Every finding on record at Apple Tree Home Health Care Services, LLC

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102 Survey Dates: 01/22, 01/23, 01/24, and 01/27/2025. Active Census: 25 At this Emergency Preparedness survey, Apple Tree Home Health Care Services, LLC was found to be out of compliance with Conditions of Participation Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 484.102 QR completed by Area 3 on 2-04-2025.

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 the comprehensive emergency preparedness program met all requirements to ensure the health, safety, and security needs of their staff and patient population for 1 of 1 agency (E0001); failed to ensure an emergency preparedness plan was in place and reviewed every 2 years at minimum (E0004); failed to ensure a facility based and community based risk assessment utilizing an all-hazards approach (E0006); failed to ensure the agency had a plan for subsistence needs for staff or patients, whether the evacuated or sheltered in place: failed to ensure access to a plan or a system / defined procedure to track the location of on-duty staff and sheltered patients under the agency’s care during an emergency (E0021); failed to develop a communication plan to be reviewed/updated at least annually (E0029); failed to ensure that an emergency preparedness communication plan included all staffing addresses and phone numbers, entities providing services under arrangements, and patient physicians for all districts/territories that the agency provided services to (E0030); failed to include contact information for Federal, State, Regional, and Local emergency preparedness officers (E0031); failed to provide a primary and alternate means for communicating with Federal, State, tribal, regional, and local emergency management agencies (E0032); failed to ensure the facility had a communication plan that is reviewed and updated at least every 2 years (E0034); failed to provide emergency preparedness training at least every 2 years and maintain documentation of all emergency preparedness training (E0037); and failed to conduct exercises to test the emergency plan annually by participating in a full scale exercise that is community based every 2 years, and conducting an additional exercise /mock drill or tabletop exercise, opposite the year of the full scale exercise (E0039). The cumulative effect of these systematic problems resulted in the agency being out of compliance with the condition, Emergency Preparedness Requirements for Medicare Participating Providers and Suppliers for Home Health Agencies, at 42 CFR 484.102 Findings include: 1. A review of the agency's policy titled “Emergency Preparedness Management Plan” undated, indicated but was not limited to, “ … Agency will have an identified plan in place to ensure the safety and well-being of clients and employees during periods of an emergency or disaster . . . Effectiveness of processes and systems will be reviewed regularly, but at least annually to assure safety …" 2. A review of the agency's policy titled "Hazard Vulnerability Analysis" undated, indicated but was not limited to, " … The proactive risk assessment … will be performed using an all hazards approach … The agency will re-visit and revise the Hazards Vulnerability Analysis (HVA) every two years and as appropriate …" 3. A review of the agency's policy titled "Emergency Disaster Plan Orientation and Training" undated, indicated but was not limited to, " … Initial training in emergency preparedness policies and procedures to all new and existing staff … Provide emergency preparedness training at least every 2 years … Maintain documentation of training … The agency must conduct exercises to test the emergency plan at least annually … Participate in a full-scale exercise that is community based; or When a community- based exercise is not accessible, conduct an annual, individual, agency-based functional exercise every 2 years …" 4. A review of the agency's policy titled "Emergency Preparedness Evacuation" undated, indicated but was not limited to, " … Establish an emergency contact list and identify individuals who will assist during an emergency …" 5. During an interview on 01/23/2024 Administrator 1 was queried regarding the Emergency Preparedness Plan. They indicated there was an additional EP binder with information that could not be located. He/she checked another building location and could not locate it.

This visit was for a complaint survey of a HHA Provider. On 01/22/2025 at 09:54 AM, the survey was announced as fully extended to the Administrator. Survey Dates: 01/21, 01/22, 01/23, 01/24, and 01/27/2025 Complaint #: 111755 with related and unrelated deficiencies cited 12 Month Unduplicated Skilled Admissions: 0 During this fully extended complaint survey, Apple Tree Home Health Care, LLC was found to be out of compliance with Conditions of Participation 484.60 Care planning, coordination, and quality of care and Condition of Participation 484.65 Quality Assessment and Performance Improvement. Based on the Condition-level deficiencies during the 01/27/2025 survey, your HHA was subject to a partial or extended survey pursuant to section 1891(c)(2)(D) of the Social Security Act on 01/27/2025. Therefore, and pursuant to section 1891(a)(3)(D)(iii) of the Act, your agency is precluded from operating a home health aide training, skills competency and/or competency evaluation programs for a period of two years beginning 01/27/2025 and continuing through 01/26/2027. 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 RN Registered Nurse DON Director of Nursing POC Plan of Care SOC Start of care SN Skilled Nursing QAPI Quality Assessment and Performance Improvement DME Durable Medical Equipment QR completed by Area 3 on 2-04-2025.

Written notice of patient's rights CFR(s): 484.50(a)(1)(i) (i) Written notice of the patient's rights and responsibilities under this rule, and the HHA's transfer and discharge policies as set forth in paragraph (d) of this section. Written notice must be understandable to persons who have limited English proficiency and accessible to individuals with disabilities; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patient’s rights were included in the admission packet for 3 of 4 admission packets reviewed during a home visit. (Patients: #4, #7, #8, and #11) Findings Include: 1. A policy titled “Home Care Bill of Rights” Policy No. C-380 indicated but was not limited to, “ … 1. A designated Registered Nurse/Therapist shall provide the client with a written notice of the Home Care Bill of Rights in advance of furnishing care to the client …” 2. A review of the agency admission packet evidenced the policy “Home Care Bill of Rights” and indicated but was not limited to, “ … A designated Registered Nurse/Therapist shall provide the client with a written notice of the Home Care Bill of Rights in advance of furnishing care to the client …” During a home visit at Patient #4's residence on 01/23/2025 at 6:16 AM, the patient's admission packet evidenced a Home Care Bill of Rights policy. The policy provided by the agency failed to ensure the patient was provided a document regarding their right to receive all the services in the POC, be free from discrimination, and abuse. 3. During a home visit at Patient #7’s residence on 01/22/2025 at 9:00 AM, the patient’s admission packet evidenced the policy Home Care Bill of Rights. The policy provided by the agency failed to ensure the patient was provided a document regarding their right to receive all the services in the POC, be free from discrimination, and abuse. 4. During a home visit at Patient #8’s residence on 01/22/2025 at 10:25 AM, their admission packet failed to evidence patient rights information. 5. During a home visit at Patient #11’s residence on 01/22/2025 at 10:25 AM, their admission packet failed to evidence patient rights information. 6. During an interview on 01/22/2025 at 10:45 AM, with the group home staff member, Person 5, at Patient #8 and Patient #11’s residence, they indicated the documents in the binder were all they had for the patients from the agency. 7. During an interview on 01/23/2025 at 9:30, the Administrator explained they provided the Bill of Rights to the patients and indicated the Bill of Rights did not include the right for the patient to have all services provided according to the plan of care and be free from discrimination and abuse. The Administrator expressed they would need a new policy to include the patient's individual rights and responsibilities. 8. During an interview with the group home (Entity 4) supervisor, Person 6, on 01/24/2025 at 2:24 PM, they indicated the documents in the admission folder were kept in Patient #7's, Patient #8’s, and Patient #11's residence, so if they had patient rights information, it would be in the group home. 410 IAC 17-12-3(a)1(A)

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 patients received the frequency of services listed in the POC (G0572), POCs were individualized and included all pertinent information (G0574), treatments were administered only as ordered by a physician (G0580), the physician was notified of the POC not being followed (G0590), document and coordinate care with other entities (G608), provide a current POC (G0612), provide a current schedule (G0614), and provide a current medication list (G0616). 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. Findings Include: 410 IAC 17-13-1(a) *

