed and dust were not completed during the visit. The aide visit note indicated these tasks were to be performed each visit. On the aide visit notes dated 07-11, 07-12, 07-13, and 07-14-2023, it failed to evidence Patient #1 received shampoo care. The aide visit note indicated this task was to be performed weekly. On the aide visit note dated 07-17-2023, HHA 3 indicated the tasks sponge bath in chair, wheelchair assistance, checking for pressure points, toileting/hygiene, and medication reminder were not applicable. The aide visit note indicated these tasks were to be performed each visit. On the aide visit note dated 07-18-2023, HHA 3 indicated the tasks wheelchair assistance, assisting with feeding, checking for pressure points, and medication reminder were not applicable. The aide visit note indicated these tasks were to be performed each visit. The aide visit notes failed to evidence the HHA followed the plan of care. The clinical record evidenced a document titled “Supervisory Visit Note” signed by the Administrator and dated 07-05-2023. The document indicated that the aide followed the Patient #1’s plan of care. 6. On 07-18-2023 at 1:45 PM, Patient #3’s clinical record was reviewed. The clinical record evidenced a plan of care with a start of care date of 01-10-2023 and a certification period of 07-09-2023 to 09-06-2023. The plan of care indicated the patient was to receive HHA services 6 hours a day, 7 days a week. The clinical record contained an Aide Plan of Care dated 07-09-2023 that indicated Patient #3 was to receive HHA services 6 hours a day, 7 days a week. The aide plan of care indicated the patient was to receive for each visit hair care, skin care, mouth/denture care, dressing, light laundry, bed made, light housekeeping in the bedroom, bathroom, and kitchen, clean equipment, dusting, sweeping, vacuuming, take out trash, water plants, prepare meal, encourage fluids, personal care, shower, check for pressure points, toileting/hygiene, medications reminder, walker, Home program exercise, and reposition in bed. The aide plan of care indicated the patient was to receive weekly shampooing and bed linen change. On the aide visit note dated 07-08-2023, HHA 5 indicated the tasks reposition in bed and dust were not applicable. The aide visit note indicated these tasks were to be performed each visit. On the aide visit note dated 07-09-2023, HHA 5 indicated the following tasks were completed during the visit: personal care, prepare meals, bed linen change, make bed, light housekeeping: bed/bath/kitchen, sweep, vacuum, take out trash, transport for errands, shopping, and other home activities. The note failed to evidence hands on care. HHA 5 failed to follow the aide plan of care. On the aide visit note dated 07-10-2023, HHA 5 indicated the following tasks were completed during the visit: personal care, prepare meals, bed linen change, make bed, light housekeeping: bed/bath/kitchen, dust, sweep, vacuum, take out trash, transport for errands and other home activities. The note failed to evidence hands on care. HHA 5 failed to follow the aide plan of care. On the aide visit note dated 07-11-2023, HHA 5 indicated the following tasks were completed during the visit: personal care, prepare meals, make bed, light housekeeping: bed/bath/kitchen, sweep, vacuum, take out trash, transport for doctor’s appointment, errands, shopping, and other home activities. The note failed to evidence hands on care. HHA 5 failed to follow the aide plan of care. On the aide visit note dated 07-12-2023, HHA 5 indicated the following tasks were completed during the visit: personal care, prepare meals, bed linen change, make bed, light housekeeping: bed/bath/kitchen, dust, sweep, vacuum, take out trash, transport for doctor’s appointment, errands, shopping, and other home activities. The note failed to evidence hands on care. HHA 5 failed to follow the aide plan of care. On the aide visit note dated 07-13-2023, HHA 5 indicated the following tasks were completed during the visit: personal care, prepare meals, bed linen change, make bed, light housekeeping: bed/bath/kitchen, sweep, vacuum, take out trash, transport for errands, shopping, and other home activities. The note failed to evidence hands on care. HHA 5 failed to follow the aide plan of care. On the aide visit note dated 07-14-2023, HHA5 indicated the following tasks were completed during the visit: personal care, prepare meals, bed linen change, make bed, light housekeeping: bed/bath/kitchen, dust, sweep, vacuum, take out trash, transport for errands, shopping, and other home activities. The note failed to evidence hands on care. HHA 5 failed to follow the aide plan of care. On the aide visit note dated 07-15-2023, HHA 5 indicated the following tasks were completed during the visit: personal care, prepare meals, make bed, light housekeeping: bed/bath/kitchen, sweep, vacuum, take out trash, transport for errands, shopping, and other home activities. The note failed to evidence hands on care. HHA 5 failed to follow the aide plan of care. On the aide visit note dated 07-16-2023, HHA 5 indicated the following tasks were completed during the visit: personal care, prepare meals, make bed, light housekeeping: bed/bath/kitchen, sweep, vacuum, take out trash, transport for errands and other home activities. The note failed to evidence hands on care. HHA 5 failed to follow the aide plan of care. On the aide visit note dated 07-17-2023, HHA 5 indicated the following tasks were completed during the visit: personal care, prepare meals, bed linen change, make bed, light housekeeping: bed/bath/kitchen, dust, sweep, vacuum, take out trash, transport for errands, shopping, and other home