Every finding on record at Benevolent Care Home Health Services LLC

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR §484.102 Survey Dates: 05/26, 05/27, and 05/28/2026 Active Census: 12 At this Emergency Preparedness survey, Benevolent Care Home Health Services LLC was found to be in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR §484.102. QR completed by Area 3 on 6/1/2026.

This visit was for an Initial State Licensure and Initial Medicaid survey for a Home Health provider. Survey Date(s): 05/26, 05/27, and 05/28/2026 12 Month Unduplicated Admissions: 12 This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Abbreviations: HHA - Home Health Aide SN- Skilled Nurse LPN- Licensed Practical Nurse RN- Registered Nurse CM- Clinical Manager POC- Plan of Care SOC- Start of Care DON- Director of Nursing DME- Durable Medical Equipment ADL- Activities of Daily Living QAPI- Quality Assurance Performance Improvement OASIS- Outcome and Assessment Information Set QR completed by Area 3 on 6/1/2026.

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 POC included the correct SOC and certification date, all necessary DME, the services provided to the patients, correct medication frequency, and goals specific to the services provided by the agency for 11 of 12 active clinical records reviewed. (Patients #1, #2, #3, #4, #5, #6, #7, #8, #10, #11, and #12) Findings Include: 8. Review of Patient #1's active clinical record revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 03/11/2026 for the certification period of 05/10/2026 through 07/08/2026, and signed by RN 1. The POC indicated Patient #1 had, but is not limited to, Essential Hypertension (high blood pressure), Unspecified systolic (congestive) heart failure (occurs when the heart's main pumping chamber, the left ventricle, becomes weak and cannot contract normally), Diabetes (chronic metabolic condition where the body resists the effects of insulin and fails to produce enough to maintain normal glucose levels causing high blood sugar), Sleep Apnea (sleep disorder in which a person's breathing repeatedly stops and starts throughout the night), and legal blindness. The POC subsection titled "Medications" indicated but is not limited to, " … Repatha [medication used to help control cholesterol] 140 mg/ml [milligrams/milliliters] subcutaneous [underneath the skin] solution prefilled syringe frequency: monthly Indication: Instruction: administer 1 sub q [subcutaneous] injection monthly …". The POC subsection titled "DME and Supplies" indicated tub/shower bench, grab bars, walker, alcohol pads, diabetic supplies, and sharps container. The POC subsection titled "Orders for Discipline and Treatments" indicated but is not limited to SN once a week for nine weeks to assess client filling medication box to determine if client is preparing correct, and to Administer subcutaneous injections as needed per MD order related to visual impairment. The POC subsection titled "Goals/Rehabilitation Potential/Discharge Plans" stated but is not limited to, " … Client will verbalize understanding of proper use of pain medication … have absence or control of pain as evidenced by optimal mobility and activity necessary for functioning and performing ADLs … will have increased mobility, self care, endurance, ROM [range of motion], and decreased pain … maintain optimal joint function, increased mobility, and independence in ADLs … strength and endurance will be improved … demonstrate proper ROM exercise and body alignment techniques …" The POC failed to evidence pertinent patient specific goals, and the specific injections to be administered by the RN. During a home visit on 05/27/2026 at 1:00 PM, Patient #1 indicated they administered a nebulizer treatment earlier in the day due to feeling short of breath. The POC failed to include DME: nebulizer and supplies. Review of Patient #1's active clinical record revealed a SOC OASIS assessment dated 03/11/2026 and signed by RN 1. The OASIS failed to evidence a skill was performed. Review of Patient #1's active clinical record revealed a document titled "RN Visit Note". The visit note dated 03/18/2026 and signed by RN 1 indicated but is not limited to, " … Medications were prefilled for the upcoming week …" The visit note dated 04/08/2026 and signed by RN 1 indicated but is not limited to, " … Changed Libre monitoring device …" The visit note dated 04/15/2026 and signed by RN 1 indicated but is not limited to, " … Patient has G7 libre monitoring device, changed in today's visit …" The visit note dated 05/06/2026 and signed by RN 1 indicated but is not limited to, " … Libre monitoring device changed on today's visit …" The visit note dated 05/20/2026 