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure patients received the frequency of the services listed in their POCs for 3 of 7 active clinical records (Patients #4, #8, and #12) reviewed with HHA services only and 1 of 1 patient receiving SN services only.(Patient #5) Findings Include: 5. Review of the clinical record for Patient #4 revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 09/27/2024 for the certification period of 11/18/2024 through 01/16/2025 signed by the DON. The POC evidenced, but was not limited to, Patient #4 would receive a HHA 8 hours a day, 7 days a week for 9 weeks and a PCA 8 hours a day, 6 days a week for 9 weeks. Review of the clinical record for Patient #4 revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 09/27/2024 for the certification period of 01/17/2025 through 03/17/2025 signed by the DON. The POC evidenced, but was not limited to, Patient #4 would receive a HHA 8 hours a day, 7 days a week for 9 weeks and a PCA (Patient Care Aide, how the agency refers to attendant care) 8 hours a day, 6 days a week for 9 weeks. Review of the clinical record for Patient #4 revealed a document titled "PCA Care Plan" with a care period of 11/18/2024 through 01/16/2025 signed by the DON. Review of the clinical record for Patient #4 revealed a document titled "PCA Care Plan" with a care period of 01/17/2025 through 03/17/2025 signed by the DON. Review of the clinical record for Patient #4 revealed a document titled "PHYSICIAN ORDER" dated 01/15/2025 AM and signed by the DON. The document evidenced but was not limited to, a verbal order was received "to continue HHA services for this certification period". Review of the clinical record for Patient #4 revealed a document titled "PCA Visit Note" and "Aide Visit Note" dated 11/18/2024 through 11/22/2024 and signed by HHA 8. The clinical record failed to evidence Patient #4 received HHA services 8 hours a day, 7 days a week for the week of 11/18/2024 through 11/22/2024. Review of the clinical record for Patient #4 revealed a document titled "Aide Visit Note" dated 11/25/2024 through 11/30/2024 and signed by Person 3. The clinical record revealed a document titled "PCA Visit Note" dated 11/29/2024 and 11/30/2024. The clinical record failed to evidence Patient #4 received HHA services 8 hours a day, 7 days a week for the week of 11/25/2024 through 11/30/2024. Review of the clinical record for Patient #4 revealed a document titled "Aide Visit Note" dated 12/02/2024 through 12/04/2024 and signed by Person 3. The clinical record revealed a document titled "PCA Visit Note" dated 12/03/2024 and 12/04/2024. The clinical record failed to evidence Patient #4 received HHA services 8 hours a day, 7 days a week for the week of 12/02/2024 through 12/04/2024. Review of the clinical record for Patient #4 revealed a document titled "Aide Visit Note" dated 12/05/2024 and 12/06/2024, and signed by Person 3. The clinical record revealed a document titled "PCA Visit Note" dated 12/05/2024 and 12/06/2024. The clinical record failed to evidence Patient #4 received HHA services 8 hours a day, 7 days a week for the week of 12/05/2024 through 12/06/2024. Review of the clinical record for Patient #4 revealed a document titled "PCA Visit Note" dated 12/07/2024, 12/09/2024 through 12/14/2024, 12/16/2024 through 12/20/2024, 12/23/2024, 12/24/2024, 12/26/2024 through 12/31/2024, 01/01/2025 through 01/04/2025, and signed by HHA 8. The clinical record revealed a document titled "Aide Visit Note" dated 12/10/2024 and signed by HHA 8. The clinical record failed to evidence Patient #4 received HHA services 8 hours a day for the following visits 12/07/2024, 12/09/2024 through 12/14/2024, 12/16/2024 through 12/20/2024, 12/23/2024, 12/24/2024, 12/26/2024 through 12/31/2024, 01/01/2025 through 01/04/2025. Review of the clinical record for Patient #4 revealed a document titled "PCA Visit Note" dated 12/21/2024 and signed by HHA 9. The clinical record failed to evidence Patient #4 received HHA services 8 hours a day for the visit on 12/21/2024. Review of the clinical record for Patient #4 revealed a document titled "PCA Visit Note" dated 01/06/2025 through 01/11/2025, 01/13/2025 through 01/15/2025, 01/17/2025, 01/20/2025 through 01/25/2025, and signed by HHA 3. The clinical record failed to evidence Patient #4 received HHA services 8 hours a day for the visits conducted on 01/06/2025 through 01/11/2025, 01/13/2025 through 01/15/2025, 01/17/2025, 01/20/2025 through 01/25/2025. The clinical record failed to evidence the agency provided the HHA services as written in the individualized plan of care. During an interview on 01/21/2025 at 1:18 PM, Person 1 indicated they were a family member and caregiver of Patient #4. Person 1 indicated Patient #4 is supposed to be receiving HHA services from the agency Monday through Saturday 11:00 PM until 7:00 AM. During an interview on 01/23/2025 at 11:52 AM, the Administrator was queried about what PCA meant to their agency. The Administrator indicated PCA is how the agency refers to attendant care. During an interview on 01/23/2025 at 3:11 PM, the Administrator indicated a PCA is less hands on, does more house work, and is the patient's companion. When queried about Patient #4's POC including HHA and PCA hours, the Administrator indicated Entity 9, an insurance company, denied the HHA hours, but would provide PCA hours. The Administrator indicated all of her PCAs are HHAs, so Patient #4 technically has a HHA and the agency just bills the visit as PCA in order to receive payment. During an interview on 01/24/2025 at 2:50 PM, when queried about the PCA and HHA hours for Patient #4 the Administrator indicated Person 1 had to return to work, so the agency started services while waiting for the prior authorization to come through. The Administrator indicated the agency was providing a HHA 8 hours a day, 7 days a week and when the prior authorization came back insurance only approved 3 hours a day, 3 days a week, so all HHA hours were used. The Administrator indicated after the agency received this notice Patient #4 was placed on hold and Person 1 was notified. The Administrator indicated appeals were filed and a RN case manager assisted with the appeals. The Administrator indicated Entity 9, an insurance company, approved attendant care 6 days a week. The Administrator indicated for Entity 9, an insurance company, to provide payment visits have to be scheduled as PCA due to Entity 9, an insurance company, not providing payment for visits scheduled as HHA. 410 IAC 17-13-1(a) 1. A policy titled "Plan of Care" indicated but was not limited to, " … Home care services are furnished under the supervision and direction of the client's physician/allowed non-physician practitioner (NPP) …" 2. A review of Patient #5's clinical record evidenced a POC with a SOC of 03/13/2021 and a certification period from 12/23/2024 to 02/20/2025. The POC included the following diagnoses: Quadriplegia (paralysis of all four limbs), Convulsions (uncontrolled jerking), constipation, reduction deformities of the brain, tracheostomy (a surgical procedure to create an opening in the front of the neck to open the airway and allow the individual to breath) status, Severe intellectual disabilities, feeding difficulties, and a cystostomy (a surgical opening to create an opening in the bladder for urine to expel from the body into a collection bag). The POC evidenced the patient received SN services eight hours a day, six days a week, for 9 weeks. Review of the SN visit notes evidenced the following: During the week of 12/23/2024 through 12/28/2024, evidenced SN visits were conducted on 12/23, 12/24, 12/26, and 12/27/2024. A missed visit was documented on 12/25/2024 and revealed the caregiver would assume care. The record failed to evidence SN visit notes on 12/22 or 12/28/2024. During the week of 12/29/2024 through 01/04/2025, evidenced SN visits were conducted on 12/30, 12/31, 01/02, and 01/03/2025. The record failed to evidence SN visit notes on 12/29/2024, 01/01/2025, and/or 01/04/2025. During the week of 01/05/2025 through 01/11/2025, evidenced SN visits were conducted on 01/09/2025 and 01/10/2025. Missed visit notes were documented on 01/06, 01/07, and 01/08/2025 and indicated the caregiver would assume care for the patient. The record failed to evidence SN visit notes on 01/05/2025 or 01/11/2025. During the week of 01/12/2025 through 01/18/2025, evidenced SN visits were conducted on 01/13, 01/14, 01/15, 01/16, and 01/17/2025. The record failed to evidence SN visit notes on 01/12 or 01/18/2025. During an interview with Person 7, Patient #5's relative and caregiver, on 01/24/2025 at 12:07 PM, they indicated a nurse was supposed to come 6 days a week and every other Sunday, but rarely had this occur. Person 7 explained the agency had difficulty staffing Patient #5's time for around two months. They confirmed LPN 1 was good, but on average, missed about one visit a week. They indicated there had been a nurse, who no longer was employed by the agency, had worked the weekends for Patient #5. They explained LPN 1 informed them when they were not going to be able to be at the patient's residence, the office staff never contacted them regarding missed visits or if they would want another nurse to come assist the patient for the days LPN 1 was not able to be there. They confirmed they needed all the assistance they could get because they had to work and had reached out to the agency a couple times to inform them of this. During an interview with LPN 1 on 01/24/2025 at 12:23 PM, they indicated they were with Patient #5 Monday through Friday from 9:00 AM to 5:00 PM. They explained they sometimes worked weekends, but Patient #5 did not have weekend coverage. They indicated the family helped take care of the patient and "did what they can to make up for it", when the LPN was unable to provide care. When queried regarding their process for if when they were unable to work a day, LPN 1 explained they informed the staff at the office and they would take it from there. During an interview on 01/27/2025 at 4:06 PM, the Clinical Manger and the Administrator indicated if the relative, Person 7, was there on the weekend for Patient #5, they did not go out to provide care for the patient because the caregiver would. They explained if there were no missed visit notes or dates for the visits, a missed visit note had not been completed and the physician was not notified. 3. A review of Patient #8’s clinical record evidenced a POC with a SOC of 06/11/2022 and a certification period from 11/27/2024 to 01/25/2025. The POC included the following diagnoses: Autistic disorder (a developmental disability where the individual has difficulty communicating and social communication), Impulse disorder, and Mental disorder. The POC evidenced the patient received HHA services one hour a day, 7 days a week for 9 weeks. Review of the HHA visit notes evidenced the following: During the week of 12/01/2024 through 12/07/2024, evidenced HHA visits were conducted on 12/02, 12/03, 12/04, 12/05, 12/06, and 12/07/2024. The record failed to evidence SN visit notes on 12/01/2024. During the week of 12/08/2024 through 12/14/2024, evidenced HHA visits were conducted on 12/09, 12/10, 12/11, 12/12, and 12/13/2024. The record failed to evidence HHA visit notes on 12/08/2024 and 12/14/2024. During the week of 12/15/2024 through 12/21/2024, evidenced HHA visits were conducted on 12/16, 12/17, 12/18, 12/19, and 12/20/2024. The record failed to evidence HHA visits on 12/15/2024 and 12/21/2024. During the week of 12/22/2024 through 12/28/2024, evidenced HHA visits were conducted on 12/22, 12/23, 12/24, 12/26, and 12/27/2024. A missed visit was documented on 12/25/2024 and revealed the caregiver would assume care. The record failed to evidence HHA visit notes on 12/28/2024. During the week of 12/29/2024 through 01/04/2025, evidenced HHA visits were conducted on 12/30/2024, 12/31/2024, 01/02, 01/03, and 01/04/2025. The record failed to evidence HHA visit notes on 12/29/2024 and 01/01/2025. During the week of 01/05/2025 through 01/11/2025, evidenced HHA visits were conducted on 01/05, 01/06, 01/07, 01/08, 01/09, and 01/10/2025. The record failed to evidence an HHA visit note on 01/11/2025. During the week of 01/12/2025 through 01/18/2025, evidenced HHA visits were conducted on 01/13, 01/14, 01/15, 01/16, and 01/17/2025. The record failed to evidence HHA visit notes on 01/12/2025 and 01/18/2025. During the week of 01/19/2025 through 01/25/2025, evidenced HHA visits were conducted on 01/20, 01/21, 01/22, 01/23, and 01/24/2025. The record failed to evidence HHA visit notes on 01/19/2025. During an interview with Patient #8’s group home, Entity 4, Supervisor, Person 7, on 01/24/2025 at 2:24 PM, they indicated the agency communicated with them regarding missed visits and offered for other aides to come out when visits were missed. During an interview with the Clinical Manager and the Administrator on 01/27/2025 at 3:42 PM, they indicated if there were no missed visit notes or dates for the visits, a missed visit note had not been completed. 4. A review of Patient #12’s clinical record evidenced a POC with a SOC of 08/13/2024 and a certification period from 12/11/2024 to 02/08/2025. The POC evidenced the following diagnoses: Functional Quadriplegia (a condition caused by another medical condition where the person is unable to move their extremities), history of traumatic brain injury, dysphagia (difficulty swallowing), and contracture (shortening of the muscles causing stiffness and limited range of motion) of the right and left hand. The POC revealed the patient received HHA services nine hours a day, seven days a week, for nine weeks. A review of the HHA visit notes evidenced the following: During the week of 12/11/2024 through 12/14/2024, evidenced HHA visits were conducted on 12/11/2024 and 12/12/2024. The record failed to evidence HHA visit notes on 12/13/2024 and 12/14/2024. During the week of 12/15/2024 through 12/21/2024, evidenced HHA visits were conducted on 12/16, 12/17, and 12/18/2024. The record failed to evidence HHA visit notes on 12/15, 12/19, 12/20, and 12/21/2024. During the week of 12/22/2024 through 12/28/2024, evidenced HHA visits were conducted on 12/25 and 12/26/2024. The record failed to evidence HHA visit notes on 12/22, 12/23, 12/24, 12/27, and 12/28/2024. During the week of 12/29/2024 through 01/04/2025, evidenced HHA visits were conducted on 12/30/2024, 12/31/2024, 01/01/2025, and 01/02/2025. The record failed to evidence HHA visit notes on 12/29/2024, 01/03/2025, and 01/04/2025. During the week of 01/05/2025 through 01/11/2025, evidenced HHA visits were conducted on 01/06, 01/08, and 01/09/2025. A missed visit note was documented on 01/07/2025 and indicated the reason was “Availability”. The missed visit notes evidenced the physician was not notified of the missed visit. The record failed to evidence HHA visit notes on 01/05, 01/10, and 01/11/2025. During the week of 01/12/2025 through 01/18/2025, evidenced HHA visits were conducted on 01/13, 01/14, 01/15, and 01/16/2025. The record failed to evidence HHA visit notes on 01/12, 01/17, and 01/18/2025. During the week of 01/19/2025 through 01/25/2025, evidenced HHA visits were conducted on 01/20, 01/21, 01/22, and 01/23/2025. The record failed to evidence HHA visit notes on 01/19, 01/24, and 01/25/2025. A review of Patient #12’s clinical record evidenced a Physician order dated 11/22/2024 for the certification period from 10/12/2024 to 12/10/2024. The order revealed the caregiver had dismissed four different aides and only accepted one aide who could only work four days a week. The order indicated the caregiver was agreeable to four days a week. During an interview with Person 8, Patient #12’s relative and caregiver, on 01/27/2025 at 10:54 AM, they indicated they were unsatisfied with the services provided by the agency. They explained how the agency did not communicate with them, could not fill more of the patient’s hours, and received services four days a week. They indicated they needed all seven days as ordered on the POC because the patient kept them awake all night for their tube feeding and their behavior issues. Person 8 explained the agency had sent different aides who had not worked out, but needed an agency who could follow through with their promises. Person 8 expressed if the agency failed to provide an aide for the patient, “it is on me”, and they had to take breaks when giving the patient a bath because it made them exhausted. During an interview with the Clinical Manager and the Administrator on 01/27/2025 at 3:20 PM, they indicated they should have changed the frequency of HHA services to four days a week for Patient #12 because it was the only time the HHA was able to be staffed. They indicated the physician order from 11/22/2024 reflected why the patient did not receive their ordered frequency, but confirmed the order was from the previous certification period and the current POC indicated the patient should receive services seven days a week.