activities. The note failed to evidence hands on care. HHA 5 failed to follow the aide plan of care. On the aide visit note dated 07-18-2023, HHA 5 indicated the following tasks were completed during the visit: personal care, prepare meals, bed linen change, make bed, light housekeeping: bed/bath/kitchen, dust, sweep, vacuum, take out trash, transport for errands, shopping, and other home activities. The note failed to evidence hands on care. HHA 5 failed to follow the aide plan of care. The aide visit notes failed to evidence the HHA followed the plan of care. The clinical record evidenced a document titled “Supervisory Visit Note” signed by the Administrator and dated 07-07-2023. The document indicated that the aide followed the Patient #3’s plan of care. During an interview with the Administrator and the Scheduler on 07-19-2023 at 12:15, they indicated Patient #3 received waiver hours through the agency for Attendant Care Services. The Administrator indicated they do not list Attendant Care services on the plan of care. They indicated the notes on the dates from 07-09-2023 to 07-18-2023 were for the Attendant Care services. During an interview with the Scheduler on 07-19-2023 at 12:43 PM, they confirmed Patient #3 received waiver services for Attendant care with the agency, and they were not with the Personal service agency side, Entity 1. 7. On 07-19-2023 at 12:57 PM, Patient #4’s clinical record was reviewed. The clinical record evidenced a plan of care with a start of care date of 07-23-2023 and a certification period of 07-08-2023. The plan of care evidenced orders for the patient to have received HHA services 6 hours a day, 7 days a week. The clinical record evidenced an Aide Plan of Care dated 07-08-2023, it indicated the patient was to receive HHA services 6 hours a day, 7 days a week. The aide plan of care indicated the patient was to receive for each visit hair care, skin care, dressing, light laundry, bed linen change, bed made, light housekeeping in the bedroom, bathroom, and kitchen, clean equipment, sweeping, vacuuming, take out trash, prepare meal, encourage fluids, assist with feeding, personal care, shower, toileting/hygiene, medications reminder, and assistance with cane. The aide plan of care indicated the patient was to receive weekly shampooing, foot care, nail care, dusting, tub bath with an indication that the patient was able to determine if they wanted a bath or shower. On the aide visit note dated 07-07-2023, HHA 6 indicated personal care, cleaning equipment, vacuuming, taking out the trash, toileting/hygiene were not applicable during the home visit. The aide visit note indicated these tasks were to be performed each visit. On the aide visit note dated 07-10-2023, HHA 6 indicated personal care, bed linen change, making the bed, cleaning equipment, vacuuming, taking out the trash, and toileting/hygiene were not applicable during the home visit. The aide visit note indicated these tasks were to be performed each visit. On the aide visit note dated 07-11-2023, HHA 6 indicated personal care, bed linen change, making the bed, cleaning equipment, vacuuming, taking out the trash, and toileting/hygiene were not applicable during the home visit. The aide visit note indicated these tasks were to be performed each visit. On the aide visit note dated 07-12-2023, HHA 6 indicated personal care, bed linen change, making the bed, cleaning the equipment, vacuuming, taking out the trash, and toileting/hygiene were not applicable during the home visit. The aide visit note indicated these tasks were to be performed each visit. On the aide visit note dated 07-13-2023, HHA 6 indicated personal care, bed linen change, making the bed, cleaning the equipment, vacuuming, taking out the trash, and toileting/hygiene were not applicable during the home visit. The aide visit note indicated these tasks were to be performed each visit. On the aide visit note dated 07-14-2023, HHA 6 indicated personal care, bed linen change, making the bed, cleaning the equipment, vacuuming, taking out the trash, and toileting/hygiene were not applicable during the home visit. The aide visit note indicated these tasks were to be performed each visit. On the aide visit note dated 07-16-2023, HHA 7 indicated they did not complete light laundry for the patient. The aide visit note indicated this task was to be performed each visit. On the aide visit note dated 07-17-2023, HHA 6 indicated personal care, bed linen change, making the bed, cleaning the equipment, vacuuming, taking out the trash, and toileting/hygiene were not applicable during the home visit. The aide visit note indicated these tasks were to be performed each visit. On the aide visit note dated 07-18-2023, HHA 6 indicated personal care, bed linen change, making the bed, cleaning the equipment, sweeping, vacuuming, taking out the trash, and toileting/hygiene were not applicable during the home visit. The aide visit note indicated these tasks were to be performed each visit. On the aide visit note dated 07-19-2023, HHA 6 indicated personal care, bed linen change, making the bed, cleaning the equipment, vacuuming, taking out the trash, and toileting/hygiene were not applicable during the home visit. The aide visit note indicated these tasks were to be performed each visit. The aide visit notes failed to evidence the HHA followed the plan of care. The clinical record evidenced a document titled “Supervisory Visit Note” signed by the Administrator and dated 07-06-2023. The document indicated that the aide followed the Patient #4’s plan of care. 8. During an interview with the Administrator on 07-18-2023 at 2:55 PM, they indicated the HHAs were to document the tasks they performed