and signed by RN 1 indicated but is not limited to, " … Libre glucose monitoring device was changed today and applied to right upper arm …". The POC failed to evidence an order to change the Libre device, and the correct SOC date. Review of Patient #1's active clinical record revealed a document from Entity 2, a health network, titled "Continuity of Care Document". The document stated, " … evolocumab (Repatha Sure Click 140 mg/mL subcutaneous solution) start date: 3/5/26 140 milligram subcutaneous every 2 weeks … Insulin aspart [insulin is a hormone created by the pancreas to control blood glucose, insulin aspart is a fast acting insulin] … start date 2/4/26 Inject subq [subcutaneous] per sliding scale with dinner … insulin glargine [long acting insulin] start date 2/19/26 16 units subcutaneous at bedtime …" The POC failed to evidence all medications and the correct frequency of Repatha. During an interview on 05/28/2026 at 11:48 AM, Patient #1 indicated they were currently on insulin. Patient #1 indicated since they take Mounjaro (injectable medication used to lower blood glucose in adults with Type 2 Diabetes Mellitus), they take insulin every once in a while. During an interview on 05/28/2026 at 12:10 PM, RN 1 indicated the services they provided Patient #1 were set-up medications, completed a full assessment, checked vital signs, and administered Mounjaro weekly and Repatha monthly. When queried regarding the Repatha given weekly, they explained there was a documentation error for the visit dates 04/22/2026 and 04/29/2026. They explained for patient's with the Libre device, it was changed every 10-14 days. They indicated the order to change the Libre device should have been included on the POC. 9. Review of Patient #4's active clinical record revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 03/21/2026 for the certification period of 05/20/2026 through 07/18/2026, and signed by the DON. The POC indicated Patient #4 had, but is not limited to, Type 2 Diabetes Mellitus (chronic condition where the body does not make enough insulin or resists it), Fibromyalgia (a chronic condition characterized by widespread musculoskeletal pain, ongoing fatigue, and sleep problems), and Gout (a painful, inflammatory form of arthritis characterized by sudden, severe attacks of pain, swelling, and redness in the joints). Review of Patient #4's active clinical record revealed a SOC OASIS assessment dated 03/21/2026 and signed by the DON. The OASIS failed to evidence a skill was performed. Review of Patient #4's active clinical record revealed a document titled "RN Visit Note". The visit note dated 03/25/2026 and signed by the DON indicated but is not limited to, " … weekly medications set up by skilled nursing …" The POC failed to evidence the correct SOC date. 10. Review of Patient #6's active clinical record revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 03/12/2026 for the certification period of 05/11/2026 through 07/05/2026, and signed by the DON. The POC indicated Patient #6 had, but is not limited to, Hypertensive Heart Disease with Heart Failure (occurs when long-term, unmanaged high blood pressure forces the heart to work too hard. This prolonged strain causes the heart muscle to thicken and weaken over time, eventually preventing the heart from pumping or filling with blood properly), Primary Generalized Osteoarthritis (condition affecting the joints, tissues around the joints, and other connective tissues), Essential Hypertension (high blood pressure), and Heart Failure (chronic condition where the heart muscle is too weak or too stiff to pump enough blood and oxygen to meet the body's needs). Review of Patient #6's active clinical record revealed a SOC OASIS assessment dated 03/12/2026 and signed by the DON. The OASIS failed to evidence a skill was performed. Review of Patient #6's active clinical record revealed a document titled "RN Visit Note". The visit note dated 03/20/2026 and signed by the DON indicated but is not limited to, " … Medications were prefilled for the upcoming week …" The POC failed to evidence the correct SOC date. 11. Review of Patient #8's active clinical record revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 03/18/2026 for the certification period of 05/17/2026 through 07/15/2026, and signed by the DON. The POC indicated Patient #8 had, but is not limited to, Hemiplegia following cerebral infarct affecting left dominant side (complete paralysis of the left side of the body caused by an stroke (blockage of blood flow in the brain)), Type 2 Diabetes Mellitus (chronic condition where the body does not make enough insulin or resists it), Essential Hypertension (high blood