Every finding on record at Better Living Home Health Care, Inc

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR §484.102 Survey Dates 12/09/2025-12/12/2025 & 12/15/2025-12/17/2025 Active Census: 40 At this Emergency Preparedness survey, Better Living Home Health Care, INC was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR §484.102. QR Completed on 01/02/2026 by A4JG

This visit was for a Federal Recertification and State Re-Licensure survey of a Home Health Provider. Survey Dates: 12/09/2025-12/12/2025 & 12/15/2925-12/17/2025 12-Month Unduplicated Skilled Admissions: 55 Partially Extended on 12/15/2025 at 10:45 AM This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Abbreviations: RN Registered Nurse LPN Licensed Practice Nurse POC Plan of Care SOC Start of Care OASIS Outcome and Assessment Information Set EMR Electronic Medical Record SN Skilled Nurse

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to complete an initial assessment within 48 hours of a referral and failed to document the reason for the delayed start of care for 6 of 10 record reviews. (Patients #1, #2, #3, #8, #9, #10) Findings include: 1. Review of a policy titled "Initial Assessments" indicated but was not limited to, "…POLICY An initial client assessment will be performed within twenty-four (24) to forty-eight (48) hours of approved referral and documented in the client's clinical record by the case manager/team leader…" 2. The clinical record for Patient #1 included a referral received on 08/26/2024 that had an initial nursing assessment completed on 09/10/2024 for the POC certification period of 05/24/2025 to 07/22/2025. The review failed to evidence documentation, physician orders, or communication notes in the record to indicate a reason for delay between referral receipt and admission into the agency. The agency failed to perform an initial assessment within 48 hours of referral. 3. The clinical record for Patient #2 included a referral received on 01/16/2020 that had an initial nursing assessment completed on 01/22/2024 for the POC certification period of 09/11/2024 to 11/09/2024. The review failed to evidence documentation, physician orders, or communication notes in the record to indicate a reason for delay between referral receipt and admission into the agency. The agency failed to perform an initial assessment within 48 hours of referral. 4. The clinical record for Patient #3 included a referral received on 02/03/2025 that had an initial nursing assessment completed on 02/28/2025 for the POC certification period of 07/09/2025 to 09/06/2025. The review failed to evidence documentation, physician orders, or communication notes in the record to indicate a reason for delay between referral receipt and admission into the agency. The agency failed to perform an initial assessment within 48 hours of referral. 5. The clinical record for Patient #8 had no referral at all but an initial nursing assessment completed on 06/01/2023 for the POC certification period of 10/14/2025 to 12/12/2025. The agency failed to provide evidence the initial assessment was completed within 48 hours of referral. 6.The clinical record for Patient #9 included a referral received on 06/24/2025 and evidenced an initial nursing assessment; however, the assessment date was illegible due to being cut off on the document. No additional documentation was found in the record for the POC certification period of 10/25/2025 to 12/23/2025 to verify when the assessment occurred. The agency failed to provide evidence that the initial assessment was completed within 48 hours of referral. 7. The clinical record for Patient #10 included a referral received on 05/28/2024 that had an initial nursing assessment completed on 06/21/2024 for the POC certification period of 10/14/2025 to 12/12/2025. The review failed to evidence documentation, physician orders, or communication notes in the record to indicate a reason for delay between referral receipt and admission into the agency. The agency failed to perform an initial assessment within 48 hours of referral. 8. During an interview on 12/10/2025 at 2:15 PM, the Administrator and Director of Nursing indicated they were not sure why the referral date and time the initial assessment wasn't completed within the 48 hour window required as it is agency policy for this timeline to be met. The Administrator indicated discussions have occurred with the intake coordinators in the past but they have since been relieved of duty and the new intake coordinator is still in their 90 day window of hire and in training. The Administrator also indicated one thought for several of the patients are that they were receiving services from the PSA agency affiliated with the home health agency already and either the skilled care was requested by the patients themselves, during a supervisory visit, or at a recertification of services to check for qualification switch or add those services. 17-14-1(a)(1)(A)

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 and interview, the agency failed to ensure a discharge summary containing all essential medical information concerning the patient's current disposition, diagnosed conditions for which care was being provided, treatment choices, and after discharge goals for care was provided to their primary care provider or receiving agency to guarantee the safe and effective change in care for 3 of 3 closed records reviewed (Patient #1, #2, and #3). Findings include: 1. The agency's policy "CLIENT DISCHARGE AND TRANSFER POLICY" states planning for discharge or transfer from home health services begins at admission, the patient/caregiver/family should participate and is informed of the date and reason, the agency will continue to provide care or instructions for care when discharge or transfer is to take place, and the patients physician or receiving agency will be informed. 2. The clinical record for Patient #1 (SOC 09/26/2024, certification period of 05/24/2025 to 07/22/2025) documented a discharge date of 06/30/2024, a discharge/transfer note signed by the nurse on 07/14/2025, and a discharge order signed by the patient's primary physician on 08/14/2025. The record failed to evidence a discharge and transfer summary with all required elements for the patient was completed and documentation it was sent to the primary care physician or receiving agency. 3. The clinical record for Patient #2, POC certification period of 09/11/2024 to 11/09/2024, documented a discharge date of 10/20/2024 with a discharge order written, signed and sent by the nurse case manager to the patient's primary physician on 10/23/2024. The record failed to evidence a full discharge summary with all required elements for the patient was completed and documentation it was sent to the primary care physician or receiving agency. 4. The clinical record for Patient #3, POC certification period of 07/09/2025 to 09/06/2025, documented a discharge date of 09/05/2025 with a narrative of patient plan to move to structure family care program with caregiver, a communication note from the family caregiver indicating a move to structure family care program with patient and last date to work would be 09/02/2025, and another communication note on 09/04/2025 requesting a discharge from the agency due to receipt of approval for the structured family care program. The record failed to evidence a discharge and transfer summary with all required elements for the patient was completed and documentation it was sent to the primary care physician or receiving agency. 5. During an interview on 12/15/2025 at 2:15 PM, the Administrator and Director of Nursing (CM) indicated when a discharge or transfer occurs an OASIS assessment should be completed if a visit can be done, the physician is notified, and a communication note is put into the clinical record. The Director of Nursing (CM) did not verbalize a timeframe for when these items are supposed to be completed. The Administrator added discharge and/or transfer summaries should be completed for all patients that are discharging or transferring from the agency and this should be noted in the record and sent to the patient's primary physician. 6. During an interview on 12/16/2025 at 9:45 AM, the Administrator indicated that after reviewing the records for the discharged/transferred patients in question, there was a note in the clinical record for the patient that was non-skilled, however it was not sent to the patient's physician. For the other two patients, the Administrator indicated no completed summaries or notes to show they were sent to the physician in the clinical record. 17-13-2(a)(b)(9)