and follow the aide plan of care. 410 IAC 17-14-1(n) 1. A review of an agency's undated policy titled, 'HOME HEALTH AIDE: DOCUMENTATION C-800' revealed, "...3. The designated Registered Nurse...is responsible for reviewing the Home Health Aide's charting before it is placed in the chart..." A review of an agency's undated policy titled, 'HOME HEALTH AIDE SUPERVISION C-340' revealed, "...8. The aide visit record is reviewed by the supervising nurses...to assure services are being provided according to the care plan." 2. On 07-18-2023 a Clinical Record Review of Patient #2 evidenced a 'AIDE Plan of Care' dated 07-17-2023 which revealed the following tasks for the HHA to perform each visit: skin care, mouth/denture care, nail care, dressing, make bed, light housekeeping, sweep, vacuum, take out trash, prepare meal, encourage fluids, assist with medication reminders, personal care, shower, check for pressure points, toileting/hygiene, and assist with ambulation, provide supervision. Further record review revealed the following HHA 8's daily visit notes : on 07-10-2023 failed to evidence: a shower, encourage fluid intake, and medication reminder was completed and a note indicating why tasks were not completed; on 07-11-2023 failed to evidence a shower, encourage fluid intake, and medication reminder was completed and a note indicating why tasks were not completed; on 07-12-2023 failed to evidence a shower, light housekeeping, sweep, vacuum, and medication reminder was completed and a note indicating why tasks were not completed; on 07-14-2023 failed to evidence: a shower, encourage fluid intake, light housekeeping, sweep, vacuum, and medication reminder was completed and a note indicating why tasks were not completed; on 07-15-2023 failed to evidence, a shower, encourage fluid intake, light housekeeping, and medication reminder was completed and a note indicating why tasks were not completed; on 07-16-2023 failed to evidence: a shower, encourage fluid intake, sweep, vacuum, and medication reminder was completed and a note indicating why tasks were not completed; and on 07-17-2023 failed to evidence a shower, encourage fluid intake, assistance with feeding, light housekeeping, vacuum, and medication reminder was completed and a note indicating why tasks were not completed. The HHA failed to follow the Aide Plan of Care. A Supervisory Visit Note dated 07-13-2023 and signed by Administrative Staff 3 at 11:58 AM, evidenced HHA 8 followed the client's Care Plan. 3. On 07-18-2023 a Clinical Record Review of Patient #5 evidenced a 'AIDE Plan of Care' dated 07-13-2023 which revealed the following tasks for the HHA to perform each visit: hair care, skin care, mouth/denture care, foot care, nail care, dressing, light laundry, make bed, light housekeeping, sweep, prepare meal, encourage fluids, assist with feeding, personal care, shower, check for pressure points, toileting/hygiene, and medication reminders. Further record review revealed the following HHA 9's visit notes: on 07-07-2023 failed to evidence light laundry was completed and a note indicating why the task was not completed; on 07-08-2023 failed to evidence light laundry was completed and a note indicating why the task was not completed; on 07-10-2023 failed to evidence light laundry was completed and a note indicating why the task was not completed; on 07-11-2023 failed to evidence light laundry was completed and a note indicating why the task was not completed; on 07-13-2023 failed to evidence light laundry was completed and a note indicating why the task was not completed; on 07-14-2023 failed to evidence light laundry was provided and a note indicating why the task was not completed; on 07-15-2023 failed to evidence light laundry was completed and a note indicating why the task was not completed; and on 07-17-2023 failed to evidence light laundry was completed and a note indicating why the task was not completed. The HHA failed to follow the Aide Plan of Care. A Supervisory Visit Note signed and dated by Administrative Staff 3 on 07-13-2023 at 10:00 AM, evidenced HHA 9 followed the client's Care Plan. 4. On 07-18-2023 a Clinical Record Review of Patient #6 evidenced a 'AIDE Plan of Care' dated 07-14-2023 which revealed the following tasks for the HHA to perform each visit: skin care, mouth/denture care, dressing, prepare meal, personal care, check for pressure points, medications reminder, and assist with ambulation with use of walker/cane. Further record review revealed the following HHA 10's visit notes: on 07-07-2023 failed to evidence mouth/denture care, check for pressure points was completed and a note indicating why tasks were not completed; on 07-11-2023 failed to evidence mouth/denture care and check for pressure points was completed and a note indicating why tasks were not completed ; on 07-12-2023 failed to evidence mouth/denture care was completed and a note indicating why tasks were not completed , on 07-13-2023 failed to evidence mouth/denture care was completed and a note indicating why tasks were not completed ; on 07-14-2023 failed to evidence mouth/denture care and check for pressure points was completed and a note indicating why tasks were not completed ; on 07-18-2023 failed to evidence mouth/denture care and check for pressure points was completed and a note indicating why tasks were not completed; and on 07-19-2023 failed to evidence mouth/denture care and check for pressure points was completed and a note indicating why tasks were not completed . The HHA failed to follow the Aide Plan of Care. A Supervisory Visit Note signed and dated by Administrative Staff 3 on 07-12-2023 at 11:18 AM, evidenced HHA 10 followed the client's Care Plan.