pressure), Bilateral primary osteoarthritis of knee (condition affecting the joints, tissues around the joints, and other connective tissues), Gout (painful, inflammatory form of arthritis characterized by sudden, severe attacks of pain, swelling, and redness in the joints), and Chronic Kidney Disease (long-term condition where your kidneys are damaged and gradually lose their ability to properly filter waste and excess fluid from your blood). Review of Patient #8's active clinical record revealed a SOC OASIS assessment dated 03/18/2026 and signed by the DON. The OASIS failed to evidence a skill was performed. Review of Patient #8's active clinical record revealed a document titled "RN Visit Note". The visit note dated 03/20/2026 and signed by the DON indicated but is not limited to, " … Skilled nursing completed weekly medication setup to ensure proper dosing and adherence …" The POC failed to evidence the correct SOC date. 12. Review of Patient #11's active clinical record revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 03/14/2026 for the certification period of 05/13/2026 through 07/11/2026, and signed by the DON. The POC indicated Patient #11 had, but is not limited to, Essential Hypertension (high blood pressure), Pain in joints of right hand, Pain in joints of left hand, Pain in unspecified foot, and Hemiplegia following unspecified cerebrovascular disease affecting left nondominant side (complete paralysis of the left side of the body caused by an stroke (blockage of blood flow in the brain)). Review of Patient #11's active clinical record revealed a SOC OASIS assessment dated 03/18/2026 and signed by the DON. The OASIS failed to evidence a skill was performed. Review of Patient #11's active clinical record revealed a document titled "RN Visit Note". The visit note dated 03/20/2026 indicated the medication box was filled. The POC failed to evidence the correct SOC date. 1. An agency policy titled "Plan of Care" indicated but was not limited to, " … Is a written plan that specifies the care and services necessary to meet the patient-specific needs … the measurable outcomes that the agency anticipates would occur as a result of implementing & coordinating the plan of care. … supplies, and equipment required … all medications and treatments … patient-specific measurable outcomes/goals …" 2. During a home visit at Patient #2's residence on 05/27/2026, the Alternate Administrator/Alternate DON was observed performing wound care. The patient had a urostomy (an alternate route for urine to be removed from the body surgically placed in the abdomen, when the bladder was not functioning appropriately) and ostomy (a surgical opening in the abdomen used to remove waste from the body for individuals with an impaired digestive tract). A review of Patient #2's active clinical record evidenced a POC with a SOC of 04/23/2026 and an initial certification period from 04/23/2026 and 06/21/2026. The POC listed the following diagnoses: Stage four Pressure Ulcer of the left buttocks (a severe wound exposing muscles, tendons, or bones), Diabetes (a condition where the body is unable to produce enough insulin or use it appropriately), and Paraplegia (partial or complete inability to feel or move the lower half of the body). The Patient received wound care seven days a week for nine weeks from a SN. The DME listed on the POC included but was not limited to: hospital bed, motorized wheelchair, bed assist bar, ABDs (abdominal pads), chux/underpads, Diabetic Supplies, drainage bag, dressing supplies, exam gloves, gauze pads, irrigation set, syringe, and tape. A review of an OASIS assessment dated 04/23/2026 by the Administrator/DON failed to evidence they performed wound care during the SOC visit. A RN visit note dated 04/24/2026 evidenced the first visit wound care was performed on Patient #2. The POC failed to include all DME the patient had and the correct SOC and certification period for the first date wound care was performed on the patient. 3. An attempt to enter Patient #3's residence for a home visit was made on 05/27/2026 at 2:26 PM. The address listed on the POC was used to locate the patient's residence at Location 4. Upon arrival at Location 4, it was evidenced Patient #3's relative lived there and the patient lived at another location. A review of Patient #3's active clinical record evidenced a POC with a SOC of 03/18/2026 and an initial certification period from 03/18/2026 to 05/16/2026. A review of Patient #3's active clinical record evidenced a POC with a SOC of 03/18/2026 and a recertification period from 05/17/2026 to 07/15/2026. The POC listed the following diagnosis Type 2 Diabetes Mellitus (a condition where the body is unable