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 patient orders were recorded in the plan of care that accurately reflected the type of treatment provided at each nursing visit for 1 of 4 home visit observations. (Patient #4) Findings include: The agency’s policy “Client Plan of Care” states that services are furnished under physician supervision and based on a plan of care that is established, periodically reviewed, and updated. The policy requires that changes in the plan of care be documented through written and signed modifications. The agency’s “Care Coordination” policy requires clinicians to update physician orders, update the plan of care, and communicate changes in orders or findings to supervisors and team members. The clinical record review for Patient #4 (SOC 03/04/2019; certification period 11/27/2025–01/25/2026) evidenced an active physician order dated 05/03/2024 directing enteral feedings via G‑tube pump (liquid nutrition delivered through a tube that goes directly into the stomach. via small electric pump controls how fast the formula goes in.) at 50 mL/hr, advancing as tolerated to 250 mL/hr, with 50 mL/hr of water between feeds. The POC dated (11/27/2025-01/25/2026) failed to include the pump, the formula, Nourish 6-8 oz via tube every 2-3 hours, and the MD order for tube feed administration failed to be specific. Review of the 12/10/2025 skilled nursing visit note showed the nurse administered the feeding via bolus push, not by pump as ordered. During an observation on 12/11/2025 at 8:59 AM, RN 1 administered a bolus (liquid nutrition given all at once) feeding of Nourish formula mixed with water using a syringe and extension set. RN 1 checked residuals and flushed the tube per routine bolus procedure. When interviewed, RN 1 stated the patient had temporarily used a pump during a stomach ulcer episode but had returned to bolus feedings once the ulcer healed. RN 1 was unaware that the pump order remained active in the clinical record and believed it had been discontinued. During an interview on 12/10/2025 at 3:30 PM, the Director of Nursing confirmed the patient receives bolus feedings and stated there is no pump in the home. The Director of Nursing was unaware an active pump order remained in the EMR and could not explain why it continued to appear despite being discontinued. 17-13-1(a)(1)(A)(B)(1-8)