An Emergency Preparedness survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102 for a Home Health Provider. Survey Dates: 04-20-2023, -4-21-2023, 04-24-2023, and 04-25-2023 Facility # 014070 CCN: 15K153 Census: 27 Unduplicated Skilled Admissions: 6 At this Emergency Preparedness survey, AM PM Home Health Services LLC was found to have been out of compliance with Conditions of Participation 42 CFR 484.102 Emergency Preparedness requirements for Medicaid Participating Providers and Suppliers, including staffing and the implementation of staffing during the Pandemic. QR by Area 3 on 5-3-2023

Establishment of the Emergency Program (EP) CFR(s): 484.102 §403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.542, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must establish and maintain a [comprehensive] emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements: * (Unless otherwise indicated, the general use of the terms "facility" or "facilities" in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This CONDITION is not met as evidenced by: Based on record review and interview, the agency failed to ensure an Emergency Preparedness was maintained, reviewed, and/or revised if needed, with tabletop exercise conducted with an after-action analysis documented since 2020 for 1 of 1 Emergency Preparedness program. Findings Include: 1. On 04-25-2023 at 10:30 AM, a binder titled “Emergency Management,” was reviewed and contained an undated policy titled “Emergency Management Policy”, policy number B-400. The policy indicated but was not limited to, “ … The AM-PM Home Health Services will develop and maintain a written emergency management plan describing the process for disaster readiness and emergency management and implements it as appropriate ... ” 2. On 04-25-2023 at 09:05 AM, the Scheduler, Administrative Staff #4, provided a binder titled, “Emergency Management.” The binder contained documents that listed potential disasters that may occur that evaluated how prepared the agency was for the disaster and the risk associated with the disaster. The documents evidenced the evaluation was completed monthly. There was no evidence of a tabletop exercise had been completed by the agency. 3. On 04-25-2023 at 09:16 AM, the Administrator provided a binder titled “Governing Body Minutes.” The binder contained Governing Body minutes from June 15, 2022, September 23, 2022, and January 3, 2023. There was no evidence the following elements of an Emergency Preparedness program (policies/procedures, communication plan, training and testing) had been reviewed and updated if needed. 4. On 04-25-2023 at 11:51 AM, an interview was conducted with the Administrator and Alternate Administrator. The Administrator indicated the agency had not completed a tabletop exercise since their last survey in the year 2020. The Administrator indicated the Emergency Preparedness plan had not been worked on since their last survey in 2020. The Alternate Administrator stated they reviewed the policies and procedures every 6 months, but indicated they did not document when policies and procedures were reviewed. The Administrator indicated they updated and reviewed the communication plan annually, but was unable to provide any documentation of any agency Emergency Preparedness review and updates if needed.

This visit was for a Federal Recertification of a Home Health Provider. A fully extended survey was announced on 04-24-2023 at 10:36 AM. Survey dates: 04-20-2023, 04-21-2023, 04-24-2023, and 04-25-2023 Census: 27 Unduplicated Skilled patients: 6 Based on the Condition-level deficiencies during the 4-25-2023 survey, your home health agency was subject to an extended survey pursuant to section 1891(c)(2)(D) of the Social Security Act in relation to Emergency Preparedness 42 CFR 484.102; Care Planning, Coordination, and Quality of care, 42 CFR 484.60; 42 CFR 484.65 Quality Assessment and Performance Improvement; and 42 CFR 484.70 Infection Control. Therefore, and pursuant to section 1891(a)(3)(D)(iii) of the Act, your agency is precluded from operating or being involved with any onsite health aide training and/or competency evaluation program for the two years beginning April 25, 2023, continuing through April 24, 2025. QR by Area 3 on 5-3-2023

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 agency failed to ensure they met the needs of 5 of 5 active (Patient #1, 2, 3, 4, and 8) patients whose clinical record was reviewed by failing to provide patient-specific interventions, education, and measurable outcomes and goal (G574), having failed to promptly inform the physician of missed visits (Patient #2) for 1 of 5 active patients (G590), and include indications for medications on the plan of care (Patient #8) for 1 of 5 active patients (G616). The cumulative effects 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 the Condition of Participation of 42 CFR 484.60, Care Planning, Coordination of Care, 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 agency failed to ensure the plan of care contained specific individualized interventions and goals for 5 of 5 (Patients #1, 2, 3, 6, and 8) active clinical records reviewed and include the frequency of skilled nursing visits in 1 of 5 (Patient #3) active clinical records reviewed, as required by agency policy. Findings Include: 4. A review of Patient’s #1 plan of care with a recertification period of 02-15-2023, through 04-15-2023, failed to evidence complete and specific goals including, Cardio-Pulm Assessment(heart/lungs), Medication set-up/management of automatic dispensing machine, GU/Renal status(kidney/bladder), Neurological Status, and home health aide. The plan of care failed to contain specific parameters for GU/Renal status, and neurological status. 