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 observation, record review, and interview, the agency failed to ensure the plan of care was individualized and included all necessary elements including allergies, advanced directive, caregiver status, medication frequency, DME, seizure plan, correct enteral feeding rate, vital sign parameters, psychosocial status, hospitalization risk, frequency, duration, and interventions for skilled nursing services, and parameters to notify the physician of INR (International Normalized Ratio, blood test that measures how long it takes for a person's blood to clot) for 10 of 11 active clinical records reviewed. (Patients #1, 2, 3, 4, 5, 6, 7, 8, 12, and 13) Findings Include: 7. A review of Patient #1's clinical record evidenced a POC with a SOC of 10/14/2024 and a certification period from 12/13/2024 to 02/10/2025. The POC included the following diagnoses: Insomnia (having difficulty falling or staying asleep), Hypertension (high blood pressure), Hypothyroidism (a condition where the thyroid does not produce enough of its' hormone causing issues with heart rate, temperature, and metabolism), Anxiety, and long term use of anticoagulants (medications to prevent or treat blood clots). The sections titled "Caregiver Status" and "Hospitalization Risk" evidenced the statement, "There is no data for this section." The patient received 8 hours a day, 7 days a week of HHA services. The POC revealed the patient took 5 milligrams (mg) of Apixaban (an anticoagulant) orally, 50 micrograms (MCG) of Cholecalciferol orally, 75 mg of Clopidogrel (prevents clotting) orally, 10 mg of Escitalopram Oxalate (antidepressant) orally, 40 mg of Lipitor (treats high cholesterol) orally, 25 mg of Losartan Potassium (for high blood pressure) orally, 25 mg of Metoprolol Tartrate (treat high blood pressure) orally, 400 MCG/spray of Nitroglycerin (to relieve chest pain) orally on the top of the tongue, and 50 mg of Trazodone (for depression) orally. The frequency listed for all of the listed medications evidenced "Frequency: 1". The section titled "Allergies" was left blank. The POC for Patient #1 failed to evidence the patient's caregiver, hospitalization risk, frequency of medications, and allergies. During an interview on 01/24/2025 at 9:04 AM, HHA 5 (Patient #1's aide and relative) indicated they took care of Patient #1 around the clock. They explained the patient needed care 24 hours a day, 7 days a week for assistance with walking to the restroom and incontinence clean up. During an interview on 01/27/2025 at 4:20 PM, the Clinical Manager and the Administrator indicated no caregiver was listed on the POC and should have included Patient #1's significant other and HHA 5. They explained the patient's hospitalization risk, allergies, and medication frequencies. 8. A review of Patient #5's clinical record evidenced a POC with a Soc of 03/13/2021 and a certification period from 12/23/2024 to 02/20/2025. The POC included the following diagnoses: Quadriplegia (paralysis of all four limbs), Convulsions (uncontrolled jerking), constipation, reduction deformities of the brain, tracheostomy (a surgical procedure to create an opening in the front of the neck to open the airway and allow the individual to breath) status, Severe intellectual disabilities, feeding difficulties, and a cystostomy (a surgical opening to create an opening in the bladder for urine to expel from the body into a collection bag). The section titled "Caregiver Status" indicated, " … Caregiver lives with patients but works during the day. …". The Durable Medical Equipment (DME) section included a Nebulizer, hospital bed, oxygen, wheelchair, percussion vest ceiling track system, suction machine, feeding bags, feeds, bard buttons, 60 milliliter (mL) syringes, feeding extension, two by two gauze, silk tape, and exam gloves. The patient's diet consisted of Peptamin AF 1.5 formula at 75ml per an hour. The patient had a functional limitation of bowel and bladder incontinence. The orders evidenced the SN was to notify the patient's Pulmonologist (physician specializing in treating conditions of the respiratory system) for oxygen saturation less than 89%. For seizures, the patient would have 5mg of Nayzilam (treatment for seizures) given through a nasal spray for seizures lasting more than 5 minutes and the dose could be repeated one time if the seizure does not stop after 5 minutes. During an interview with Person 7, Patient #5's relative and caregiver, on 01/24/2025 at 12:07 PM, they explained the patient's seizure plan was for them to give an extra 0.5 mg tablet of Klonopin (medication used to prevent seizures) if the patient had more than one seizure in a half an hour. Person 7 indicated they would protect the patient's face from the bars on the bed during the seizure. They revealed they had suction tubing, extra inner cannula inserts, and a Kangaroo Joey feeding pump. They indicated the feeding pump has run at 85 ml per an hour for 10-15 years. Patient #5's POC failed to include Person 7, Patient #5's relative and caregiver, as their caregiver, all of the patient's DME, the correct rate for the enteral (a tube allowing nutrients to go directly into the stomach) feeding pump, the patient's seizure diagnosis, the correct seizure medication, seizure plan for the patient, parameters for heart rate, temperature, blood pressure, and respirations for when to notify the physician. During an interview on 01/27/2025 at 4:06 PM, the Clinical Manger and the Administrator indicated Person 7 was Patient #5's relative and caregiver and they should be specifically mentioned on the POC. They revealed they thought the order for the tube feeding was 75 ml per hour. They indicated they should have listed the incontinent supplies, the extra tracheostomy supplies, tracheostomy mask, and the feeding pump. The Clinical Manager explained the patient had no set seizure plan, and the clinician and caregiver were to follow the orders on the POC. When queried regarding the Nayzilam being listed instead of the Klonopin, the Clinical Manager explained they thought Nayzilam was the medication the patient was on for their seizures. 9. A review of Patient #7's clinical record evidenced a POC with a SOC of 07/11/2017 and a certification period from 12/01/2024 to 01/29/2025. The POC included the following diagnoses: Benign prostatic hyperplasia with lower urinary tract symptoms (a condition were the bladder is pressed on by the enlarged prostate causing frequent urination and difficulty in completely emptying the bladder. Diffuse traumatic brain injury (nerve fibers in the brain are torn causing damage), Hyperlipidemia (high levels of fat in the blood), Type 2 Diabetes Mellitus (a condition where the body is unable to appropriate regulate sugar levels in the body), Anxiety, and Edema (fluid buildup in the body's tissues causing swelling). The section titled "Caregiver Status" indicated but was not limited to, " … has no caregiver that currently lives in home …". The DME section revealed the patient had a walker, wheelchair, oxygen, tub/shower bench, cane, grab bars, and exam gloves. The SN summary evidenced the patient would receive SN services for medication refills. The orders for the patient was HHA services six hours a day, 7 days a week, for 9 weeks. During a home visit at Patient #7’s residence on 01/22/2025 at 9:00 AM, a nasal cannula, urinal, an overhead bar lift over the bed, and a floor-to-ceiling grab bar next to the patient’s bed. During an interview with the Clinical Manager and the Administrator on 01/27/2025 at 3:54 PM, they indicated the patient refused to take anything for their blood sugar and had no glucometer for the patient. They revealed the patient used to have SN services, but no longer receives those services. The Clinical Manager indicated the patient lived in a group home, Entity 4. They confirmed the staff with Entity 4 were there for the patient to supervise and assist when needed. They confirmed their availability should have been included on the POC. They explained all of Patient #7’s DME was to be listed on the POC and they were missing the incontinence supplies, urinal, and the overhead lift. The Clinical Manager explained they do not include vital signs on the POC. 10. A review of Patient #8’s clinical record evidenced a POC with a SOC of 06/11/2022 and a certification period from 11/27/2024 to 01/25/2025. The POC included the following diagnoses: Autistic disorder (a developmental disability where the individual has difficulty communicating and social communication), Impulse disorder, and Mental disorder. The section titled "Caregiver Status" indicated but was not limited to, " … has no caregiver that currently lives in home …". The POC failed to include the caregiver and their availability and vital sign parameters for when to notify the physician. During an interview with the Clinical Manager and the Administrator on 01/27/2025 at 3:42 PM, the Clinical Manager indicated Entity 4 had a staff member looking after them 24 hours a day, 7 days a week to ensure the patient’s safety. They revealed they had not seen the group home staff as caregivers, but confirmed Entity 4 staff members took care of Patient #8. They indicated they never included vital sign parameters on the POC because the physician never gave them parameters for the patients. 11. A review of Patient #12’s clinical record evidenced a POC with a SOC of 08/13/2024 and a certification period from 12/11/2024 to 02/08/2025. The POC evidenced the following diagnoses: Functional Quadriplegia (a condition caused by another medical condition where the person is unable to move their extremities), history of traumatic brain injury, dysphagia (difficulty swallowing), and contracture (shortening of the muscles causing stiffness and limited range of motion) of the right and left hand. The sections titled “Caregiver Status” and “Hospitalization Risk” indicated but was not limited to, “ … There is no data for this section …” The DME evidenced the patient had a wheelchair, grab bars, hospital bed, and exam gloves. The POC revealed the patient’s diet was regular with supplemental protein shakes. During an interview with Person 8, Patient #12’s relative and caregiver, on 01/27/2025 at 10:54 AM, they indicated they were the caregiver for Patient #12 and the patient required constant supervision. They explained the patient’s main source of nutrients was 6 cartons of Jevity nutrition supplement through the patient’s Gastrostomy tube (a small tube in the stomach to deliver nutrients and medication for people who are unable to have anything by mouth). They indicated they patient had their feeding at night for seven hours. They explained they had all the tubing, feeding, and feeding pump for the patient. Person 8 indicated the patient lost 11 of their teeth and had behavioral issues causing the patient to have difficulty eating and drinking by mouth. The POC failed to evidence Patient #12’s caregiver, their hospitalization risk, include the tubing, feeding, incontinence supplies, and the feeding pump. During an interview with the Clinical Manager and the Administrator on 01/27/2025 at 3:20 PM, they indicated Person 8 was Patient #12’s caregiver and should have been listed on the POC. They explained the patient’s hospitalization risk was to be included on the POC. The Clinical Manager revealed the patient was able to eat food by mouth and was unaware the patient was on tube feedings. They explained the incontinent supplies and tube feeding supplies should have been listed on the POC. 410 IAC 17-13-1(a)(1)(D)(ii, iii, viii, ix, and xiii) 1. A review of an agency's policy titled "PLAN OF CARE," indicated but was not limited to, " … The Plan of Care should be completed in full to include: … type, frequency, and duration of all visits/services … need for / presence of home medical equipment and assistive devices … specific dietary or nutritional requirements … medications … medical supplies and equipment … safety measures … treatment goals … other appropriate items …" 2. Review of the clinical record for Patient #2 revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 12/18/2023 for the certification period of 12/12/2024 through 02/09/2025 signed by the DON. The POC evidenced Patient #3 has a diffuse TBI (Traumatic Brain Injury, injury to the brain caused by an external force), cramp and spasm, other irregular eye movement, and Circadian rhythm sleep disorder (a sleep disorder that occurs when the body's internal clock is out of sync with a person's body). The POC subsection titled "Advanced Directive" evidenced "there is no data for this section". The POC subsection titled "Caregiver Status" evidenced "there is no data for this section". The POC subsection titled "Psychosocial Status" evidenced "there is no data for this section". The POC subsection titled "Hospitalization Risk" evidenced "there is no data for this section". The POC subsection titled "DME & Supplies" included, "Wheelchair, Hospital Bed, Hoyer life, Standing lift, Exam gloves, non-sterilized gloves". The POC subsection titled "Functional Limitations," included but was not limited to, "Bowel/Bladder Incontinence". The POC failed to evidence if Patient #2 has an Advanced Directive, the status of his caregiver, what his psychosocial status is, and DME: incontinent supplies. During an interview on 01/7/2025 at 2:39 PM, the DON indicated Patient #2 does not have an advanced directive as far as they know. When queried about Patient #2's caregiver status, they indicated Patient #2 does have a caregiver. When queried about Patient #2's psychosocial status, they indicated Patient #2 has no needs at this time. When queried about Patient #2's hospitalization risk, they indicated Patient #2 is a low hospitalization risk. When queried if Patient #2 used incontinent supplies, they indicated Patient #2 does use incontinent supplies and should be listed on the POC. 3. Review of the clinical record for Patient #3 revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 09/23/2024 for the certification period of 01/21/2025 through 03/21/2025 signed by RN 1. The POC evidenced, but was not limited to Patient #3 has Gastro-esophageal reflux disease (condition where acidic gastric fluid flows backward into the esophagus, resulting in heartburn), chronic kidney disease (condition where the kidneys slowly lose their ability to filter waste products and excess fluid from the blood), pure hypercholesterolemia (high levels of cholesterol in the blood), and obstructive sleep apnea (sleep disorder that occurs when the upper airway is blocked during sleep, causing breathing to be interrupted). The POC subsection titled "Orders for Discipline and Treatment," included but was not limited to, SN frequency every 30 days, SN to instruct client to wear proper footwear when ambulating, SN to instruct client to use prescribed assistive device when ambulating, SN to instruct client to change positions slowly, SN to instruct the Client to remove clutter from client's path, SN to instruct the client to contact agency to report any fall. The POC failed to evidence Patient #3 would receive one visit a week for 9 weeks for the SN to provide medication box set up, assistance with monitoring and notifying the physician of INR values, and parameters for when to notify the physician of INR value. During an interview on 01/25/2024 at 4:45 PM, RN 1 indicated they provide care for Patient #3. When queried about what services they provide to Patient #3, RN 1 indicated they perform the recertifications, weekly medication set up, and notifies the physician of Patient #3's INR (International Normalized Ratio, a blood test that measures how well your blood clots) weekly. When queried about having orders to perform medication box set ups and parameters to notify the MD and including this information on the POC, RN 1 indicated they understood. During an interview on 01/27/2025 at 2:45 PM, the DON indicated the POC should include frequency and duration of nursing services, medication box set up, and parameters for when to notify the physician of the INR level. 4. Review of the clinical record for Patient #4 revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 09/27/2024 for the certification period of 01/17/2025 through 03/17/2025 signed by the DON. The POC evidenced Patient #4 has Chronic obstructive pulmonary disease (condition involving the constriction of the airways and difficulty or discomfort in breathing), Type 2 Diabetes Mellitus (chronic disease that occurs when the body does not produce enough insulin or use the insulin correctly), history of a TIA (Transient Ischemic Attack, temporary disruption of blood flow to the brain, causing temporary stroke like symptoms), Hypertension (high blood pressure), and bilateral amputee. The POC subsection titled "Caregiver Status" evidenced "there is no data for this section". The POC subsection titled "Hospitalization Risk" evidenced "there is no data for this section". The POC subsection titled "DME & Supplies," evidenced but was not limited to, "Wheelchair and Exam Gloves". During a home visit on 01/23/2025 at 6:16 AM, HHA 3 was observed providing care for Patient #4. Patient #4 was observed to have a hospital bed, incontinent supplies, and a nebulizer and associated equipment. The POC failed to evidence DME: hospital bed, incontinent supplies, and nebulizer and associated equipment. During an interview on 01/23/2025 at 2:20 PM, the Administrator indicated a hospital bed is considered DME and should be listed on the POC. During an interview on 01/23/2025 at 3:11 PM, the DON indicated the nebulizer machine and associated equipment and incontinent supplies should be included on the POC. 5. Review of the clinical record for Patient #6 revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 11/25/2024 for the certification period of 11/25/2024 through 01/23/2025 signed by the DON. The POC evidenced Patient #6 has, but is not limited to, End Stage Renal Disease (chronic disease that has progressed to the point that the kidneys no longer function), dependence of renal dialysis (clinical purification of the blood as a substitute for the normal function of the kidney), Type 2 Diabetes Mellitus (chronic disease that occurs when the body does not produce enough insulin or use the insulin correctly), Schizophrenia (chronic mental illness characterized by significant disruptions in thought process, perceptions, emotions, and social interactions), Congestive Heart Failure (condition where the heart muscle is weakened or damaged and cannot pump blood effectively), Chronic Obstructive Pulmonary Disease (condition involving the constriction of the airways and difficulty or discomfort in breathing), Arteriovenous fistula (abnormal connection between an artery and vein, used for dialysis). The POC subsection titled, "Safety Measure" evidenced but is not limited to, Anticoagulant (blood thinner) Precautions, Fall Precautions, Keep Pathway Clear, Safety in ADLs, Sharps Safety, Standard Precautions/Infections. The POC failed to evidence Patient #6 requires Left Arm Precautions. During an interview on 01/27/2025 at 3:00 PM, the DON indicated they had not thought to include Left Arm Precautions on the POC. 6. Review of the clinical record for Patient #13 revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 05/14/2020 for the certification period of 12/25/2024 through 02/23/2025 signed by the DON. The POC evidenced Patient #13 has, but is not limited to, Subacute cutaneous lupus erythematosus (type of lupus that causes raised , scaly, or ring-shaped red lesions on the skin), Type 2 Diabetes Mellitus (chronic disease that occurs when the body does not produce enough insulin or use the insulin correctly), and Hypertension (high blood pressure). The POC subsection titled "Orders for Discipline and Treatment," included but was not limited to, SN frequency one time a week for 9 weeks, SN to assess pain levels and effectiveness of medications and current pain management therapy every visit, SN to instruct client to take pain medication before pain becomes severe to achieve better pain control, SN to instruct client on nonpharmacologic pain relief measures, including relaxation techniques, massage, stretching, positioning, and hot/cold packs, SN to assess 02 saturation on room air (freq) q visit. Report to physician 02 saturation less than 90%, SN to assess/ instruct on diabetic management to include: nail, skin, & foot care, medication administration and proper diet, SN to instruct client to wear proper footwear when ambulating, SN to instruct client to use prescribed assistive device when ambulating, SN to instruct client to change position slowly. The POC failed to evidence the SN performs a medication box set up weekly. During an interview on 01/ 27/2025 at 3:15 PM, the DON indicated the medication box set up should be added to the POC.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to provide services as ordered by the physician for 4 of 7 clinical records (Patient #4, 6, 8, and 12) reviewed with HHA services only and 2 of 3 patient receiving SN services (Patient #3 & Patient #5). Findings Include: 1. A review of an agency's policy titled "Physician/Non-Physician Practitioner (NPP) Orders," indicated but was not limited to, "POLICY All medications, treatments and services provided to clients must be ordered by a physician/allowed non-physician practitioner (NPP) …". 2. Review of the clinical record for Patient #3 revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 09/23/2024 for the certification period of 01/21/2025 through 03/21/2025 signed by RN 1. The POC evidenced, but was not limited to, Patient #3 would receive a HHA 4 hours a day, 7 days a week for 9 weeks and SN every 30 days. Review of the clinical record for Patient #3 revealed a document titled "PHYSICIAN ORDER" dated 01/20/2025 AM and signed by the DON. The document evidenced but was not limited to, a verbal order was received "to continue HHA services for this certification period … HHA to assist with personal care, incontinent care, and ADL's per POC under supervision of an RN …". Review of the clinical record for Patient #3 revealed a document titled "RN Visit Note" dated 01/22/2025 AM and signed by RN 1. The clinical record failed to evidence an order from a physician to provide SN services weekly. During an interview on 01/25/2024 at 4:45 PM, RN 1 indicated they provide care for Patient #3. When queried about what services they provide to Patient #3, RN 1 indicated they perform the recertifications, weekly medication set up, and notifies the physician of Patient #3's INR (International Normalized Ratio, a blood test that measures how well your blood clots) weekly. When queried about having orders to perform medication box set ups and parameters to notify the MD and including this information on the POC, RN 1 indicated they understood. 3. Review of the clinical record for Patient #6 revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 11/25/2024 for the certification period of 11/25/2024 through 01/23/2025 signed by the DON. The POC evidenced, but was not limited to, Patient #6 would receive a HHA 2 hours a days, 5 days a week for 9 weeks. Review of the clinical record for Patient #6 revealed a document titled "Physician Order" dated 11/26/2024 and signed by RN 1. The order evidenced, but was not limited to, "Services on hold pending PA approval". Review of the clinical record for Patient #6 revealed a document titled "HHA Visit" dated 01/15/2025 through 01/17/2024, 01/20/2025 through 01/22/2025, and signed by HHA 1. The clinical record failed to evidence an order from a physician to resume providing services for Patient #6. During an interview on 01/24/2025 at 12:06 PM, HHA 1 indicated they provide services for Patient #6. When queried when services started, they indicated their first day was a Wednesday and they have been providing services for not even two weeks. When queried how it was decided for HHA 1 to start services, they indicated the agency called and asked if HHA 1 could fit Patient #6 into their schedule because they were already in the area where Patient #6 lives providing care for other patients. During an interview on 01/24/2025 at 3:37 PM, the Administrator indicated the agency had notified Entity 10, a group home, services would be placed on hold until the Prior Authorization (PA) was completed and for Entity 10, a group home, to assume care until the PA was approved. The Administrator indicated the agency cannot afford to start services until the PA is approved, and was not sure how long the agency allowed for services to be placed on hold before further action needs to be taken. During an interview on 01/25/2025 at 4:45 PM, RN 1 indicated they performed the SOC for Patient #6. When queried about obtaining a resume services order from the physician before providing services, RN 1 indicated "that would make sense". During an interview on 01/27/2025 at 3:00 PM, the DON indicated the agency should have obtained a resume services order from the physician after a patient has been placed on hold. 410 IAC 17-13-1(a)