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: Based on record review and interview, the nurse failed to ensure integration of all specialized doctors, therapists, specialty clinics, and/or agencies involved in care or treatment outside of the ordering physician and home health were communicated clearly through care coordination and the documentation included what actions were taken, how changes to the patient's status occurred, and if orders and the POC were followed and/or affected for patients diagnosed with acute and chronic conditions for 7 of 7 skilled patients reviewed. (Pt #1, #2, #4, #5, #6, #7, and #9) Findings include: 1. The agency's policy "Care Coordination" states the RN is responsible for utilizing comprehensive coordinated health care through communication with all personnel involved with a patient, via a case conference if possible, and documentation in the clinical record about those changes/revisions/updates to any part of the care plan. 2. The clinical record for Patient #1 (SOC 09/26/2024, certification period of 05/24/2025 to 07/22/2025) included a POC that had orders for skilled nursing to setup patient's medication weekly, monitor patient glucose levels, and delegate/supervise interventions for the home health aide to implement to help the patient with identified areas of concern in completing activities of daily living. The record included a summary dated 05/19/2025 of the previous certification period (03/25/2025-05/23/2025) which indicated care and resources needed to help manage the patient's past medical history that resulted in limited use of the right side of the body combined with multiple diagnosed conditions effecting several body systems, including mental illness and addiction that require more than five (5) medications regularly to treat and/or stabilize. The nurse states on the POC summary the patient is seeing three (3) specialists besides the ordering physician, has another agency providing assistance with instrumental activities of daily living, and no support system or involvement from family or friends in day-to-day life. The nurse failed to demonstrate how skilled care was used to coordinate the patient's care and the documentation lacked explanation of what was coordinated, why coordination was needed, and if patient identified outcomes and/or the home health POC was affected. 3. The clinical record for Patient #2 (SOC 02/05/2020, certification period of 09/11/2024 to 11/09/2024) included a POC that had orders for skilled nursing to setup patient's medication weekly, apply transdermal pain patch weekly, provide teaching about medications and management to attain compliance, and delegate/supervise interventions for the home health aide to implement to help the patient with identified areas of concern in completing activities of daily living. The record included a summary dated 09/09/2024 of the previous certification period (07/13/2024-09/10/2024) which indicated the patient has physical deformities of both hands that make opening pill bottles or setting up a weekly planner independently very difficult, an extensive medical history with multiple diagnosed conditions effecting several body systems, including mental illness that require more than five (5) medications regularly to treat and/or stabilize. The nurse states on the POC summary the patient is seeing five (5) specialists, besides the ordering physician, two (2) different specialty clinics providing skilled care/treatment, physical therapy provided in home weekly, and has another agency providing assistance with instrumental activities of daily living. The nurse failed to demonstrate how skilled care was used to coordinate the patient's care and the documentation lacked explanation of what was coordinated, why coordination was needed, and if patient identified outcomes and/or the home health POC was affected. 4. The clinical record for Patient #4 (SOC 03/04/2019; certification period 11/27/2025–01/25/2026) included a POC that had orders for skilled nursing to administer g-tube feedings and medications as ordered every visit; assess activity tolerance, cognitive and/or sensory limitations and impairments, motor function, pain levels their contributing factors and any relief modalities at every visit; assess patency and placement of g-tube prior to medication, hydration, and nutrition administration and the site and surrounding tissue (for complications, erythema, swelling, and purulent drainage); implement interventions to prevent skin breakdown; monitor vital signs and pulse oximetry as needed for respiratory distress; perform suctioning as needed throughout visit and mouth care every visit and as needed; check residual prior to each feeding and hold for 30 minutes if it is greater than 100 mL, then recheck within the hour and call the physician if the residual remains greater than 100 mL; may provide g-tube care and dressing changes upon family request; and provide activities of daily living every visit, The record included a summary dated 11/22/2025 of the previous certification period (09/28/2025-11/26/2025) which indicated the patient has had positive results from Deep Brain Stimulation (DBS-A surgical procedure using implanted electrodes and a pacemaker-like device to send electrical signals to the brain.) that decreased generalized spasticity and improved tone, Botox injections in the face and neck areas have been implemented to promote possible eating and speaking capabilities; continues to use wheeled walker as needed or walk independently with stand by assistance; and physical, occupational, speech, and craniosacral therapy moved locations but still working with the patient. The nurse failed to demonstrate how skilled care was used to coordinate the patient's care and the documentation lacked explanation of what was coordinated, why coordination was needed, and if patient identified outcomes and/or the home health POC was affected. 5. The clinical record for Patient #5 (SOC 01/08/2015, certification period 11/11/2025-01/09/2026) included a POC that had orders for skilled nursing to administer medications when ordered and assess new/changed medications, side effects, and interactions; check Freestyle Libre system for blood sugar level and give sliding scale insulin as directed, fingerstick blood sugar check if needed in the absence of the Freestyle Libre system; and delegate/supervise interventions for the home health aide to implement to help the patient with identified areas of concern in completing activities of daily living. The record included a summary dated 11/11/2025 of the previous certification period (09/12/2025-11/10/2025) which indicated the patient has triplegic cerebral palsy with some use of the right upper extremity, is non-ambulatory/non-weight bearing, confined to a bed/wheelchair with use of Hoyer lift for all transfers who lives with grandparents that provide all care. The nurse states on the POC summary the patient requires 24-hour supervision and is total care dependent as he/she suffers severe cognitive deficits, epilepsy secondary to hydrocephalus, vision impairment, complete incontinence of bowel and bladder, and is provided complete assistance with all activities of daily living. The nurse failed to demonstrate how skilled care was used to coordinate the patient's care and the documentation lacked explanation of what was coordinated, why coordination was needed, and if patient identified outcomes and/or the home health POC was affected. 6. The clinical record for Patient #6 (SOC 08/19/2024, certification period 10/13/2025-12/11/2025) included a POC that had orders for skilled nursing to setup patient's medication weekly and manage adherence to proper administration, assess and educate about medications ordered, any new or changed prescriptions, known side effects or possible interactions, and delegate/supervise interventions for the home health aide to implement to help the patient with identified areas of concern in completing activities of daily living. The record included a summary dated 10/09/2025 of the previous certification period (08/14/2025-10/12/2025) which indicated the patient has right hemiplegia (paralysis or severe weakness affecting the right side of the body, typically from an injury to the left side of the brain (like a stroke) or the spinal cord, causing difficulty moving the arm, leg, and sometimes face on the affected side) that resulted from a cerebral infarct (stroke) along with several other diagnosed conditions that involve many body systems, including a mental health history, that requires more than five (5) medications regularly to treat, control, and/or stabilize. The nurse states on the POC summary the patient has at least three (3) specialists involved in care, other than ordering primary care physician, requires the use of DME to remain mobile within the home, requires the assistance of an aide to provide transfers, personal hygiene, meal prep, and reminders or prompts to complete tasks daily, and has another agency providing assistance with instrumental activities of daily living. The nurse failed to demonstrate how skilled care was used to coordinate the patient's care and the documentation lacked explanation of what was coordinated, why coordination was needed, and if patient identified outcomes and/or the home health POC was affected. 7. The clinical record for Patient #8 (SOC 06/27/2023, certification period 10/14/2025-12/12/2025) included a POC that had orders for skilled nursing to setup patient's medication weekly, manage adherence to proper administration, assess and educate about medications ordered, any new or changed prescriptions, known side effects or possible interactions and notify the physician if any are observed/reported or if non-compliance occurs. The record included a summary dated 10/13/2025 of the previous certification period (08/15/2025-10/13/2025) which indicated the patient has right hemiplegia due to late effect Cerebrovascular Accident (CVA or stroke) causing contracture of right hand and limited use of entire right side. The patient suffers from aphasia, mixed anxiety-depressive disorder, deficits with thought processing and memory, ambulation is slow with slouched gait that leans to the right, right foot drop and dragging of the right leg as a result of the CVA that causes difficulty with communication, mobility, and engagement with others that frustrates the patient and triggers outbursts and/or behaviors. The patient can no longer drive, cook or prepare meals, needs assistance to get to all activities/ appointments outside the home, requires help to complete all ADL's and IADL's, and has a very limited support system available. The patient takes more than five (5) medications regularly to treat and/or stabilize conditions or ailments. The nurse states on the POC summary the patient has another agency providing assistance with all ADL's and IADL's. The nurse failed to demonstrate how skilled care was used to coordinate the patient's care and the documentation lacked explanation of what was coordinated, why coordination was needed, and if patient identified outcomes and/or the home health POC was affected. 8. The clinical record for Patient #9 (SOC 06/27/2025, certification period 10/25/2025-12/23/2025) included a POC that had orders for an aide to assist with personal hygiene, dressing, pet care, and preparation of meals as well as attend to IADL's so patient is able to remain in home, and skilled nursing delegated/supervised interventions implemented to help the patient with identified areas of concern. The record included a summary dated 10/23/2025 of the previous certification period (08/26/2025-10/24/2025) which indicated the patient has a displaced fracture of the top end of the right upper arm and has been suffering from bilateral legs and back pain for which regular use of narcotic pain relief is used, a medical history with chronic conditions that have to be monitored and managed regularly and require more than five (5) medications taken regularly to treat and/or stabilize. The nurse states on the POC summary the patient wishes to include skilled nursing for help with management of medications and compliance which was started on 09/08/2025. The nurse failed to demonstrate how skilled care was used to coordinate the patient's care and the documentation lacked explanation of what was coordinated, why coordination was needed, and if patient identified outcomes and/or the home health POC was affected. 9. During an interview on 12/15/2025 at 2:15 PM, the Administrator and Director of Nursing (CM) indicated documentation needs to give more information on how coordination is completed, why it is needed, who is involved and why, and what affects it has on the patient, orders and/or home health POC approved by physician. 17-12-2(g)