5. A review of Patient #3’s plan of care with a recertification period of 03-09-2023, failed to evidence goals for vital signs, medication safety, pulse oximetry (oxygen level), respiratory status, GU/Renal status (kidney/bladder), nutrition and hydration, gastrointestinal (stomach), bowel movements, neurological status (brain function), teaching on the disease process of kidney failure and disease complications, chest pain management, medication compliance, and fall precautions. The POC failed to evidence a specific goal in relation to infection control and for medication safety, the goal for both stated, “Patient will remain safe at home during plan of care." 6. A review of Patient #8’s plan of care with a recertification period of 02-08-2023 to 04-08-2023, failed to evidence complete and specific goals including, medication compliance, disease process, pain level, HHA aide, fall precautions and transfer safety, vital signs (blood pressure, pulse, lung sounds), weight monitoring, anticoagulation therapy( blood thinners), and chest pain management. The plan of care failed to contain specific parameters for blood pressure, weight management, pain level, and call orders to the physician when the parameters are out of range. 410 IAC 17-13-1(a)(1)(D)(iv, xiv) 1. On 04-25-2023 at 09:12 AM, a review of an undated agency policy titled “Plan of Care”, policy number C-580, indicated but was not limited to, “… Type, frequency, and duration of all visits/services… Treatment goals…." 2. A review of the clinical record for Patient #2, with the start of care date of 11-28-2017, contained a plan of care (POC) for the recertification period of 03-02-2023 to 04-30-2023. The POC indicated orders for Skilled Nursing (SN) every 60 days for recertification evaluation and Home Health Aide (HHA) 4 hours a day, 5 days a week for 26 weeks for personal care and Activities of daily living (ADL). The POC contained an "Orders and Goals" section that indicated but was not limited to, "... Order: Skilled nursing to assess and evaluate: Cardiovascular/Pulmonary Status. Goal: (none listed)… Order: Skilled nursing to assess and evaluate: Fall precautions, Transfer safety. Goal: (none listed)… Order: Skilled nursing to teach and instruct: Signs and symptoms of hypo/hyperglycemia and appropriate actions to take. Goal: (none listed)…." The POC failed to evidence patient-specific measurable goals. 3. A review of the clinical record for Patient #4, with the start of care date of 12-20-2017, contained a POC for the recertification period of 03-24-2023 to 05-22-2023. The POC indicated orders for SN every 60 days for recertification evaluation and HHA 6 hours a day, 7 days a week, for 9 weeks for ADLs and Instrumental Activities of daily living (IADL). The POC contained an "Orders and Goals" section that indicated but was not limited to, "... Order: Skilled nursing to assess and evaluate: Cardiovascular/Pulmonary status. Goal: (none listed)… Order: Skilled nursing to teach and instruct: Disease process and potential complications. Goal: (none listed)…." The POC failed to evidence patient-specific measurable goals.

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 agency failed to promptly notify the attending physician of a hold in home health aide care visits until the last day of the hold or until after the visits were held for 1 of 2 (Patient #3) active clinical records reviewed with missed care visits. Findings Include: A review of the clinical record for Patient #3 indicated a start of care of 08-02-2018 and a recertification period of 03-09-2023 to -5-07-2023 with orders for a home health aide (HHA) 5 days a week for 4 hours a day to assist with activities of daily living (ADL’s) and Instrumental Activities of Daily Living (IADL’s) including personal hygiene, safe transfers, light housekeeping, and meal preparation. A review of visit notes evidenced that during the weeks of March 13 through March 24th the home health aide did not make any scheduled visits. A document received from the administrator on 04-24-2023 at 2:15 PM titled “Verbal Order” indicated the agency placed a request with the physician to approve a hold order for the home health aide for the dates of March 13th-March 24th. The document was dated 04-24-2023. The agency failed to notify the physician of the missed visits at or near the time the missed visits occurred. 410- IAC 17-3-1(a)(2) 1. On 04-25-2023 at 09:12 AM, a review of an undated agency policy titled “Plan of Care”, policy number C-580, indicated but was not limited to, “… Professional staff shall promptly alert the physician to any changes that suggest a need to alter the Plan of Care ….” 2. A review of the clinical record for Patient #2, with the start of care date of 11-28-2017, contained a plan of care (POC) for the recertification period of 03-02-2023 to 04-30-2023. The POC indicated orders for Home Health Aide (HHA) 4 hours a day, 5 days a week for 26 weeks for personal care and Activities of daily living (ADL). A review of documents titled “Aide Visit Note – Daily” failed to evidence HHA visits during the weeks of 03-13-2023 through 03-24-2023. On 04-21-2023 at 02:28 PM, the Administrator provided a document titled “Verbal Order”, dated and signed by the Administrator on 04-21-2023. The document indicated the agency requested HHA services be placed on hold for Patient #2 for the dates of 03-13-2023 to 03-24-2023. The agency failed to promptly notify the physician of the missed visits at or around the time the missed visits occurred. 3. On 04-21-2023 at 02:28 PM, the Administrator indicated the aide was unavailable for the weeks of 03-13-2023 to 03-24-2023, and Patient #2 refused a replacement. The Administrator stated, "I just sent the order to the physician now."