to produce enough insulin or use it appropriately). The patient received SN services once a week for nine weeks to inject 12.5 milligrams (mg)/0.5 milliliters (ml) of Mounjaro (used to lower blood sugar levels in people with Type 2 Diabetes) weekly and 1000 micrograms (mcg)/ml of Cyanocobalamin (used to improve Vitamin B12 deficiency) monthly under the skin, into the fatty tissue. Patient #3's active clinical record evidenced a SOC assessment completed on 03/18/2026 by RN 2. The note failed to evidence the RN performed a skilled service during the assessment. An RN visit note dated 03/26/2026 by RN 2 evidenced the RN gave Patient #3 their Mounjaro injection. A review of the RN visit notes dated 03/26, 04/01, 04/08, 04/15, 04/22, 04/29, 05/06, and 05/20/2026 failed to evidence the nurse gave Patient #3 their Cyanocobalamin injection. During an interview on 05/27/2026 at 2:26 PM, Person 3 indicated Patient #3 was not at their house, and returned home. Person 3 refused to answer any further questions. During an interview on 05/27/2026 at 2:30 PM, RN 3 indicated Patient #3's address was located at Location 5. During an interview on 05/27/2026 at 2:50 PM, RN 2 was observed providing care for Patient #3 at Location 5. RN 2 indicated they administer Patient #3's Mounjaro and a family member administered the B-12 injection. RN 2 indicated the B-12 injection was monthly so family was available to administer the injection. The POC failed to include only the injection performed by the RN, the correct address, and the correct SOC and certification periods when the first skill was performed. 4. A review of Patient #5's active clinical record evidenced a POC with a SOC of 03/18/2026 and an initial certification period from 03/18/2026 to 05/16/2026. A review of Patient #5's active clinical record evidenced a POC with a SOC of 03/18/2026 and a recertification period from 05/17/2026 to 07/15/2026. The POC listed the following diagnosis Type 2 Diabetes Mellitus (a condition where the body is unable to produce enough insulin or use it appropriately). The patient received SN services once a week for nine weeks to inject 2 mg/ 3 ml of Ozempic (used to lower blood sugar levels in people with Type 2 Diabetes and assist with weight loss) weekly, under the skin into the fatty tissue. Patient #5's active clinical record evidenced a SOC assessment completed on 03/18/2026 by RN 2. The note failed to evidence the RN performed a skilled service during the assessment. A RN visit note dated 03/25/2026 evidenced the RN gave Patient #5 their Ozempic injection. The POC failed to include the correct SOC and certification periods when the first skill was performed. 5. A review of Patient #7's active clinical record evidenced a POC with a SOC of 03/11/2026 and an initial certification period from 03/11/2026 to 05/09/2026. A review of Patient #7's active clinical record evidenced a POC with a SOC of 03/11/2026 and a recertification period from 05/10/2026 to 07/08/2026. The POC listed the following diagnoses: Systolic, Congestive Heart Failure (the left ventricle of the heart becomes weak causing the heart to not pump enough oxygenated blood to the rest of the body, Hypertension (high blood pressure), Atrial Fibrillation (a quivering heart rhythm in the upper portion of the heart causing blood to flow ineffectively to the lower portions of the heart, and Type 2 Diabetes Mellitus. The patient received SN services once a week for nine weeks for medication setup and skilled education. The section titled "Goals/Rehabilitation Potential/Discharge Plans" indicated but was not limited to " … Client will verbalize understanding of proper use of pain medication … The Client/Caregiver will verbalize understanding of symptoms of cardiac complications and when to call 911 … Client will be free from signs and symptoms of constipation … Client will have increased mobility, self care, endurance, ROM (sic range of motion) and decreased pain …" Patient #7's active clinical record evidenced a SOC assessment completed on 03/11/2026 by RN 1. The note failed to evidence the RN performed a skilled service during the assessment. The RN visit note dated 03/18/2026 evidenced the first date the RN performed a skilled service for Patient #7. A recertification assessment dated 05/10/2026 by RN 1 included Patient #7 received education in regards to their disease management and medications. The POC failed to include the correct SOC and certification periods when the first skill was performed and goals related to the education the skilled nurse provided. 