Patients receive education and training CFR(s): 484.60(d)(5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure that ongoing education and training was provided and documented based on the skilled needs assessed and goals identified in the comprehensive assessment for 4 of 7 skilled patient records reviewed. (Patients #1, #2, #6, and #8) Findings included: 1. The agency's policy "PATIENT EDUCATION" states that all patients receive appropriate, timely, and individualized education to promote safe and effective care, improve health outcomes, and support patient independence while in the home setting. Ongoing education should be based on assessed needs, orders, and the POC and the clinicians should implement this education with verbal instruction, demonstration and return demonstration, written materials, visual aids or videos, and teach-back method to verify comprehension and all elements should be documented clearly in the patient's record. 2. A review of clinical record for Patient #1 (SOC 09/26/2024, certification period of 05/24/2025 to 07/22/2025) included a Home Health Care Certification and Plan of Care signed by the Alternate Clinical Manager on 05/19/2025. Patient #1 had orders to receive skilled nursing services one (1) time per week for management of medication, set up of medication planner and compliance with prescribed administration for nine (9) weeks. The clinical record failed to evidence that education was provided to the patient and/or caregiver about the medications prescribed, why they are needed, what they were taken for, signs and symptoms of side effects or adverse reactions, and interactions with other prescribed or over-the-counter drugs or vitamins, how the teaching was implemented, and the response of the patient to the education. 3. The clinical record for Patient #2 (SOC 02/05/2020, certification period of 09/11/2024 to 11/09/2024) included a Home Health Care Certification and Plan of Care signed by RN 3 on 09/09/2024. Patient #2 had orders to receive skilled nursing services one (1) time per week for management of medication, set up of medication planner and compliance with prescribed administration for nine (9) weeks. The clinical record failed to evidence that education was provided to the patient and/or caregiver about the medications prescribed, why they are needed, what they were taken for, signs and symptoms of side effects or adverse reactions, and interactions with other prescribed or over-the-counter drugs or vitamins, how the teaching was implemented, and the response of the patient to the education. 4. The clinical record for Patient #6 (SOC 08/19/2024, certification period 10/13/2025 to 12/11/2025) included a Home Health Care Certification and Plan of Care signed by RN 2 on 12/10/2025. Patient #6 had orders to receive skilled nursing services one (1) time per week for management of medication, set up of medication planner and compliance with prescribed administration for nine (9) weeks. The clinical record failed to evidence that education was provided to the patient and/or caregiver about the medications prescribed, why they are needed, what they were taken for, signs and symptoms of side effects or adverse reactions, and interactions with other prescribed or over-the-counter drugs or vitamins, how the teaching was implemented, and the response of the patient to the education. 5. The clinical record for Patient #8 (SOC 06/27/2023, certification period 10/14/2025 to 12/12/2025) included a Home Health Care Certification and Plan of Care signed by the Alternate Clinical Manager on 10/13/2025. Patient #8 had orders to receive skilled nursing services one (1) time per week for management of medication, set up of medication planner and compliance with prescribed administration for nine (9) weeks. The clinical record failed to evidence that education was provided to the patient and/or caregiver about the medications prescribed, why they are needed, what they were taken for, signs and symptoms of side effects or adverse reactions, and interactions with other prescribed or over-the-counter drugs or vitamins, how the teaching was implemented, and the response of the patient to the education. 6. During an interview on 12/15/2025 at 10:56 AM, the Administrator and Director of Nursing indicated the EMR system uses charting by exception which prevents thorough explanation of education completed by the nurse and response of the patient. They indicated nurses should be putting this into the narrative. 17-14-1(a)(1)(G)