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 observation and record review, the agency failed to provide an updated list of medications, schedules, dosages, and indications in 1 (Patient #4) of 3 home visits. Findings Include: During an observation at Patient #8’s residence on 04-21-2023 at 12:00 PM, a folder containing patient information failed to evidence a current list of medications and instructions. 1. On 04-21-2023 at 12:40 PM, the Administrator provided an undated policy titled “Medication Management”, the policy indicated but was not limited to, “… Program Specific… Specific instructions for how and when to take the medications will be reviewed and documented… Medication Orders… b. Dose and time drug is to be given and any time limitations. c. Indication for the drug….” 2. On 04-21-2023 at 12:40 PM, the Administrator provided an undated policy titled “Medication Profile”, the policy indicated but was not limited to, “… The profile will be reviewed and updated as needed to reflect current medications the client is taking… To provide a complete list of ALL medications the client is taking and an evaluation of the client’s knowledge of the effects of these medications….” 3. On 04-21-2023 at 8:00 AM, an interview was conducted at Patient #4’s residence. The Patient indicated they were unable to locate their admission folder since they moved to their new residence.

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 provide documentation they had maintained a Quality Assessment and Performance Improvement program for 2023. The cumulative effects 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 the Condition of Participation of 42 CFR 484.65, Quality Assessment and Performance Improvement. Findings Include: 1. On 04-25-2023 at 09:40 AM, a binder titled, “QAPI (sic Quality Assessment and Performance Improvement,)” was reviewed and contained a policy titled “Performance Improvement”. The policy indicated but was not limited to, “… AM-PM Home Health Services shall establish a performance improvement plan to continuously measure, assess, and improve the performance of clinical and other processes… Special Instructions … 7. The Board of Directors will receive information about findings and activities that is needed to fulfill their responsibility for the quality of client care and safety and security of clients, staff, and others … 13. The Performance Improvement Plan is evaluated at least annually ….” 2. On 04-25-2023 at 09:16 AM, the Administrator provided a binder titled “Governing Body Minutes”. The binder contained Governing Body minutes from June 15, 2022, September 23, 2022, and January 3, 2023. There was no evidence QAPI and policies and procedures were reviewed or discussed. 3. On 04-25-2023 at 09:40 AM, documents titled “Quality Assurance/Performance Improvement” were reviewed. The years were noted on the documents, 3 of the 4 documents had the year 2022 and 1 of the 4 documents had the year 2023. The documents evidenced a review of issues that indicated but was not limited to, “Infection control … Incidents… QAPI/Quarterly chart audits … compliance issue s….” There was no documentation/evidence of performance improvement plans initiated. 4. On 04-25-2023 at 11:26 AM, an interview with the Administrator and Alternate Administrator was conducted. When queried regarding the involvement of the governing body, the Administrator indicated the governing body was aware of the incidents and they communicated with the governing body the concerns. There was no evidence in the Governing Body notes of QAPI or incidents being discussed. 5. On 04-25-2023 at 11:03, a document titled “Aide Meeting Notes”, dated January 21, 2023, was reviewed. The document indicated but was not limited to, “… Nurses … went over … Incident reports (Falls, hospital, and missed visits). Aides were advised again how important it is to call the online phone after hrs (sic hours) or office during hours to let them know if there is an issue with any of the clients ….” There was no documentation/evidence of any further in-service training or performance improvement plans initiated. On 04-25-2023 at 11:26 AM, an interview with the Administrator and Alternate Administrator was conducted. The Alternate Administrator indicated they saw a trend of falls increasing in the past few months. The Administrator indicated they would educate the Home Health Aides (HHA). There was no evidence of performance improvement plans initiated. 410 IAC 17-12-2(a)

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 agency failed to implement COVID-19 policies and procedures for the Centers for Medicare and Medicaid Services (CMS) vaccine mandate of 100% compliance for employees that provide direct care on behalf of the agency to be fully vaccinated or have a record of an approved medical or religious exemption, failed to track and mitigate the potential of adverse outcomes for the agency’s current 27 patients and their 21 agency staff, and failed to maintain an agency program for surveillance of communicable diseases, (see G682, G684, and G687) The cumulative effect of this systemic problem resulted in the agency inability to provide quality health care in a safe environment for the Condition of Participation 42 CFR 484.70, Infection prevention and control. *