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 ensure the physician was notified of the frequency of visits not being followed according to the POC for 3 of 7 active clinical records reviewed with HHA services only (Patient #6, #8, and #12) and 1 of 1 active clinical record reviewed with SN services only. (Patient #5) Findings Include: 5. Review of the clinical record for Patient #6 revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 11/25/2024 for the certification period of 11/25/2024 through 01/23/2025 signed by the DON. The POC evidenced, but was not limited to, Patient #4 would receive a HHA 2 hours a days, 5 days a week for 9 weeks. Review of the clinical record for Patient #6 revealed a document titled "Physician Order" dated 11/26/2024 and signed by RN 1. The document evidenced, but was not limited to, "Services on hold pending PA approval". The clinical record failed to evidence the physician was notified that the POC needed to be updated to reflect what services the agency would be able to provide for the certification period of 11/25/2024 through 01/23/2025. During an interview on 01/24/2025 at 3:37 PM, the Administrator indicated the agency had notified Entity 10, a group home, services would be placed on hold until the Prior Authorization (PA) was completed and for Entity 10, a group home, to assume care until the PA was approved. The Administrator indicated the agency cannot afford to start services until the PA is approved, and was not sure how long the agency allowed for services to be placed on hold before further action needs to be taken. 410 IAC 17-13-1(a)(2) 1. A policy titled "Plan of Care" indicated but was not limited to, " … 10. Professional staff shall promptly alert the physician/allowed non-physician practitioner (NPP) to any changes that suggest a need to alter the Plan of Care …" 2. A review of Patient #5's clinical record evidenced a POC with a SOC of 03/13/2021 and a certification period from 12/23/2024 to 02/20/2025. The POC included the following diagnoses: Quadriplegia (paralysis of all four limbs), Convulsions (uncontrolled jerking), constipation, reduction deformities of the brain, tracheostomy (a surgical procedure to create an opening in the front of the neck to open the airway and allow the individual to breath) status, Severe intellectual disabilities, feeding difficulties, and a cystostomy (a surgical opening to create an opening in the bladder for urine to expel from the body into a collection bag). The POC evidenced the patient received SN services eight hours a day, six days a week, for 9 weeks. Review of the SN visit notes evidenced the following: During the week of 12/23/2024 through 12/28/2024, evidenced SN visits were conducted on 12/23, 12/24, 12/26, and 12/27/2024. A missed visit was documented on 12/25/2024 and revealed the caregiver would assume care. The record failed to evidence SN visit notes on 12/22 or 12/28/2024. During the week of 12/29/2024 through 01/04/2025, evidenced SN visits were conducted on 12/30, 12/31, 01/02, and 01/03/2025. The record failed to evidence SN visit notes on 12/29/2024, 01/01/2025, and/or 01/04/2025. During the week of 01/05/2025 through 01/11/2025, evidenced SN visits were conducted on 01/09/2025 and 01/10/2025. Missed visit notes were documented on 01/06, 01/07, and 01/08/2025 and indicated the caregiver would assume care for the patient. The record failed to evidence SN visit notes on 01/05/2025 or 01/11/2025. During the week of 01/12/2025 through 01/18/2025, evidenced SN visits were conducted on 01/13, 01/14, 01/15, 01/16, and 01/17/2025. The record failed to evidence SN visit notes on 01/12 or 01/18/2025. Patient #5's clinical record failed to evidence communication notes to the physician regarding not following the frequency of the POC. During an interview with Person 7, Patient #5's relative and caregiver, on 01/24/2025 at 12:07 PM, they indicated a nurse was supposed to come 6 days a week and every other Sunday, but rarely had this occur. Person 7 explained the agency had difficulty staffing Patient #5's time for around two months. They confirmed LPN 1 was good, but on average, missed about one visit a week. They indicated there had been a nurse, who no longer was employed by the agency, had worked the weekends for Patient #5. They explained LPN 1 informed them when they were not going to be able to be at the patient's residence, the office staff never contacted them regarding missed visits or if they would want another nurse to come assist the patient for the days LPN 1 was not able to be there. They confirmed they needed all the assistance they could get because they had to work and had reached out to the agency a couple times to inform them of this. During an interview on 01/27/2025 at 4:06 PM, the Clinical Manger and the Administrator indicated if the relative, Person 7, was there on the weekend for Patient #5, they did not go out to provide care for the patient because the caregiver would. They explained there were no missed visit notes for the days they were not there because they were no visits. They indicated they should have communicated the missed visits to the physician and informed the physician about not meeting the POC orders. 3. A review of Patient #8’s clinical record evidenced a POC with a SOC of 06/11/2022 and a certification period from 11/27/2024 to 01/25/2025. The POC included the following diagnoses: Autistic disorder (a developmental disability where the individual has difficulty communicating and social communication), Impulse disorder, and Mental disorder. The POC evidenced the patient received HHA services one hour a day, 7 days a week for 9 weeks. Review of the HHA visit notes evidenced the following: During the week of 12/01/2024 through 12/07/2024, evidenced HHA visits were conducted on 12/02, 12/03, 12/04, 12/05, 12/06, and 12/07/2024. The record failed to evidence SN visit notes on 12/01/2024. During the week of 12/08/2024 through 12/14/2024, evidenced HHA visits were conducted on 12/09, 12/10, 12/11, 12/12, and 12/13/2024. The record failed to evidence HHA visit notes on 12/08/2024 and 12/14/2024. During the week of 12/15/2024 through 12/21/2024, evidenced HHA visits were conducted on 12/16, 12/17, 12/18, 12/19, and 12/20/2024. The record failed to evidence HHA visits on 12/15/2024 and 12/21/2024. During the week of 12/22/2024 through 12/28/2024, evidenced HHA visits were conducted on 12/22, 12/23, 12/24, 12/26, and 12/27/2024. A missed visit was documented on 12/25/2024 and revealed the caregiver would assume care. The record failed to evidence HHA visit notes on 12/28/2024. During the week of 12/29/2024 through 01/04/2025, evidenced HHA visits were conducted on 12/30/2024, 12/31/2024, 01/02, 01/03, and 01/04/2025. The record failed to evidence HHA visit notes on 12/29/2024 and 01/01/2025. During the week of 01/05/2025 through 01/11/2025, evidenced HHA visits were conducted on 01/05, 01/06, 01/07, 01/08, 01/09, and 01/10/2025. The record failed to evidence an HHA visit note on 01/11/2025. During the week of 01/12/2025 through 01/18/2025, evidenced HHA visits were conducted on 01/13, 01/14, 01/15, 01/16, and 01/17/2025. The record failed to evidence HHA visit notes on 01/12/2025 and 01/18/2025. During the week of 01/19/2025 through 01/25/2025, evidenced HHA visits were conducted on 01/20, 01/21, 01/22, 01/23, and 01/24/2025. The record failed to evidence HHA visit notes on 01/19/2025. During an interview with the Clinical Manager and the Administrator on 01/27/2025 at 3:42 PM, they indicated if there were no missed visit notes or dates for the visits, a missed visit note had not been completed and the physician was not notified of the frequency of the POC not being followed. 4. A review of Patient #12’s clinical record evidenced a POC with a SOC of 08/13/2024 and a certification period from 12/11/2024 to 02/08/2025. The POC evidenced the following diagnoses: Functional Quadriplegia (a condition caused by another medical condition where the person is unable to move their extremities), history of traumatic brain injury, dysphagia (difficulty swallowing), and contracture (shortening of the muscles causing stiffness and limited range of motion) of the right and left hand. The POC revealed the patient received HHA services nine hours a day, seven days a week, for nine weeks. A review of the HHA visit notes evidenced the following: During the week of 12/11/2024 through 12/14/2024, evidenced HHA visits were conducted on 12/11/2024 and 12/12/2024. The record failed to evidence HHA visit notes on 12/13/2024 and 12/14/2024. During the week of 12/15/2024 through 12/21/2024, evidenced HHA visits were conducted on 12/16, 12/17, and 12/18/2024. The record failed to evidence HHA visit notes on 12/15, 12/19, 12/20, and 12/21/2024. During the week of 12/22/2024 through 12/28/2024, evidenced HHA visits were conducted on 12/25 and 12/26/2024. The record failed to evidence HHA visit notes on 12/22, 12/23, 12/24, 12/27, and 12/28/2024. During the week of 12/29/2024 through 01/04/2025, evidenced HHA visits were conducted on 12/30/2024, 12/31/2024, 01/01/2025, and 01/02/2025. The record failed to evidence HHA visit notes on 12/29/2024, 01/03/2025, and 01/04/2025. During the week of 01/05/2025 through 01/11/2025, evidenced HHA visits were conducted on 01/06, 01/08, and 01/09/2025. A missed visit note was documented on 01/07/2025 and indicated the reason was “Availability”. The missed visit notes evidenced the physician was not notified of the missed visit. The record failed to evidence HHA visit notes on 01/05, 01/10, and 01/11/2025. During the week of 01/12/2025 through 01/18/2025, evidenced HHA visits were conducted on 01/13, 01/14, 01/15, and 01/16/2025. The record failed to evidence HHA visit notes on 01/12, 01/17, and 01/18/2025. During the week of 01/19/2025 through 01/25/2025, evidenced HHA visits were conducted on 01/20, 01/21, 01/22, and 01/23/2025. The record failed to evidence HHA visit notes on 01/19, 01/24, and 01/25/2025. A review of Patient #12’s clinical record evidenced a Physician order dated 11/22/2024 for the certification period from 10/12/2024 to 12/10/2024. The order revealed the caregiver had dismissed four different aides and only accepted one aide who could only work four days a week. The order indicated the caregiver was agreeable to four days a week. The clinical record for Patient #12 failed to evidence the physician was notified of the agency not following the frequency ordered on the POC. During an interview with Person 8, Patient #12’s relative and caregiver, on 01/27/2025 at 10:54 AM, they indicated they were unsatisfied with the services provided by the agency. They explained how the agency did not communicate with them, could not fill more of the patient’s hours, and received services four days a week. They indicated they needed all seven days as ordered on the POC because the patient kept them awake all night for their tube feeding and their behavior issues. Person 8 explained the agency had sent different aides who had not worked out, but needed an agency who could follow through with their promises. Person 8 expressed if the agency failed to provide an aide for the patient, “it is on me”, and they had to take breaks when giving the patient a bath because it made them exhausted. During an interview with the Clinical Manager and the Administrator on 01/27/2025 at 3:20 PM, they indicated they should have changed the frequency of HHA services to four days a week for Patient #12 because it was the only time the HHA was able to be staffed. They indicated the physician order from 11/22/2024 reflected why the patient did not receive their ordered frequency, but confirmed the order was from the previous certification period and the current POC indicated the patient should receive services seven days a week. They indicated the physician should have been notified of the missed visits, but was not if there were no missed visit notes or dates included on the electronic medical record.