6. A review of Patient #10's active clinical record evidenced a POC with a SOC of 03/13/2026 and an initial certification period from 03/13/2026 to 05/11/2026. A review of Patient #10's active clinical record evidenced a POC with a SOC of 03/13/2026 and a recertification period from 05/12/2026 to 06/29/2026. The POC listed the following diagnoses: Hypertension, Type 2 Diabetes Mellitus, Idiopathic constipation (chronic disorder with difficult to pass bowel movements), heart block (a disruption in the electrical signals to the heart causing the heart to beat too slowly), Hyperlipidemia (high levels of fats in the blood), and Hypothyroidism (the thyroid fails to produce enough hormone causing the body functions to slow). The patient received SN services once a week for seven weeks for medication setup, ensure accurate Ozempic (a medication used to lower blood sugar and prevent cardiovascular events), assess patient's ability to fill their medication planner, and education regarding Diabetes, Hypertension, and cardiac issues. The section titled "Goals/Rehabilitation Potential/Discharge Plans" indicated but was not limited to, " … Client will verbalize understanding of proper use of pain medication … Client will be free from signs and symptoms of respiratory distress … Client will be free from signs and symptoms of hypo (sic low)/hyperglycemia (sic high blood sugar) … Client/Caregiver will verbalize knowledge of diabetes management, S&S (sic signs and symptoms) of complications, hypo/hyperglycemia, foot care and management during illness or stress … Client will maintain low cholesterol, no cholesterol, no concentrated diet compliance … The client will be free from falls …" Patient #10's active clinical record evidenced a SOC assessment completed on 03/13/2026 by the Administrator/DON. The note failed to evidence the Administrator/DON performed a skilled service during the assessment. The RN visit note dated 03/16/2026 evidenced the first date the RN performed a skilled service for Patient #10. The POC failed to include the correct SOC and certification periods when the first skill was performed and goals related to the education and tasks the skilled nurse provided. 7. A review of Patient #12's active clinical record evidenced a POC with a SOC of 03/11/2026 and an initial certification period from 03/11/2026 to 05/09/2026. A review of Patient #12's active clinical record evidenced a POC with a SOC of 03/11/2026 and a recertification period from 05/10/2026 to 07/08/2026. The POC included the following diagnoses: Type 2 Diabetes Mellitus, Hypertension, Hyperlipidemia, and Secondary Hyperparathyroidism (over produce the parathyroid hormone to improve low calcium or high phosphorus). The patient received SN services once a week for nine weeks for assistance with medication setup and teach the patient to administer 3 milligrams (mg)/0.5 milliliters (ml) of Trulicity (used to control blood sugar levels) into the fatty layer under the skin. The section titled "Goals/Rehabilitation Potential/Discharge Plans" indicated but was not limited to, " … Client will verbalize understanding of proper use of pain medication … Client will be free from signs and symptoms of hypo/hyperglycemia … Client/Caregiver will be independent with glucometer use … Client/Caregiver will verbalize knowledge of diabetes management, S&S of complications, hypo/hyperglycemia, foot care and management during illness or stress … Client will maintain low sodium, no concentrated sweets diet compliance … The client will be free from falls … Client will remain free of adverse medication reactions … The Client/Caregiver will verbalize understanding of medication regimen, dose, route, frequency, indications, and side effects … " Patient #12's active clinical record evidenced a SOC assessment completed on 03/11/2026 by the Administrator/DON. The note failed to evidence the Administrator/DON performed a skilled service during the assessment. The RN visit note dated 03/16/2026 evidenced the first date the RN performed a skilled service for Patient #12. The POC failed to include the correct SOC and certification periods when the first skill was performed and goals related to the education and tasks the skilled nurse provided. 