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 record and interview, the agency failed to implement standard precautions to include the CMS COVID-19 vaccination mandate and failed to implement mitigation precautions for unvaccinated healthcare professionals providing direct patient care during the entire COVID-19 public health emergency pandemic. The findings include: 1. During an interview with Administrator 1 on 04-21-2023 at 10:24 AM, she indicated the agency did not require eligible staff to receive the COVID-19 vaccination as she did not think it was required. Staff were not required to be/become fully vaccinated and/or submit documentation of a medical or religious exemption. 2. A review of a 3-4-2020 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, 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 …” 3. During an interview with the Administrator on 04-2-2023 at 10:36 AM, she indicated the agency had completed incident reports for COVID-19 positive patients that were hospitalized and was unsure if any patients had been hospitalized in 2022 with the infection. She indicated the agency required staff to notify them if they were COVID-19 positive. No tracking information of positive COVID-19 employees or patients was provided. 4. A review of the Agency’s policies and procedures received from Administrator #1, on 04-21-2023 at 10:43 AM, titled, “AM-PM HOME HEALTH SERVICES LLC’S COVID 19 (sic Covid-19) PLAN,” evidenced the absence of policies and procedures addressing allowable vaccination exemptions and additional precautions for unvaccinated staff to mitigate the risk of spread of COVID-19. The administrator indicated the Agency followed OSHA (Occupational Health and Safety Administration) when developing their COVID-19 policies and procedures, not CMS. 410 IAC 17-17-12-1(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 maintain a quality assurance performance improvement program (QAPI) that provided surveillance, tracking, and investigation of infectious and communicable diseases including COVID-19 from 3-4- 2020 until current (the duration of the public health emergency for COVID-19) for 1 of 1 home health agency. A document received on 04-24-2023 at 11 AM from the Alternate Administrator, RN, titled, “Monthly Event Record” contained but not limited to, “ Infectious Disease Reporting-EMPLOYEE ILLNESS…2020." For each month of 2020 the following information was documented related to employees with Covid-19 initials, date agency notified, diagnosis, treatment, and resolution including when they would return to work. No other documents were provided for tracking Covid-19 infection occurrences. Findings Include: 1. On 04-25-2023 at 09:40 AM, a binder titled, “QAPI (sic Quality Assessment and Performance Improvement)” was reviewed and contained a policy titled “Performance Improvement”. The policy indicated but was not limited to, “… AM-PM Home Health Services shall establish a performance improvement plan to continuously measure, assess, and improve the performance of clinical and other processes… Special Instructions… 7. The Board of Directors will receive information about findings and activities that is needed to fulfill their responsibility for the quality of client care and safety and security of clients, staff, and others… 13. The Performance Improvement Plan is evaluated at least annually….” 2. On 04-25-2023 at 09:16 AM, the Administrator provided a binder titled “Governing Body Minutes”. The binder contained Governing Body minutes from June 15, 2022, September 23, 2022, and January 3, 2023. There was no evidence QAPI and policies and procedures were reviewed or discussed. 3. On 04-25-2023 at 09:40 AM, documents titled “Quality Assurance/Performance Improvement” were reviewed. The years were noted on the documents, 3 of the 4 documents had the year 2022 and 1 of the 4 documents had the year 2023. The documents evidenced a review of issues that indicated but was not limited to, “Infection control… Incidents… QAPI/Quarterly chart audits… compliance issues….” There was no evidence of performance improvement plans initiated. 4. On 04-25-2023 at 11:26 AM, an interview with the Administrator and Alternate Administrator was conducted. When queried regarding the involvement of the governing body, the Administrator indicated the governing body was aware of the incidents and they communicated with the governing body the concerns. There was no evidence in the Governing Body notes of QAPI or incidents being discussed.