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed ensure the RN coordinated care for 4 of 4 active records reviewed with patients receiving outside services (Patient #4, 5, 6, and 12). Findings Include: 4.. A review of Patient #5's clinical record evidenced a POC with a Soc of 03/13/2021 and a certification period from 12/23/2024 to 02/20/2025. The POC included the following diagnoses: Quadriplegia (paralysis of all four limbs), Convulsions (uncontrolled jerking), constipation, reduction deformities of the brain, tracheostomy (a surgical procedure to create an opening in the front of the neck to open the airway and allow the individual to breath) status, Severe intellectual disabilities, feeding difficulties, and a cystostomy (a surgical opening to create an opening in the bladder for urine to expel from the body into a collection bag). The orders evidenced the SN was to notify the patient's Pulmonologist (physician specializing in treating conditions of the respiratory system) for oxygen saturation less than 89%. During an interview on 01/27/2025 at 4:06 PM, when queried about notifying the Pulmonologist regarding the patient's oxygen saturation, the Clinical Manager was unable to provide the name of Patient #5's Pulmonologist and failed to provide documentation of coordination of care with the Pulmonologist. 5. A review of Patient #12’s clinical record failed to evidence coordination notes to Entity 13, a Home Health Agency. During an interview with Person 8, Patient #12’s relative and caregiver, on 01/27/2025 at 10:54 AM, Person 8 explained they had attendant care services for the patient every day in the evenings from Entity 13, a home health agency. During an interview with the Clinical Manager and the Administrator on 01/27/2025 at 3:20 PM, they indicated they were unaware of another agency providing care for the patient. 1. A review of an agency's policy titled "COORDINATION OF CLIENT SERVICES," indicated but was not limited to, "PURPOSE To coordinate care delivery to meet individual client needs … coordinate the nursing, therapy, aide … Coordination of care will include dealing with multiple programs for the complex clients (cardiology, wound care, diabetes, neuro, etc.) … Documentation must address the coordination activities … Involvement of the care team must be apparent in the record … Coordination will include … assisted living staff … ". 2. Review of the clinical record for Patient #4 revealed a document titled, "2025 Recertification", a recertification comprehensive assessment, dated 01/16/2025 and signed by the DON. The recertification comprehensive assessment failed to evidence Patient #4 received services from Entity 11, a Personal Care Service Agency. Review of Patient #4's clinical record failed to evidence care coordination notes with Entity 11, a Personal Care Service Agency, for the period of 01/16/2025 through 01/27/2025. During an interview on 01/21/2025 at 1:18 PM, Person 1 indicated they are a family member and caregiver of Patient #4. Person 1 indicated Patient #4 receives HHA services from the agency during the night and services from Entity 11, a Personal Care Service Agency, during the day. During an interview on 01/23/2025 at 3:11 PM, the DON failed to indicate care coordination is completed during a recertification. 3. Review of the clinical record for Patient #6 revealed a document titled, "2025 Recertification", a recertification comprehensive assessment, dated 01/21/2025 and signed by the DON. The recertification comprehensive assessment failed to evidence Patient #4 received services from Entity 10, a group home, and Entity 12, a dialysis company. Review of Patient #6's clinical record failed to evidence care coordination notes with Entity 10 and Entity 12 for the period of 01/21/2025 through 01/27/2025. During an interview on 01/27/2025 at 3:00 PM, the DON indicated they understood the importance of care coordination.