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on observation, record review and interview, the agency failed to ensure medication was reviewed and reconciled, or reflected the orders given by the physician or the way the patient was taking the medication with documentation of communication with the physician for 2 of 4 patient home visit observations. (Patients #5 and #6) Findings include: 1. The agency’s policy titled “On-Going Assessments” requires clinicians to assess patients at each visit to evaluate their response to care and identify any changes. If changes are identified including medications or treatments requiring physician approval the clinician must notify the physician and ensure updates are documented and signed accordingly. 2. The clinical record for Patient #5 for certification period 11/11/2025 through 01/09/2026 evidenced the Medication Profile was reviewed with the caregiver and documented as having no changes.During a home visit observation on 12/15/2025 at 8:53 PM, LPN 1 administered medications that were not listed on the current Medication Profile and were not reflected on the POC. LPN 1 also reported that primidone had been discontinued approximately one week earlier per the physician, but the Director of Nursing had not been notified so the medication list could be updated. LPN 1 further stated that the long‑acting insulin, ordered for bedtime administration, had been changed by the physician to morning administration due to hypoglycemia concerns, but this change was also never communicated to the Director of Nursing for reconciliation. 3. The clinical record for Patient #6 for certification period 12/12/2025 through 02/09/2026 evidenced the Medication Profile was reviewed by LPN 1 and evidenced one change, an antibiotic started for an ear infection.During a home visit observation on 12/15/2025 at 12:37 PM, the patient reported taking gabapentin differently than prescribed, taking only one capsule daily unless symptoms required more. The patient also stated that the aspirin taken daily was not an extended‑release formulation as listed, and that cyanocobalamin had always been administered intramuscularly, not subcutaneously as documented. When interviewed, RN 2 could not explain why the medication list contained incorrect formulation, route, and administration details. RN 2 acknowledged not recognizing the discrepancies during review and was unaware the patient was not taking gabapentin as prescribed. RN 2 failed to ensure the Medication Profile and POC accurately reflected the correct type, route, and administration of all medications. 4. During an interview on 12/16/2025 at 1:39 PM, the Director of Nursing indicated LPN 1 should update him/her immediately upon any change with an ordered medication or if the physician allows a medication to be taken differently than ordered so that a new order can be written, sent to the physician, signed and then put into the clinical record for it to updated on the POC. The Director of Nursing indicated that RN 2 has to ensure that each medication is checked thoroughly each time a review is done to ensure all listed medications are accurate and conform to physician's orders or updates can be sent to the physician for approval. 17-14-1(a)(2)(E)-RN 17-14-1(a)(2)(B)-LPN

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102 Survey Dates: 08/14/2023-08/18/2023 & 08/21/2023-08/22/2023 Active Census: 31 At this Emergency Preparedness survey, Better Living Home Health was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 484.102. QR by Area 4 on 09/13/2023

This visit was for a Federal Recertification and State Re-Licensure survey of a Home Health Provider in conjunction with (#1) complaint. Survey Dates: 08/14/2023-08/18/2023 & 08/21/2023-08/22/2023 Complaint: 99598 with related and unrelated deficiencies cited. 12 Month Unduplicated Skilled Admissions: 31 An Extended Survey was announced on 08/14/2023 at 4:00 PM. An Immediate Jeopardy related to §484.55 Comprehensive Assessment of Patients was identified on 07/04/2023 and §484.80 Home Health Aide Services was identified on 03/06/2023 when it was identified that patient wounds were not assessed, measured, or managed; failed to ensure a comprehensive investigation of an unanticipated death was initiated and site visit notes included sufficient documentation; and failed to ensure skills demonstration or competency for home health aides were completed. The Administrator was notified of the 1st Immediate Jeopardy on 08/18/2023 at 11:10 AM. The Administrator was notified of the 2nd Immediate Jeopardy on 08/21/2023 at 8:25 AM. An unacceptable removal plan for the first Immediate Jeopardy was received on 08/21/2023. Both Immediate Jeopardy’s were unremoved at the time of exit on 08/22/2023. Both Immediate Jeopardy’s were abated on 09/07/2023 as confirmed by an onsite verification by surveyors. During this Federal Recertification Survey, Better Living Home Health Care was found to be out of compliance with Conditions of Participation §484.55 Comprehensive Assessment of Patients; §484.60 Care Planning, Coordination of Services, and Quality of Care; §484.80 Home Health Aide Services; and §484.105 Organization and administration of services. Based on the Condition-level deficiencies during the 08/22/2023 survey, your HHA was subject to an extended survey pursuant to section 1891(c)(2)(D) of the Social Security Act on 08/14/2023. 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 08/22/2023 and continuing through 08/21/2025. This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Refer to State Form for additional State Findings.

Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to provide services as ordered in the plan of care for 1 of 3 closed records reviewed. (Patient #6) Findings include: The clinical record for Patient 6, SOC date 03/29/2018, certification period 03/03/2023 to 04/26/2023, included POC that indicated the patient should receive SN (Skilled Nurse) services three times a week for eight weeks. The clinical record indicated that 22 of 23 missed visits occurred between 03/03 and 04/25/2023 because the staff was not available to provide skilled nursing services. A discharge summary, dated 04/26/2023, indicated the patient was discharged from the agency due to skilled nursing staff not being available to provide services. The summary indicated, “…Mother…is working with (Entity 6) to find another agency to provide these services...” During an interview, on 08/21/2023 at 2:00 PM, the Administrator indicated the agency tries to obtain the necessary services to provide care to each patient, but if services can’t be provided the usual practice of the agency is to wait until the end of the certification period to discharge the patient. The Administrator indicated the patient’s family usually coordinates with their case manager to obtain services from a new agency, but the agency would assist if necessary. The Administrator indicated no documentation could be provided to show the agency actively participated in discharge planning for Patient #6 prior to 04/26/2023.