13. During an interview with RN 1 on 05/28/2026 at 12:11 PM, they explained medications were reviewed after the patient went to the doctor's office, during recertification, and new orders. The indicated if they found a discrepancy in the medications, they updated the medication profile. They indicated an order to change the Libre device should have been included on the POC. When queried regarding skills performed on the SOC OASIS assessment, they explained they had not performed skills during the SOC assessments for their patients. The POC should have included goals specific to the patient's stated needs, diagnoses, and education provided. They explained they should have specified what injections they gave the patient and all patients' DME on the POC. 14. During an interview with the Administrator/DON, Alternate Administrator/Alternate DON, HHA 1, the owner, and RN 3 on 05/28/2026 at 1:53 PM, the Administrator/DON explained all DME was to be listed on the POC. When a new medication was found, they ran a drug interaction, confirm orders with the physician, create an addendum to the POC, and send a verbal order for the physician's signature. They indicated when a nurse was not performing an injection for the patient, the POC should have reflected them not administering the medication. The Administrator/DON explained the SOC date was on the order to start care, and no skilled care was performed on a SOC OASIS assessment for the patients. They indicated they were unaware a skill should have been performed on the SOC OASIS assessment for the date to be the SOC for the patient. 410 IAC 17-13-1(a)(1)(D)(ii and xiii)

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to provide services as ordered by the physician for 2 of 3 active clinical records reviewed with patient's using a continuous glucose monitor (Patient #1 and #7). Findings Include: 3. A review of Patient #7's active clinical record evidenced a POC with a SOC of 03/11/2026 and a recertification period from 05/10/2026 to 07/08/2026. The POC listed the following diagnoses: Systolic, Congestive Heart Failure (the left ventricle of the heart becomes weak causing the heart to not pump enough oxygenated blood to the rest of the body, Hypertension (high blood pressure), Atrial Fibrillation (a quivering heart rhythm in the upper portion of the heart causing blood to flow ineffectively to the lower portions of the heart, and Type 2 Diabetes Mellitus. The patient received SN services once a week for nine weeks for medication setup and skilled education. A RN visit note, in Patient #7's clinical record, dated 03/25/2026, signed by RN 1, indicated but was not limited to, " … Patient has g7 libre device for glucose monitoring … G7 Libre monitoring device applied to right upper arm to be changed every 10 days …" A RN visit note, in Patient #7's clinical record, dated 04/01/2026, signed by RN 1, indicated but was not limited to, " … libre monitoring device changed to right arm … communicated with caregiver to be changed within 10 days …" A RN visit note dated 04/08/2026 evidenced RN 1 changed the patient's libre monitoring device to Patient #7's right arm and should have been changed in 14 days. A RN visit note, in Patient #7's clinical record, dated 04/15/2026 evidenced RN 1 applied the patient's libre device to the patient's upper right arm and was to be changed in 10 days. A RN visit note, in Patient #7's clinical record, dated 05/06/2026, by RN 1, indicated but was not limited to, " … Libre monitor changed today and applied to right arm. Education provided regarding rotating sites every 10-14 days …" A RN visit note, in Patient #7's clinical record, dated 05/13/2026, by RN 1, indicated but was not limited to, " … Libre glucose monitoring device was changed and applied to the patient's upper left arm during today's visit. … Patient and caregiver instructed that device should be changed within 10-14 days by nurse or caregiver per physician recommendations. …" A RN visit note dated 05/20/2026 evidenced RN 1 changed Patient #7's libre device to the left arm and changed within 10 to 14 days. During an interview with Patient #1, the caregiver of Patient #7, on 05/27/2026 at 3:41 PM, they explained the nurse with the agency set up Patient #7's medications from the pill bottles into the patient's medication planner and placed the patient's G7 Libre monitoring device on the patient's arm for them. During an interview with RN 1 on 05/28/2026 at 12:11 PM, they explained for patient's with the Libre device, it was changed every 10-14 days. They indicated the order to change the Libre device should have been included on the POC. 4. During an interview with the Administrator/DON, Alternate Administrator/Alternate DON, HHA 1, the owner, and RN 3 on 05/28/2026 at 1:53 PM, the Administrator/DON explained they were unaware they needed an order for the nurse to change the patient's Libre device and allowed RN 1 to change the device without orders. They indicated Patient #1's Repatha had no order for a change in frequency and the times the medication was documented as administered was a documentation error. 