Written instructions to patient include: CFR(s): 484.60(e) Standard: Written information to the patient. The HHA must provide the patient and caregiver with a copy of written instructions outlining: This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patients were provided current plans of care for 4 of 4 admission packets reviewed in patient residences. (Patient #4, #7, #8, and #11) Findings Include: 7. During a home visit at Patient #4's residence on 01/23/2026 at 6:16 AM, HHA 3 provided the Patient #4's admission packet. The admission packet evidenced information regarding advanced directives, resources for the aging, contact information to make a complaint, how to reach the Administrator, and the agency's transfer/discharge policy. The admission packet failed to evidence a past or current POC was provided to the patient. During an interview on 01/23/2025 at 9:45 AM, the Administrator indicated the agency mailed out all information the patient is to have in writing. During an interview on 01/23/2025 at 1:08 PM, Person 1 indicated they have not received a POC in the mail from the agency. 1. During a home visit at Patient #7’s residence on 01/22/2025 at 9:00 AM, the patient’s admission packet evidenced a POC with a certification period from 06/10/2023 to 08/08/2023 and a HHA care plan with a certification period from 06/10/2023 to 08/08/2024. The agency failed to ensure a current POC was provided to the patient. 2. During a home visit at Patient #8’s residence on 01/22/2025 at 10:25 AM, their admission packet evidenced a POC and a HHA care plan with a certification period from 06/06/2023 to 08/04/2023. The agency failed to ensure a current POC was provided to the patient. 3. During a home visit at Patient #11’s residence on 01/22/2025 at 10:25 AM, their admission packet evidenced a POC and a HHA care plan with a certification period from 06/05/2023 to 08/03/2023. The agency failed to ensure a current POC was provided to the patient. 4. During an interview on 01/22/2025 at 10:45 AM, with the group home staff member, Person 5, at Patient #8 and Patient #11’s residence, they indicated the documents in the binder were all they had for the patients. 5. During an interview on 01/23/2025 at 9:30, the Administrator explained they mailed out all patient’s POCs to the patients and the supervisor for the group home (Entity 4), Person 6, would have the current POCs. 6. During an interview with the group home (Entity 4) supervisor, Person 6, on 01/24/2025 at 2:24 PM, they indicated the documents in the admission folder were kept in Patient #7's, Patient’s #8, and #11’s residence, the POCs would be in the group home.

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patients were provided a current schedule of when services would be provided for 4 of 4 admission packets reviewed during home visits (Patient #4, #7, #8, and #11). Findings Include: 2. During a home visit on 01/22/2025 at 9:00 AM at Patient #7's residence, their admission packet evidenced a 2024 schedule from the months of January, March, April, May, June, July, and August. The admission packet failed to evidence a current schedule. 3. During a home visit at Patient #8’s residence on 01/22/2025 at 10:25 AM, their admission packet failed to evidence a current schedule of visits for the agency. 4. During a home visit at Patient #11’s residence on 01/22/2025 at 10:25 AM, their admission packet failed to evidence a current schedule of visits for the agency. 5. During an interview on 01/22/2025 at 10:45 AM, with the group home staff member, Person 5, at Patient #8 and Patient #11’s residence, they indicated the documents in the binder were all they had for the patients. 6. During an interview on 01/23/2025 at 9:30, the Administrator explained they mailed out all patient’s schedules to the patients and the supervisor for the group home (Entity 4), Person 6, would have the current schedules. 7. During an interview with the group home (Entity 4) supervisor, Person 6, on 01/24/2025 at 2:24 PM, they indicated the documents in the admission folder were kept in Patient #7's, Patient’s #8, and #11’s residence, the schedules would be kept with the patient in their group home. 1. During a home visit at Patient #4's residence on 01/23/2026 at 6:16 AM, HHA 3 provided Patient #4's admission packet. The admission packet evidenced information regarding advanced directives, resources for the aging, contact information to make a complaint, how to reach the Administrator, and the agency's transfer/discharge policy. The admission packet failed to evidence a past or current schedule of when services would be provided. During an interview on 01/23/2025 at 9:45 AM, the Administrator indicated the Administrator indicated the agency mailed out all information the patient is to have in writing. During an interview on 01/23/2025 at 1:08 PM, Person 1 indicated they have only received one schedule since starting services in September.

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patients were provided current medication lists for 4 of 4 admission packets reviewed in patient residences. (Patient #4, #7, #8, and #11) Findings Include: 7. During a home visit at Patient #4's residence on 01/23/2026 at 6:16 AM, HHA 3 provided the Patient #4's admission packet. The admission packet evidenced information regarding advanced directives, resources for the aging, contact information to make a complaint, how to reach the Administrator, and the agency's transfer/discharge policy. The admission packet failed to evidence a past or current medication list was provided to the patient. During an interview on 01/23/2025 at 9:45 AM, the Administrator indicated the agency mailed out all information the patient is to have in writing. During an interview on 01/23/2025 at 1:08 PM, Person 1 indicated they have not received a medication list in the mail from the agency. 1. During a home visit at Patient #7’s residence on 01/22/2025 at 9:00 AM, the patient’s admission packet evidenced a medication profile from the certification period of 04/11/2023 to 06/09/2023. 2. During a home visit at Patient #8’s residence on 01/22/2025 at 10:25 AM, their admission packet evidenced a POC and a HHA care plan with a certification period from 06/06/2023 to 08/04/2023. The agency failed to ensure a current medication profile was provided to the patient. 3. During a home visit at Patient #11’s residence on 01/22/2025 at 10:25 AM, their admission packet evidenced a POC and a HHA care plan with a certification period from 06/05/2023 to 08/03/2023. The agency failed to ensure a current medication profile was provided to the patient. 4. During an interview on 01/22/2025 at 10:45 AM, with the group home staff member, Person 5, at Patient #8 and Patient #11’s residence, they indicated the documents in the binder were all they had for the patients. 5. During an interview on 01/23/2025 at 9:30, the Administrator explained they mailed out all patient’s medication lists to the patients and the supervisor for the group home (Entity 4), Person 6, would have the current medication lists. 6. During an interview with the group home (Entity 4) supervisor, Person 6, on 01/24/2025 at 2:24 PM, they indicated the documents in the admission folder were kept in Patient #7's, Patient’s #8, and #11’s residence, the medication lists would be in the group home.

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 evidence to show measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care (G642), failed to utilize quality indicator data, including measures derived from OASIS to monitor the effectiveness and safety of services and quality of care and identify opportunities for improvement, and have the frequency and detail of the data collection approved by the HHA's governing body (G644), failed to document the agency had considered the incidence, prevalence, and high-risk/problem-prone areas to select indicators and identify performance improvement projects (G646), failed to take action at performance improvement and measure its success and track performance to ensure that improvements are sustained (G656), failed to document the reasons for conducting these projects, and the measurable progress achieved on these projects (G658), failed to evidence governing body oversight of an ongoing QAPI program for Quality improvement and patient safety is defined, implemented, and maintained with the potential to affect all 11 active patients (G660). The cumulative effect of these systemic problems resulted in the agency’s inability to ensure patients received appropriate services which could result in the agency not providing quality health care, thus resulting in non-compliance with Condition of Participation CFR 484.65 Quality Assessment/Performance Improvement. Findings Include: 1. A review of an agency's policy titled "QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT (QAPI)," indicated but was not limited to, " … Agency will develop, implement, evaluate, and maintain an effective, ongoing agency wide, data driven QAPI program … The agency will maintain documentary evidence of its QAPI program … The agency's governing body must ensure that the program reflects the complexity of its organization and services … and focuses on indicators related to improved outcomes … The program will be capable of showing measurable improvement in indicators that will improve health outcomes, client safety, and quality of care … will identify, measure, analyze, and track quality indicators … include client adverse events, and other relevant data to assess processes of care, services, and operations … frequency and detail of the data collection must be approved by the governing body … will establish timelines for review to measure success and establish ongoing activities to sustain the success … agency must document the quality improvement projects undertaken, the reasons for conducting these projects and the measurable progress achieved on these projects … The governing body is responsible for ensuring … An ongoing program for quality improvement and patient safety is defined, implemented, and maintained … agency wide assessment and performance improvement efforts address priorities for improved quality of care and client safety … All improvement actions will be evaluated for effectiveness …" 2. Record review of a document titled "Home Health Quarterly Meeting" dated 04/27/2024 failed to evidence the meeting involved discussion of quality improvement or performance improvement plans. Record review of a document titled "Home Health Quarterly Meeting" dated 07/27/2024 failed to evidence the data associated with the concern with agency staff completing COVID (respiratory illness) screenings and how this is impactful to quality patient care. 3. A review of a document titled "Board Meeting" dated 07/16/2024 evidenced call off reports, employee file reports, and medication patient reports were reviewed. The document failed to evidence what was found in the reports. The document indicated but was not limited to, " … Board has approved QAPI report but ask for a more through (sic thorough) report next year with more information …" 4. Record review of an undated document titled "ANNUAL PROGRAM EVALUATION 2024" failed to evidence quality assessment and performance improvement plans and who was involved in the oversight of the program evaluation. 5. During an interview on 01/23/2025 at 12:32 PM, the Administrator indicated there has not been a quarterly meeting to address QAPI for the fourth quarter. When queried about where the data is associated to the quarterly and annual meeting, the Administrator indicated the electronic medical record has the capability to run reports and the agency looks at the computer screen and does not print the reports. When queried if there was a report to evidence what reports had previously been run, the Administrator indicated this was not option within the electronic medical record. 6. During an interview on 01/24/2025 at 2:43 PM, the Administrator indicated the agency does not have documentation of reviewing the reports during the quarterly or annual meetings.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation, record review and interview the agency failed to perform hand hygiene and maintain infection prevention practices for 3 of 3 home visits (HHA 1, HHA 2, and HHA 3). Findings Include: 3. During a home visit on 01/22/2025 at 9:00 AM, HHA 2 was observed providing care for Patient #7. HHA 2 threw the towel, the patient used to dry themselves, into the hamper, doffed their gloves, and donned new gloves without performing hand hygiene. The HHA used a new towel to dry the patient’s back, doffed gloves, and donned new gloves without performing hand hygiene. After assisting the patient into their wheelchair, HHA 2 doffed their gloves, and donned new gloves without performing hand hygiene. HHA 2 proceeded to clean the shower, doffed gloves, and failed to perform hand hygiene before going back to assisting the patient. During an interview on 01/22/2025 at 9:40 AM, HHA 2 explained hand hygiene was to supposed to be performed before and after care and changing gloves. 4. During a home visit on 01/22/2025 at 10:25 AM, HHA 1 was observed providing care for Patient #8. HHA 1 washed their hands for five seconds, dried their hands, and turned the faucet off with their bare hands. The HHA put the patient’s clothes in the hamper, removed their gloves, washed their hands for three seconds with soap and water, and turned off the faucet with their bare hand. HHA 1 assisted the patient in drying off after their shower, doffed gloves, washed their hands with soap and water for eight seconds, and turned the faucet off with their bare hands. During an interview on 01/22/2025 at 10:55 AM, HHA 1 indicated hand hygiene was supposed to be performed before, during, and after care. When washing their hands with soap and water, HHA 1 explained they were to wash their hands for 30 seconds and turn the faucet off with a paper towel. 410 IAC 17-12-1(m) 1. A review of an agency's policy titled "HANDWASHING/HAND HYGIENE," indicated but was not limited, "PURPOSE To improve hand hygiene practices of agency staff and to reduce transmission of pathogenic microorganisms to clients and personnel in the home care setting … 3. Indications for handwashing and hand antisepsis: c. when there is prolonged or intense contact with the client (bathing the client) d. Between tasks on the same client … f. After removing gloves g. After touching objects that are potentially contaminated … HAND HYGIENE TECHNIQUE … rub hands together vigorously for at least twenty (20) seconds … ". 2. During a home visit on 01/23/2025 at 6:16 AM, HHA 3 was observed providing care for Patient #4. HHA 3 answered the door with gloved hands, and indicated they were in the process of providing incontinent care to Patient #4. With the same gloved hands, HHA 3 returned to the bedroom and resumed providing incontinent care, applied barrier cream, and placed a brief on Patient #4. With the same gloved hands, HHA 3 adjusted Patient #4's blanket. With the same gloved hands, HHA 3 obtained the bath basin, emptied the water into the toiled, flushed the toilet, and rinsed the basin in the bathroom sink. With the same gloved hands, HHA 3 took the dirty wash cloth in their left hand, went to the laundry room door, opened the door, opened the washer, placed the wash cloth inside, shut the washer door, and the laundry room door. HHA 3 removed their gloves. HHA 3 linked arms with Patient #4 to sit Patient #4 up and adjust the pillow behind their back. HHA 3 failed to remove their gloves and perform hand hygiene at appropriate intervals. During an interview on 01/23/2025 at 6:30 AM, HHA 3 indicated they should have performed glove changes and hand hygiene after removing gloves. During an interview on 01/23/2025 at 9:29 AM, the Administrator indicated HHA 3 should have washed their hands and changed gloves more often.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure RN supervisory visits were completed for 2 of 3 active records reviewed with patients receiving SN and HHA services (Patient # 3 and Patient #13). Findings Include: 1. A review of an agency's policy titled "HOME HEALTH AIDE SUPERVISION," indicated but was not limited to, "PURPOSE To observe the aide while providing care to clients, and to assess competency in basic skills as well as delegated tasks … a. When skilled services are being provided to a client, a Registered Nurse must make a supervisory visit to the client's residence no less frequently than every 14 days …" 2. Review of the clinical record for Patient #3 revealed a document titled "HHA Care Plan" with a care period of 11/22/2024 - 1/20/2025 signed by the DON. The document evidenced, but was not limited to, HHA to see the patient 5 hours a day, 7 days a week for 9 weeks. Review of the clinical record for Patient #3 revealed a document titled "RN Visit Note" dated 11/26/2024, 12/03/2024, 12/11/2024, 12/18/2024, 12/27/2024, 01/01/2025, 01/08/2025, 01/15/2025, and 01/21/2025 and signed by RN 1. Review of the clinical record for Patient #3 revealed a document titled "Supervisory Visit" dated 01/02/2025 and signed by RN 1. The clinical record failed to evidence RN 1 performed supervisory visits every 14 days. During an interview on 01/25/2025 at 4:45 PM, RN 1 indicated they should do a supervisory visit more frequently when a patient is receiving skilled services. 3. Review of the clinical record for Patient #13 revealed a document titled "Home Health Certification and Plan of Care" with a certification period of 12/26/2024 through 02/23/2025. The document evidenced, but was not limited to, HHA to see the patient 5 hours a day, 7 days a week for 9 weeks and SN once a week for 9 weeks, and every 2 weeks for supervisory visits. Review of the clinical record for Patient #13 revealed a document titled "Supervisory Visit" dated 12/30/2024 and signed by the DON. 4. During an interview on 01/27/2025 at 2:45 PM, the DON indicated a patient receiving skilled services should have supervisory visits every 14 days and a patient receiving nonskilled services should have a supervisory visit every 30 days.