Immediate reporting of abuse by all staff CFR(s): 484.50(e)(2) Any HHA staff (whether employed directly or under arrangements) in the normal course of providing services to patients, who identifies, notices, or recognizes incidences or circumstances of mistreatment, neglect, verbal, mental, sexual, and/or physical abuse, including injuries of unknown source, or misappropriation of patient property, must report these findings immediately to the HHA and other appropriate authorities in accordance with state law. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to initiate an investigation of an unanticipated death of a patient for 1 of 1 patient death reviewed. (Patient #1) Findings include: 1. A policy for advanced directives was provided, on 08/16/2023 at 3:19 PM, by the Administrator who indicated it was the most current version. The policy did not include a definition or documentation related to the implementation of an advanced directive for a full code. 2. The policy and procedure for, “Client Incident Reporting Policy”, was provided, on 08/14/2023 at 3:04 PM, by the Administrator who indicated the policy was the most current version. The policy indicated, “…Purpose 1. To provide necessary timely intervention for clients involved in incidents 2. To facilitate timely, accurate, and complete documentation of all client incidents 3. To implement a quality assurance monitoring system for client incidents. Definitions: Incident: an event, situation, or occurrence that is not consistent with agency policy, standards, or routine care of the patient. An incident has the potential to cause harm or does causes harm or property damage to a client…Unusual occurrences…The death of an individual…” It is significant to note the policy does not include guidance for staff to initiate an investigation of incidents. 3. A policy and procedure for “Client Death” was provided, on 08/14/2023 at 2:23 PM, by the Administrator who indicated it was the most current version. The policy indicated, “Purpose [sic] to establish the process to follow in the event of the death of a client [sic] Policy [sic] Post-Mortem procedures will be followed in adherence to all applicable laws…Procedure [sic]…If agency personnel is present at the time of death…The following are to be notified…RN/Case Manager/Director of Patient Services/Administrator…client’s physician…If agency personnel is not present at the time of death…Client’s physician is notified…” The policy did not include guidance for the notifications to be immediate or the procedure to follow if the death was not anticipated. 4. A policy and procedure for “Assessment of possible abuse/neglect” was provided, on 08/14/2023 at 3:04 PM, by the Administrator who indicated it was the most current version. The policy indicated, “Purpose [sic] To ensure that all suspected cases of client abuse and/or neglect are reported under the appropriate laws and regulations…The agency reports al suspected cases of abuse and /or neglect in compliance with appropriate state statutes to appropriate protection organizations…Definitions…Neglect: Failure of a caretaker to supply the client with necessary …health care [sic]…Report: any report received by the…licensing agency…of neglect that states the following (see suspected abuse and or neglect investigation report, addendum 3-3C)…What has happened…To Whom it happened…When it happened…Where it happened…Who did the abusing or was responsible for the neglect…2. The clinician will complete a suspected abuse and/or neglect investigation report with the addition of the following information…name of alleged perpetrator…The clinician will complete a suspected…neglect investigation report with the addition of the following information…name of alleged perpetrator…relations to client…information regarding suspected…neglect…date of occurrence…witness to occurrence…nature of occurrence…description of the…neglect…3. The suspected…neglect investigation report with specific information relating to the occurrence is forward [sic] to the RN/Case Manager who will…A. conduct an immediate initial investigation into the suspected…neglect [sic] B. Reviews the documentation for completeness and objectivity [sic] C. Consult the Director of Clinical Services/Administrator. 4. The Director of Clinical Services/Administrator will…A. Authorize a verbal report of the suspected…neglect to the proper authorities in accordance with state law to be filed by RN/Case Manager. B. Review all reports (incident report and follow-up investigation) [sic] C. Conducts any further review if necessary…” The addendum was requested of the Administrator, on 08/14/2023 at 3:08 PM, and was not received prior to survey exit on 08/22/2023. 5. The clinical record for patient #1, start of care (SOC) 05/31/2023 included the following: A text message thread, dated 07/04/2023 at 2:32 PM and provided by the Administrator, on 08/16/2023 at 2:40 PM, from the Intake Coordinator 1 to the Administrator, RN 2, and Scheduler 1 indicated, “…I just got a call that [name of Patient #1] just passed away…” The Administrator indicated, “…I’ll text you separately with some questions…” The separate information was requested from the Administrator, on 08/16/2023 at 2:0 PM, and was not provided. A communications note authored by RN 2, dated 07/05/2023 at 12:23 PM, indicated, “Office received a message yesterday while closed for the holiday that client [Patient 1] had expired. Family unsure of reason and coroner was arriving at time of message. Client chart to be closed at this time.” An untimed incident report, dated 07/06/2023, indicated the HHA #2 contacted the agency, on 07/04/2023 at 2:30 PM, to report Patient #1 expired in the home and the agency did not conduct an investigation. During an interview, on 08/14/2023 at 10:45 AM, the Administrator indicated HHA 2 had not immediately reported the unanticipated death of Patient #1 to the agency, an investigation of the event was not conducted because HHA 2 was “…not on the clock…”, and they did not know the details of the event. During an interview, on 08/14/2023 at 3:49 PM, PM 1 of Entity 4 indicated Patient #1 was seen at the office of NP 1 in April 2023 for signs and symptoms of a urinary tract infection, was treated with an antibiotic, and the infection resolved. PM 1 indicated Patient #1 was evaluated in the NP office, on 05/02/2023, and laboratory test results were reviewed with HHA 3 on 05/03/2023. PM 1 indicated the office record did not include documentation related to advanced directives. PM 1 indicated NP 1 was notified by Coroner 1, on 07/04/2023 at 10:08 AM, that Patient 1 was found deceased in the home. PM 1 indicated supporting documentation would be provided as soon as it was assembled, but was not received. A second request for the documentation was made to PM 1, on 08/16/2023 at 10:17 AM, and no response or documentation was received by the time of exit on 08/22/2023. During an interview on 08/16/2023 at 10:41 AM, HHA 2 indicated they found Patient 1 without a pulse or respiration upon rising, on 07/04/2023 at approximately 8:00 AM, and initiated EMS. A certificate of death, received from County Health Department 1, on 08/16/2023 at 1:45 PM and dated 07/05/2023, indicated Patient #1 died at home on 07/04/2023 at 8:00 AM and Coroner 1 was contacted. The certificate indicated the death was natural and caused by lifelong epilepsy, microcephaly, cerebral palsy, and quadriplegia. The record indicated an autopsy was not performed and the death was certified by NP 1.

Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient's eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This CONDITION is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure the skilled nurse performed a wound assessment and measurements for patients with open wounds and failed to visually assess patients for skin integrity issues on home visits. The agency failed to ensure skin assessments, catheter monitoring, and health status assessments were not delegated to an outside Entity. The agency Administrator, skilled nurse, and human resource personnel indicated the care and assessment depended on the patient’s payer source. This puts all patients with active wounds at risk for infection and further deterioration based on their payer source. (See tag G526); and failed to ensure an ongoing visual assessment of skin, catheters, and ostomies were performed on home visits and documented in the comprehensive / updated assessment (See tag G536); and failed to update the comprehensive assessment to accurately reflect the patient status of a wound (See tag G544) The cumulative effect of this problem resulted in being out of compliance with Condition of Participation §484.55 Comprehensive assessments of patients and has the likelihood to affect all current patients receiving services from this provider.

Content of the comprehensive assessment CFR(s): 484.55(c) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the following information: This STANDARD is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure the comprehensive assessment accurately reflected the patient's status at the time of the home visit for 1 of 1 home visit observations with a known wound. (Patient #3) Findings include: 1. A 2022 policy titled On-Going Assessments was provided by the Administrator on 08/15/2023 at 2:50 PM. The policy indicated, but was not limited to, “1. During each home visit, the case manager/team leader … re-evaluates the client according to the problems identified …2. Using the standards of care identified by the agency, the clinician re-assesses each client for: … D. skin integrity … E. elimination …” 2. A 2023 policy titled Comprehensive Assessment was provided by the Administrator on 08/22/2023 at 8:25 AM. The policy indicated, but was not limited to, "Purpose ... to accurately reflect the patient's current health status including information that may be used to demonstrate the patient's progress toward achievement of desired outcomes. ... 5. The Comprehensive Assessment will be updated and revised ... as frequently as the patient's health status warrants ... 6. ... assessment will include: ... living arrangements supportive devices, ... medications ..." 3. During a home visit on 08/15/2023 at 11:00 AM Registered Nurse (RN) 2 asked the caregiver from Entity 1 what the skin around Patient #3’s ostomy bag looked like, the color of urine in the foley catheter bag, and if Patient #3 had any new skin breakdown. RN 2 then documented Entity 1’s caregiver’s assessment. RN 2 was asked when Patient #3’s wound was assessed and measured. RN 2 stated it depends on the patient’s payer source as to what kind of assessment was to be performed. RN 2 was asked if Patient #3’s wound was open or closed and would only repeatedly reply that our job was only intervention and prevention. RN 2 stated he/she does not coordinate care with the wound center or Entity 1. RN 2 failed to visually assess Patient #3’s ostomy, urine, and skin assessment and failed to coordinate care with Entity 1 and the wound center. The current plan of care was reviewed along with RN 2 and RN 2 stated the name of Entity 1 and Entity 1’s frequency was not included in the plan of care. RN 2 stated the agency would call SWIRCA’s case manager if needed. The clinical record for Patient #3, the start of care (SOC) date 11/20/2019, contained a comprehensive Assessment dated 06/27/2023 which indicated Patient #3 had a right abdominal fold abscess (build-up of pus) and a pressure ulcer (injury to the skin) on the coccyx (tailbone) that was reported by the mother. The note indicated the agency was waiting for physician orders for the patient to see the wound clinic. The Braden Scale total score was 15 (mild risk for pressure ulcer). A review of the skilled visit notes for the certification period 07/02/2023 to 08/15/2023 failed to indicate an assessment of the right abdominal abscess and record wound stage, assessments, and measurements of the coccyx wound. A review of the plan of care for the certification period 07/02/2023 to 08/30/2023, included orders for skilled nursing (SN) visits 4 times a week for 1 week, 5 times a week for 7 weeks, and 3 times a week for 1 week. Patient #3’s diagnosis was Quadriplegia (paralysis of all 4 limbs). The POC indicated for skilled nursing to assess colostomy (opening into the abdomen) and urostomy (collects urine into a bag outside of the body) every visit for a stoma (small opening in the abdomen which is used to remove body waste, such as feces and urine, into a collection bag) changes and verify with mother stoma status every visit for changes. The POC did not indicate for the skilled nurse to assess, measure, and manage Patient #3’s wound or implement any interventions based on the Braden Score (an evidence-based assessment tool used to assess and document a patient's risk for developing pressure injuries). During an interview on 08/15/2023 at 9:20 AM the agency Administrator and human resource personnel indicated the care and assessment depended on the patient’s payer source. This puts all patients with active wounds at risk for infection and further deterioration based on their payer source. During an interview on 08/15/2023 at 12:10 PM the Administrator was unaware Patient #3’s wound was not visually assessed and measured by the nurse during nursing visits. The Administrator stated the agency does not have any orders to treat wounds from the physician therefore they have no patients with wounds on census. The Administrator stated the expectation was for the nurse to visually assess the patient’s skin and urine in a catheter bag while in the patient’s home. The Administrator stated the expectation was for the skilled nurse to measure the patient's wound weekly. The Administrator stated the agency does not have a specific wound care policy or a Braden Scale Intervention Guide. 4. During a home visit on 08/15/2023 at 8:30 AM RN 2 asked Patient #4 if he/she had any skin issues or open areas to which he/she replied "no". RN 2 failed to visually assess Patient #4's skin for any skin issues or open areas. The clinical record for Patient #4, contained a Comprehensive Assessment dated 06/20/2023, which indicated the patient had a Braden Score of 18 (mild risk for skin breakdown). 410 IAC 17-15-1(a)