410 IAC 17-13-1(a) 1. Review of an agency policy dated 04/2024 and titled "Verbal Orders" indicated, but is not limited to, " … Drugs and treatments are administered by Agency staff only as ordered by the medical provider …" 2. Review of Patient #1's active clinical record revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 03/11/2026 for the certification period of 03/11/2026 through 05/09/2026, and signed by RN 1. The POC indicated Patient #1 had but is not limited to, Essential Hypertension (high blood pressure), Unspecified systolic (congestive) heart failure (occurs when the heart's main pumping chamber, the left ventricle, becomes weak and cannot contract normally), Diabetes (chronic metabolic condition where the body resists the effects of insulin and fails to produce enough to maintain normal glucose levels causing high blood sugar), Sleep Apnea (sleep disorder in which a person's breathing repeatedly stops and starts throughout the night), and legal blindness. The POC subsection titled "Medications" indicated, but is not limited to, " … Repatha [medication used to help control cholesterol] 140 mg/ml [milligrams/milliliters] subcutaneous [underneath the skin] solution prefilled syringe frequency: monthly Indication: Instruction: administer 1 sub q [subcutaneous] injection monthly …" The POC subsection titled "Orders for Discipline and Treatments" indicated, but is not limited to SN once a week for nine weeks to set up medication weekly related to forgetfulness and exhaustion, and to administer subcutaneous injections as needed per MD (Medical Doctor) order. Review of Patient #1's active clinical record revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 03/11/2026 for the certification period of 05/10/2026 through 07/08/2026, and signed by RN 1. The POC indicated Patient #1 had, but is not limited to, Essential Hypertension, Unspecified systolic (congestive) heart failure, Diabetes , Sleep Apnea, and legal blindness. The POC subsection titled "Medications" indicated, but is not limited to, " … Repatha 140 mg/ml subcutaneous solution prefilled syringe frequency: monthly Indication: Instruction: administer 1 sub q injection monthly …" The POC subsection titled "Orders for Discipline and Treatments" indicated, but is not limited to, SN once a week for nine weeks to assess client filling medication box to determine if client is preparing correct, and to Administer subcutaneous injections as needed per MD order related to visual impairment. Review of Patient #1's active clinical record revealed a document titled "Physician Order". The orders dated 03/11/2026 through 05/28/2026 failed to evidence an order to change the Libre monitor or to change the frequency of Repatha injection. Review of Patient #1's active clinical record revealed a document from Entity 2, a health network, titled "Continuity of Care Document". The document stated, " … evolocumab (Repatha Sure Click 140 mg/mL subcutaneous solution) start date: 3/5/26 140 milligram subcutaneous every 2 weeks … Insulin aspart [insulin is a hormone created by the pancreas to control blood glucose, insulin aspart is a fast acting insulin] … start date 2/4/26 Inject subq [subcutaneous] per sliding scale with dinner … insulin glargine [long acting insulin] start date 2/19/26 16 units subcutaneous at bedtime …" Review of Patient #1's active clinical record revealed a document titled "RN Visit Note". The visit note dated 04/08/2026 and signed by RN 1 indicated but is not limited to, " … Changed Libre monitoring device …" The visit note dated 04/15/2026 and signed by RN 1 indicated but is not limited to, " … Patient has G7 libre monitoring device, changed in today's visit …" The visit note dated 04/22/2026 and signed by RN 1 indicated but is not limited to, " … administered prescribed subcutaneous injections (Repatha …" The visit note dated 04/29/2026 and signed by RN 1 indicated but is not limited to, " … Administered Repatha injection …" The visit note dated 05/06/2026 and signed by RN 1 indicated but is not limited to, " … Libre monitoring device changed on today's visit …" The visit note dated 05/13/2026 and signed by RN 1 indicated but is not limited to, " … SN administered patient's … Repatha injection …" The visit note dated 05/20/2026 and signed by RN 1 indicated but is not limited to, " … Libre glucose monitoring device was changed today and applied to right upper arm …" During an interview with RN 1 on 05/28/2026 at 12:11 PM, they explained Patient #1's Mounjaro was administered to the patient weekly and Repatha monthly. When queried regarding the Repatha given weekly, they explained there was a documentation error for the visit dates 04/22/2026 and 04/29/2026. They explained for patient's with the Libre device, it was changed every 10-14 days. They indicated the order to change the Libre device should have been included on the POC.