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on record review and interview, the governing body failed to ensure the Quality Assurance Performance Improvement Plan (QAPI) was maintained for 1 of 1 Governing body. Findings Include: 1. A review of the Administrator job description included but was not limited to, “ … 10. Provides leadership in developing and maintaining data collection, recording, and reporting systems to ensure proper service … data collection, and measurement of outcomes. …” 2. A review of a document titled "Home Health Quarterly Meeting" dated 04/27/2024 failed to evidence quality improvement measures were discussed and data was reviewed for the quarter. A review of a document titled "Board Meeting" dated 07/16/2024 evidenced call off reports, employee file reports, and medication patient reports were reviewed. The document failed to evidence what was found in the reports. The document indicated but was not limited to, " … Board has approved QAPI report but ask for a more through (sic thorough) report next year with more information …" A review of the document titled "Home Health Quarterly Meeting" dated 07/27/2024 failed to evidence data associated with quality improvement measures. A review of the undated document titled "Annual Program Evaluation 2024" failed to evidence the data used to generate the report and the patients affected by the missing information for the patient care reports. 3. During an interview on 01/23/2025 at 12:32 PM, the Administrator indicated there had not been a quarterly report since 07/27/2024. When queried regarding the data used to generate the annual and quarterly report, the Administrator indicated they ran a report through their electronic medical record system for their reports. The Administrator explained there was no evidence of the reports they ran for each quarter and annually. 4. During an interview on 01/24/2025 at 2:43 PM, the Administrator indicated the agency had not documented what data reports they reviewed for the QAPI meetings. 410 IAC 17-12-1(c)(1)

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102 Survey Dates: 09-21-2023, 09-22-2023, and 09-25-2023 Active Census: 15 At this Emergency Preparedness survey, Apple Tree Home Health LLC was not found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 484.102. QR by Area 3 on 09/28/2023.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to update and review a community-based risk assessment for 2 years (2022-present). Findings include: 1. A policy received from the Administrator on 09-21-2023 titled “ Hazard Vulnerability” indicated but was not limited to “The agency will re-visit and revise its Hazards and Vulnerability Analysis annually and as appropriate….” 2. A review of the Agency’s Emergency Preparedness Materials failed to evidence any community-based risk assessment occurred for the years 2021, 2022, and present. 3. During an interview on 09-25-2023 at 10:07 AM, the Administrator reported the Agency’s office has not done a community-based risk assessment since the office moved from Fort Wayne to Indianapolis approximately 2 ½ years ago.

This visit was for a Federal Recertification and State Re-Licensure survey of a Home Health Provider. Survey Dates: 09-21-2023,-09-22-2023, and 09-25-2023 12-Month Unduplicated Skilled Admissions: 17 This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Refer to State Form for additional State Findings. QR by Area 3 on 09/28/2023.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation, record review and interview, the agency failed to ensure home health aide (HHA) 3 followed standard infection prevention precautions while performing a bed bath for 1 of 1 bed bath observation, with the potential to affect all patients who require a bed bath. Findings include: 1. A review of Centers for Disease Control and Prevention (CDC) hand hygiene guidelines (retrieved from https: //www.cdc.gov/ handhygiene/ providers/ index.html) indicated hand hygiene and clean gloves were required after moving from a soiled body part to a clean body part 2. An observation of a bed bath occurred 9/22/2023 at 9:30 AM with HHA 3 with Patient #5. At the beginning of the bed bath, HHA 3 washed hands, put on gloves, and brought a basin of warm water to the patient’s bedside. HHA 3 washed the patient, excluding the genital/ anal area. HHA 3 opened the door with soiled gloves on, replaced the water in the basin, washed hands for less than 12 seconds and put on new gloves. HHA 3 removed the incontinence brief, washed the genital/ anal area, and applied a moisture barrier to the patient’s bottom. HHA 3 wiped gloves on a used towel and put Patient #5 into a new brief. HHA 3 opened the door with soiled gloves and dumped the basin of water. HHA 3 then applied lotion and dressed patient. HHA 3 transferred the patient to a wheelchair and pushed the patient into the dining room. HHA 3 picked up a food container, put it down, removed soiled gloves, washed hands, and donned clean gloves prior to feeding the patient. 3. During an interview at the time of the visit, HHA 3 confirmed he/ she failed to change gloves and wash hands after bathing the patient. 410 IAC 17 - 12 - 1(m)

This was a federal and state complaint survey. IN00349140 - Substantiated with findings Survey Dates: March 25, 26, 29, 30; 2021 Facility number: 014207 Provider number: 15K164 Current census: 17 These deficiencies reflects State Findings cited in accordance with 410 IAC 17. Refer to the State Form for additional State Findings.

Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure patients and caregivers were notified or received at least a 15-day discharge notice prior to termination of services for 2 of 2 discharge records reviewed (#4, 5). Findings include: 1. An agency transfer and discharge policy required to be signed by the patient upon admission stated "...I understand that the Agency will keep me or my caregiver involved in the process and I will be provided with proper notice as soon as applicable, being at least (15) calendar days before the services are stopped...." 2. The clinical record of patient #4 was reviewed on 3/29/21 and indicated a start of care date of 2/14/20 and a tentative discharge date of 3/31/21. The last plan of care in the record was dated 12/21/20-2/18/21. A discharge notice letter addressed to Home Health Aide (HHA) L (patient #4's daughter) was evidenced in the record dated 2/15/21 that stated "per our conversation on 2/13/21, Apple Tree Home Health Care Services will no longer be able to service your mother [patient #4]. We will allow you time to find adequate home care services for your mother. Please contact [patient #4] physician concerning receiving help with your search. We thank you for the opportunity to service your mother and wish you the best in all endeavors. Discharge date will be 3/31/21." The discharge letter was accompanied by 2 (two) certified mail envelopes. One was addressed and had been mailed to the home of patient #4 and was returned to sender due to "Insufficient Address." The second one was sent to the address of HHA L which was returned to sender due to "unclaimed, unable to forward." An email document dated 2/15/21 was sent from the administrator to an email account in HHA L's name which indicated "Please find attached the list of other agencies in your area that may be able to comply with your mother's needs. If you have any questions please feel free to call the office." A document titled "Mail Message," within the electronic medical record (EMR) was dated 3/15/21 from the administrator to HHA L and the clinical manager which stated "Apple tree Home Health Care Services sent 2 certified letters to your address on file (which is your grandmother's home) and to your mother's house [patient #4]. The letter that was sent out to you was concerning the discharging of your mother on March 31, 2021, as we previously discussed. Email has been sent out to you with a list of other agencies that can provide your mother's care. We do hope this rectifies any and all problems you have with the care your mother receives under Apple Tree Home Health...." During an interview on 3/25/21 at 10:54 AM, HHA L (patient #4's daughter) stated she requested copies of patient #4's medical chart almost 2 weeks ago and still had not received anything. HHA L stated she received no discharge notice from the agency for her mother, that she did have a Gmail email account for Apple Tree but she didn't use it. She then checked the email and stated there is no email messages present and sent a screenshot confirming. 3. The clinical record of patient #5 was reviewed on 3/29/21 and indicated a start of care date of 2/14/20 and a discharge date of 3/20/21. The record contained a plan of care for the certification period of 2/8/21-4/8/21 which indicated a primary diagnoses of heart failure. Skilled nurse visits were documented on 3/5/21 and 3/19/21. Both visits failed to evidence discussion/notice of discharge from services. A comprehensive discharge assessment was completed by the registered nurse on 3/20/21. During an interview on 3/29/21 at 10:21 AM, patient #5 indicated he/she did not refuse services. The patient indicated the primary nurse left and she was not told. Services terminated without any notice, and when she was notified that the preferred staff left, the patient indicated they did not want anyone else in the home. The patient indicated there was no assistance provided by the agency to find another agency, nor did they have a case worker to assist. Patient #5 stated they currently did not have a home health agency, but "probably" did need one. 410 IAC 17-12-2(i)

Discharge or Transfer Summary Content CFR(s): 484.58(b)(1) Standard: Discharge or transfer summary content. The HHA must send all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care. This STANDARD is not met as evidenced by: Based on record review, the agency failed to ensure a transfer/discharge summary was sent to the patient's healthcare practitioner post discharge for 1 of 1 discharged patient records reviewed (#5). Findings include: The clinical record of patient #5 was reviewed on 3/29/21 and indicated a start of care date of 2/14/20 and a discharge date of 3/20/21. The record contained a plan of care for the certification period of 2/8/21-4/8/21 which indicated a primary diagnoses of heart failure. A comprehensive discharge assessment was completed by the registered nurse on 3/20/21 but failed to evidence any transfer/discharge summary.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure that an individualized plan of care orders was established for 1 of 1 patient without valid current physician orders (#4). Findings include: An undated agency policy titled "Plan of care," Policy # C-580 stated "...An individualized plan of care signed by the physician shall be required for each client ...." The clinical record of patient #4 was reviewed on 3/29/21 and indicated a start of care date of 2/14/20 and a tentative discharge date of 3/31/21. The last plan of care in the record was dated 12/21/20-2/18/21. The agency failed to complete a comprehensive assessment or plan of care for the certification period 2/19/21- 4/19/21 yet continued to allow the HHA to continue to make visits. The calendar in the electronic medical record indicated a visit was last completed by home health aide (HHA) L on 3/27/21 for personal care assistant, but no documentation had been completed. The record failed to evidence communication with the physician after that certification period. During an interview on 3/25/21 at 10:54 AM, HHA L stated she had continued to see the patient for care through Apple tree. During an interview on 3/30/21 at 12:00 PM, the administrator was notified that there were no orders for patient care after 2/18/21. She stated she knew that but couldn't ever get in contact with the employee and didn't know if they could discharge patient due to no orders.