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 observation, record review, and interview, the agency failed to ensure their COVID-19 Vaccine Mandate policy and procedures were implemented and failed to ensure that the agency met the COVID-19 Vaccine Mandate at 100% compliance for 21 of 21 employees that provide the agency's direct care and the with the potential of adverse outcomes for the agency’s current 27 patients. The findings include: 1. A review of a document received from Administrator 1 on 04-21-2023 at 11:04 AM, titled, “AM-PM HOME HEALTH SERVICES LLC’S COVID 19 PLAN,” with no date of implementation indicated, contained but was not limited to, “ AM-PM HOME HEALTH SERVICES LLC is committed to providing a safe and healthy workplace for all employees … has developed the following COVID 19 plan, which includes policies and procedures to minimize the risk of transmission of COVID-19, by OSHA’s (sic Occupational and Safety Health Administration) Covid … encourages employees to receive the COVID-19 vaccination … ” The agency failed to implement a policy regarding the COVID-19 guidelines according to the Centers for Medicaid and Medicare (CMS) COVID-19 vaccination mandate for CMS participants. 2. A review of a document received from Administrator 1 on 04-21-2023 at 11:04 AM titled, "AM PM COVID-19 EMERGENCY PLAN, Caring for Clients in their home," dated November 11th, 2020, contained but not limited to, "When making a home visit ... Complete (name of electronic medical record) questionnaire for client and self weekly ... Prevention measures (Mask procedure and Hand Washing) ... Monitor your client's symptoms ... a) If the client has flu-like symptoms such as fever, cough, or shortness of breath, both the client and the caregiver should wear face masks. B. If you suspect a possible Covid-19 case assist the client in contacting their health care (sic healthcare) provider ... WHAT TO DO IF YOU ARE ILL OR TEST POSITIVE FOR COVID ... Inform Agency Staff ... your client will be re-assigned (sic reassigned) ... stay home when you're sick ... Return to work when the following conditions have been met per CDC (Center for Disease Control) ... AM PM highly recommends all staff to receive the COVID vaccine to help ensure protection for yourself and your clients." The agency failed to implement and update policies and procedures to address additional precautions for unvaccinated staff by not monitoring vaccination status or implementing additional precautions for unvaccinated staff to mitigate the spread of Covid-19, in accordance with CMS's vaccination for COVID-19 (or evidence of a medical or religious exemption) mandate of . 3. A review of 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, 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 90 days on, the expected minimum threshold will be 100%. 4. During an interview with Administrator #1 on 04-21-2023 at 10:24 AM, she indicated the agency did not require staff to receive the Covid -19 vaccination as she did not think it was required. When queried regarding the implementation date of the Agency’s document titled " Covid 19 Plan", she was not able to provide a date.

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 agency failed to demonstrate members of the governing body were responsible and completed a review of the agency’s budget and Quality Assurance Performance Improvement Plan (QAPI) for 2022 and 2023. Findings Include: 1. On 04-20-2023 at 12:05 PM, a review of the agency’s Admission packet was conducted. The Admission packet evidenced a document titled “Code of Conduct” indicated but was not limited to, “… the Governing Body, will comply with all applicable federal and state laws, applicable professional standards of practice and agency policy and procedures ….” 2. On 04-25-2023 at 09:16 AM, the Administrator provided a binder titled “Governing Body Minutes.” The binder contained Governing Body minutes from June 15, 2022, September 23, 2022, and January 3, 2023. There was no documentation/evidence of Quality Assurance Performance Improvement (QAPI), policies and procedures, or that the agency’s budget was reviewed or discussed among the governing body. 3. On 04-25-2023 at 11:21 AM, an interview was conducted with the Administrator. When queried regarding the discussions between the Governing Body members, the Administrator indicated they discuss what is going on with the patients, new hires, new patients, hospital visits, incidents, aide meetings, and possibly QAPI, Emergency Preparedness (EP), and the agency budget. The Administrator indicated the policies were reviewed but stated, “not necessarily documented in the minutes.” The administrator indicated there was no evidence in the Governing Body Meeting documents of QAPI, EP, policies and procedures, and the agency’s budget having been discussed. 410 IAC 17-12-1(b)

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 interviews, the agency failed to answer their 24-hours per day number 3 of 3 different days the number was called with the potential to affect all 27 agency patients. Findings Include: 3. On 04-23-23 at 4:10 PM the On-Call number was called and went to voicemail identifying the number as the On-Call number of AM-PM Home Health, a voice message was left requesting a call back to verify the On-Call number was active. No return phone call was received. 4. On 04-24-2023 at 06:38 AM the On-Call number was called and went to voicemail identifying the number as the On-Call number of AM-PM Home Health, a voice message was left requesting a call back to verify the On-Call number was active. 5. On 04-24-2023 at 8:35 AM received a phone call from the Agency's Owner from the office, reporting the voicemail should have been forwarded to the On-Call nurse. She was contacting the phone service provider for answers. 410 IAC 17-12-1(C)(1) 1. On 04-25-2023 at 09:12 AM, a review of an undated policy titled “Provision for 24-Hour RN (sic Registered Nurse) Availability” indicated but was not limited to, “… A Registered Nurse shall be accessible at all times, 24 hours per day, by telephone to meet client needs… The on-call Nurse shall respond to all messages in a timely manner….” 2. On 04-20-2023 at 09:10 PM, the on-call (a nurse designated to respond to patient emergencies after office hours) number was called with a voicemail left that requested a return call. On 04-21-2023 at 08:43 AM, the Owner of the agency returned the call.