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 infection control practices were maintained for 1 of 2 home visits with a SN performing an injection and medication set up (RN 1) and for 1 of 1 home visits with a HHA (HHA 1). Findings Include: During an interview with RN 1 on 05/28/2026 at 12:11 PM, they explained hand hygiene was supposed to be performed upon entering and leaving the house and when they changed gloves. 3. During a home visit at Patient #4's residence on 05/27/2026 at 1:00 PM, HHA 1 was observed assisting the patient with showering. HHA 1 assisted the patient to their bathroom and into the bathtub. They removed their glove, buzzed the Administrator/DON into the patient's residence, and donned new gloves without performing hand hygiene. The HHA washed the patient's back for them, doffed gloves, and donned new gloves without performing hand hygiene. During an interview with HHA 1 on 05/28/2026 at 9:15 AM, they indicated hand hygiene should have been performed every time they changed their gloves and when they switched tasks. During an interview with the Administrator/DON and the Alternate Administrator/Alternate DON on 05/28/2026 at 1:53 PM, they explained hand hygiene was supposed to be performed when changing gloves. They indicated a barrier should have been placed under the medication box to ensure the medication remained clean if the clinician missed the box. 410 IAC 17-12-1(m) 1. Review of an agency policy dated 04/2024 and titled "Hand Hygiene" indicated, but is not limited to, " … Current CDC Hand Hygiene Guidelines: … Clean hands before and after patient care and with each glove change … Employees providing care/service in the home will wash their hands at least: … Before and after contact with the patient, After touching an inanimate object on or near the patient …" 2. During a home visit on 05/27/2026 at 1:00 PM, RN 1 was observed providing care for Patient #1. RN 1 performed hand hygiene, put on gloves, then auscultated Patient #1's lungs, heart, and abdomen. With the same gloved hands, RN 1 checked Patient #1's vital signs, assessed Patient #1's feet, and weight. RN 1 removed their gloves and put on new gloves. RN 1 cleansed Patient #1's left middle quadrant with an alcohol pad and administered Mounjaro (injectable medication used to lower blood glucose levels). RN 1 cleaned their equipment and removed their gloves. RN 1 put on new gloves, cleansed the right middle quadrant with an alcohol pad, administered the Repatha (injectable medication used to help lower cholesterol), and removed their gloves. RN 1 returned their equipment to the nursing bag. RN 1 performed hand hygiene, put on clean gloves, and filled the pill organizer. RN 1 removed their gloves, performed hand hygiene, with their bare hands picked up a pill from the table, received verification the patient was agreeable to use the pill from the table, placed the pill into the organizer. RN 1 completed charting and then hand hygiene. RN 1 failed to follow infection control practices while providing care to Patient #1. During an interview with RN 1 on 05/28/2026 at 12:11 PM, they explained hand hygiene was supposed to be performed upon entering and leaving the house and when they changed gloves.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the nursing notes included a complete assessment and description in 1 of 1 active clinical records reviewed with a patient with a wound. (Patient #2) Findings Include: 1. An agency policy titled "Wound Care" indicated but was not limited to, " … v. A description of the appearance of the wound will be documented- in detail. You must describe: Type of wound (open or closed) …" 2. A review of Patient #2's active clinical record evidenced a POC with a SOC of 04/23/2026 and an initial certification period from 04/23/2026 and 06/21/2026. The POC listed the following diagnoses: Stage four Pressure Ulcer of the left buttocks (a severe wound exposing muscles, tendons, or bones), Diabetes (a condition where the body is unable to produce enough insulin or use it appropriately), and Paraplegia (partial or complete inability to feel or move the lower half of the body). The Patient received wound care seven days a week for nine weeks from a SN. A review of the RN visit notes dated 05/04, 05/05, 05/06, 05/07, 05/08, 05/09, 05/10, 05/11, 05/12, 05/18, 05/19, 05/20, 05/21, 05/22, 05/23, 05/24, and 05/25/2026, by the Alternate Administrator/Alternate DON, indicated but was not limited to, " … Wound Care/Dressing Change … Wound was measured, cleaned, packed, and drainage was noted …" The visit notes failed to evidence the amount of drainage, color of the drainage, color of the wound, and the general look of the wound. During an interview with the Administrator/DON, Alternate Administrator/Alternate DON, HHA 1, the owner, and RN 3 on 05/28/2026 at 1:53 PM, the Alternate Administrator/Alternate DON indicated the wound size, color, and drainage color were to be documented on each visit note. They explained the visit notes should have been more specific to reveal the overall look of the wound. 410 IAC 17-14-1(a)(1)(E)