Communication with all physicians CFR(s): 484.60(d)(1) Assure communication with all physicians involved in the plan of care. This ELEMENT is not met as evidenced by: Based on record review the agency failed to ensure communication with all physicians involved in 3 of 4 active records reviewed (#1, 2, 4). Findings include: 1. The clinical record of patient #1 was reviewed on 3/29/21 and indicated a start of care date of 3/13/21. The record contained a plan of care for the certification period of 3/13/21-5/12/21 which listed the patients diagnoses as: Quadriplegia, Other reduction deformities of brain, Abdominal distention (Gaseous), encounter for attention to tracheotomy, unspecified convulsions, severe intellectual disabilities, encounter for attention to cystostomy (general term for the surgical creation of an opening into the bladder most commonly for catheterization), and constipation; and orders for the skilled nurse to visit 8 hours per day, 7 days per week. During an interview with patient #1's mother on 3/29/21 at 7:52 PM, she indicated the patient was NPO (nothing by mouth), received all fluids and medications in the G-tube, and enteral feedings by feeding pump to the J-tube, was non-verbal and made noises like that of a baby, had allergies to beestings only, and has never had a catheter or cystostomy. Additionally, the mother stated the patient had several physicians that were involved in his care, including but not limited to, Physicians A (primary care physician), B (neurologist), C (pulmonologist), and D (for management of gastric tubes). The record failed to evidence that physician's B, C, or D were notified that the patient was admitted to services, or regarding any care orders. 2. The clinical record of patient #2 was reviewed on 3/25/21 and indicated a start of care date of 3/13/21. The record contained a plan of care for the certification period of 3/13/21-5/12/21 which listed the patients diagnoses as: pneumonia, pressure ulcer of the sacrum, Huntington's disease, dementia, and other malaise and indicated the patient was on hospice. The record failed to evidence any communication with the hospice physician regarding the patient's care. 3. The clinical record of patient #4 was reviewed on 3/29/21 and indicated a start of care date of 2/14/20 and a tentative discharge date of 3/31/21. The last plan of care in the record was dated 12/21/20-2/18/21. The calendar in the electronic medical record indicated a visit was last completed by home health aide (HHA) L on 3/27/21 for personal care assistant, but no documentation had been completed. The record failed to evidence communication with the physician after that certification period.

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on observation, record review, and interview the skilled nurse (SN) failed to complete a thorough and complete assessment of the patient for 2 of 2 skilled nursing assessments observed (#1, 3). Findings include: 1. Constantine, L., MSN, RN, C-FNP. (2004, June 15). Overview of Nursing Health Assessment. Retrieved March 30, 2021, from rn.com "... PULMONARY ASSESSMENT: When examining the pulmonary system ... Inspect the thoracic cage, palpate the thoracic cage, Auscultate the anterior and posterior chest: Have patient breath slightly deeper than normal through their mouth, Auscultate from C-7 to approximately T-8, in a left to right comparative sequence. You should auscultate between every rib ... Identify any adventitious breath sounds. ...." 2. The clinical record of patient #1 was reviewed on 3/29/21 and indicated a start of care date of 3/13/21. The record contained a plan of care for the certification period of 3/13/21-5/12/21 which listed the patients diagnoses as: Quadriplegia, Other reduction deformities of brain, Abdominal distention (Gaseous), encounter for attention to tracheotomy, unspecified convulsions, severe intellectual disabilities, encounter for attention to cystostomy (general term for the surgical creation of an opening into the bladder most commonly for catheterization), and constipation. The plan of care additionally stated "Respiratory orders for trach [tracheotomy] care: ... Skilled nurse to assess and manage patient's oxygen level. On 3 liters of oxygen per mask ...." A home visit observation was completed on 3/26/21 at 8:47 AM with patient #1 (start of care 3/13/21) and licensed practical nurse (LPN) E. The patient was observed lying in bed, not guarded, no facial grimaces, or moaning to indicate discomfort, and was non-verbal, had contractures (fixed tightening of muscle, tendons, ligaments, or skin which prevents normal movement of the associated body part) of extremities, had a gastrostomy tube (G-tube- surgically placed device used to give direct access to your child's stomach for supplemental feeding, hydration or medications) and jejunostomy tube (J-tube-plastic tube placed through the skin of the abdomen into the midsection of the small intestine to deliver food and medicine), and the patient was unable to respond to the LPN during care. During LPN E's physical assessment, she auscultated the lungs posteriorly (on back) in 4 areas, then anteriorly (in front) in 1 area and then auscultated heart sounds. LPN E failed to auscultate lung sounds in all lung fields and failed to verify oxygen settings. The oxygen concentrator was observed, and setting was set between 3.5 and 4 liters, not 3 liters per order. 3. The clinical record of patient #3 was reviewed on 3/25/21 and indicated a start of care date of 3/13/21. The record contained a plan of care for the certification period of 3/13/21-5/12/21. A home visit observation was completed on 3/26/21 at 11:45 AM with registered nurse (RN) G and patient #3. The patient's residence was observed in a group home (housing for adults with intellectual and developmental disabilities live as independently as possible). RN G took the patient's vital signs, then auscultation anterior chest in 1 area before auscultating in 4 areas posteriorly. RN G failed to auscultate the lung fields in all areas. 4. During an interview on 3/30/21 at 1:35 PM, the administrator stated during a nursing assessment all lung fields should be auscultated. IAC 17-12-2(g)

Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This ELEMENT is not met as evidenced by: Based on record review and interview, the registered nurse (RN) failed to supervise the licensed practical nurse (LPN) and the agency failed to have a policy for LPN supervision for 1 of 1 record review of patients observed with skilled nursing orders (#1). Findings include: The clinical record of patient #1 was reviewed on 3/29/21 and indicated a start of care date of 3/13/21. The record contained a plan of care for the certification period of 3/13/21-5/12/21 which listed the patients diagnoses as: Quadriplegia, Other reduction deformities of brain, Abdominal distention (Gaseous), encounter for attention to tracheotomy, unspecified convulsions, severe intellectual disabilities, encounter for attention to cystostomy (general term for the surgical creation of an opening into the bladder most commonly for catheterization), and constipation; orders for the skilled nurse to visit 8 hours per day, 7 days per week and SN for (but not limited to) wound assessment and management of the laceration wound on left leg. Skilled nurse visits were completed on 3/15/21-3/19/21 and 3/22/21-3/26/21 by LPN E. The record failed the evidence communication or supervision between the LPN and RN. During an interview on 3/28/21 from 8:02 AM-8:40 AM, the clinical manager (director of nursing) stated LPN supervisory visits were completed every 14 days. During an interview on 3/30/21 at 1:35 PM, the administrator stated LPN supervisory visits were completed every 6 months.

Documentation of competency evaluation CFR(s): 484.80(c)(5) The HHA must maintain documentation which demonstrates that the requirements of this standard have been met. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure all home health aides (HHA) had completed a competency evaluation and test which was maintained in the personnel record for 2 of 2 HHA personnel files reviewed (F, H). Findings include: 1. An undated agency policy titled "Home health aide services," Policy C-220 stated, "...All individuals providing home health services will be qualified trough training and/or competency evaluations ... Only aides who meet required standards will provide direct care ...." 2. A review of HHA F's personnel file on 3/30/21 (unknown hire date), failed to evidence a skills competency evaluation or written test. 3. A review of HHA H's personnel file on 3/30/21 (unknown hire date), failed to evidence a skills competency evaluation or written test. 4. During an interview on 3/30/21 at 1:35 PM, the administrator stated HHA competency skills evaluation and tests should be present in the personnel record. IC 17-14-1(I)(2)

Report all branch locations to SA CFR(s): 484.105(d)(1) The parent HHA is responsible for reporting all branch locations of the HHA to the state survey agency at the time of the HHA's request for initial certification, at each survey, and at the time the parent proposes to add or delete a branch. This ELEMENT is not met as evidenced by: Based on observation and interview, the agency failed to report a branch location that was being used for training purposes. Findings include: A home visit observation was conducted with licensed practical nurse (LPN) E on 3/26/21 at 8:47 AM, with patient #1 (start of care 3/13/21). At the time of the observation LPN E was asked about her initial training with the agency. She stated the clinical manager did her training at the "Fort Wayne office." When asked if she knew the address to the office, she looked in her documents and stated "5812 W Hills Road." After completion of the home visit, the surveyor drove to 5812 W. Hills Road and went into the establishment. Staff were present at the door. I asked if this was an office for Apple tree. The staff at the door stated this was the office of the home health agency entity G. The entity had cubicles in the office, at least 2 staff people were present, and medical signs posted. At that time RN G arrived at entity G. She informed surveyor that she had to transfer her patients to another home health agency and the office was entity G. Additionally, RN G stated on 3/13/21 she moved 5 patients from entity G to Apple tree until she is given a full home health license. She stated that in addition to the patients she brought all her aide staff with her and the administrator of Apple tree used entity G's office to complete training and orientation. Additionally, she stated apple tree staff do use entity G's office to chart.

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure nurses completed skilled care per professional standards for 1 of 1 home visit observed with skilled care observation (#1). Findings include: MCCONNELL, E., 2002. Administering medication through a gastrostomy tube, Nursing 2002: December 2002 - Volume 32 - Issue 12 - p 22, stated "...Give liquid medications whenever possible to prevent clogging and enhance absorption. Dilute with at least 30 ml [milliliters] of water. ... If a tablet can be safely crushed, use a pill crusher to grind it to a fine powder and mix it with 30 to 50 ml of warm water. ... Put your patient in semi-Fowler position [positioned on their back with the head and trunk raised to between 15 and 45 degrees, although 30 degrees is the most frequently used bed angle] ... attach a 30-60 ml piston syringe ... To verify placement and patency, aspirate for gastric contents, note the residual volume, and follow your facility's policy for reinstilling it ... Pinch the tubing to seal it and add 30 ml of water to the syringe. Release the tubing, let the water flow by gravity to flush it ... Pour the diluted medication into the syringe and release the tubing to administer it. If you're giving more than one drug, flush between each dose with 15 to 30 ml of water, clamp ...." The clinical record of patient #1 was reviewed on 3/29/21 and indicated a start of care date of 3/13/21. The record contained a plan of care for the certification period of 3/13/21-5/12/21 which listed the patients diagnoses as: Quadriplegia, Other reduction deformities of brain, Abdominal distention (Gaseous), encounter for attention to tracheotomy, unspecified convulsions, severe intellectual disabilities, encounter for attention to cystostomy (general term for the surgical creation of an opening into the bladder most commonly for catheterization), and constipation. A home visit observation was completed on 3/26/21 at 8:47 AM with patient #1 and licensed practical nurse (LPN) E. The patient was observed lying in bed a gastrostomy tube (G-tube- surgically placed device used to give direct access to your child's stomach for supplemental feeding, hydration, or medications) and jejunostomy tube (J-tube-plastic tube placed through the skin of the abdomen into the midsection of the small intestine to deliver food and medicine) were observed. LPN E was observed prepping medications for administration. All liquid medications were placed in a medication cup, then all pills were crushed and placed into another medication cup, and syringes of liquid medication were prepped as well. All medications were taken to bedside. LPN E attached a 60 milliliter (ml) piston syringe to the end of the G-tube. LPN E then added all liquid medications to the piston syringe to be administered via gravity into the G-tube. Then, LPN E dumped the crushed medication powder (by itself) into the piston syringe then added a red liquid and shook the tube. This was completed 3-4 times until all powder had been administered into the patient's stomach. LPN E then clamped the G-tube off.