Update of the comprehensive assessment CFR(s): 484.55(d) Standard: Update of the comprehensive assessment. The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient's condition warrants due to a major decline or improvement in the patient's health status, but not less frequently than- This STANDARD is not met as evidenced by: Based on observation, record review, and interview, the agency failed update the comprehensive assessment to accurately reflect the patient status of a wound for 1 of 1 patient wound observations. (Patient #3) Findings include: A 2023 policy titled Comprehensive Assessment was provided by the Administrator on 08/22/2023 at 8:25 AM. The policy indicated, but was not limited to, "Purpose ... to accurately reflect the patient's current health status including information that may be used to demonstrate the patient's progress toward achievement of desired outcomes. ... 5. The Comprehensive Assessment will be updated and revised ... as frequently as the patient's health status warrants ... 6. ... assessment will include: ... living arrangements supportive devices, ... medications ..." Review of the Comprehensive Assessment dated 06/27/2023 indicated Patient #3 had a right abdominal fold abscess (build-up of pus) and a pressure ulcer (injury to skin) on coccyx (tailbone) that was reported by the mother. The note indicated the agency was waiting for physician orders. The narrative note indicated the mother reports the Primary Care Physician (PCP) was supposedly ordering wound care outpatient with [name WWC]. The narrative note indicated the mother manages suprapubic catheter changes, ostomy care, and all other aspects of care. The Braden Scale (evidence-based assessment tool used to assess and document a patient's risk for developing pressure injuries) total score was 15 (mild risk for pressure ulcer). Review of the skilled visit notes for the certification period 07/02/2023 to the 08/15/2023 home visit failed to indicate an assessment of the right abdominal abscess and record wound stage, assessments, and measurements of the coccyx wound. The agency failed to update the comprehensive assessment to include an accurate assessment of Patient #3’s wound. During a home visit on 08/15/2023 at 11:00 AM Registered Nurse (RN) 2 asked the caregiver from Entity 1 what the skin around Patient #3’s ostomy bag looked like, the color of urine in the foley catheter bag, and if Patient #3 had any new skin breakdown. RN 2 then documented Entity 1’s caregiver’s assessment. RN 2 was asked when Patient #3’s wound gets assessed and measured. RN 2 stated it depends on the patient’s payer source as to what kind of assessment was to be performed. RN 2 was asked if Patient #3’s wound was open or closed and would only repeatedly reply that our job was only intervention and prevention. RN 2 stated he/she does not coordinate care with the wound center or Entity 1. RN 2 failed to visually assess Patient #3’s ostomy, urine, and skin assessment and failed to coordinate care with Entity 1 and the wound center. The agency failed to update the comprehensive assessment to accurately reflect any improvement, worsening, or changes with the patient’s wound status. During an interview on 08/15/2023 at 10:30 AM the Administrator was unaware Patient #3’s wound was not visually assessed and measured by the nurse during nursing visits. The Administrator stated the agency does not have any orders to treat wounds from the physician therefore they have no patients with wounds on census. The Administrator stated the expectation was for the nurse to visually assess the patient’s skin and urine in a catheter bag while in the patient’s home. The Administrator stated the expectation was for the skilled nurse to measure the patients wound weekly. The Administrator stated the agency does not have a specific wound care policy or a Braden Scale Intervention Guide. During an interview on 08/15/2023 at 10:30 AM the agency Administrator and human resource personnel indicated the care and assessment depended on the patient’s payer source. This puts all patients with active wounds as risk for infection and further deterioration based on their payer source. 410 IAC 17-14-1(a)(1)(B)

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on record review and interview, the agency failed to ensure HHAs were competent to provide patient care prior to first patient contact, failed to ensure education and training for advanced directives and safety precautions were provided to family caregivers in accordance with plans of care, and failed to ensure the HHA visit notes were thorough and complete to promote effective oversight (See Tag G0572); the agency failed to ensure all medications, diagnosis, and all pertinent information were included on the plan of care; and failed to ensure home health aides (HHA) were competent to carry out assigned patient care tasks in a safe, effective, and efficient manner (See tag G0574); the agency failed to effectively integrate and coordinate the care provided by an outside agency to assure patients’ needs were met; and failed to ensure services were provided in accordance with the plan of care. (See tag G0606) The cumulative effect of the deficient practice resulted in the agency being out of compliance with Condition of Participation §484.60 Care planning, coordination of services, and quality of care and has the likelihood to affect all current patients receiving services from the provider.

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 HHAs were competent to provide patient care prior to first patient contact, failed to ensure education and training for advanced directives and safety precautions were provided to family caregivers in accordance with plans of care for 6 of 6 active HHAs (HHA 1, 6, 8, 21, 22, 23) and 1 of 1 former HHA (HHA 2). Findings include: 1. The clinical record for Patient #1, SOC date 05/31/2017, indicated Patient #1 was a full code with the diagnoses including, but not limited to, epilepsy, fetal alcohol syndrome, and cerebral palsy. A review of the plan of care dated 06/29/2023 to 08/27/2023 indicated Patient #1 should receive HHA (Home Health Aide) services 2-3 times per week for one week, then 5-6 times per week for eight weeks. The plan indicated the HHA should provide the following services: Turn patient every 1-2 hours while in bed during waking hours; Change adult diapers as needed during the shift, and skincare with each change; Bath-sponge/bed bath 5x/week and as needed, plus skincare and shave as needed (2 to 3 times a week); Provide complete care, the client totally dependent and requires 24-hour supervision. The HHA visit narrative notes, dated from 06/29/2023 through 07/03/2023, indicated the following: 06/29/2023 from 8:00 AM-12:00 PM and another note from 6:00 PM-9:00 PM “…Note: No international travel, no illness, no contact within 14 days with someone who is ill with covid 19 [sic], covid [sic] screening negative aides temp 98.2…” 06/30/2023 from 8:00 AM-12:00 PM: “…Note: No international travel, no illness, no contact within 14 days with someone who is ill with covid 19 [sic], covid screening negative aides temp 98.3…” 06/30/2023 from 6:00 PM-9:00 PM: “…Note: No international travel, no illness, no contact within 14 days with someone who is ill with covid 19 [sic], covid screening negative aides temp 98.1…” 07/01/2023 from 8:00 AM-12:00 PM and again from 6:00 PM-9:00 PM “…Note: No international travel, no illness, no contact within 14 days with someone who is ill with covid 19 [sic], covid [sic] screening negative aides temp 98.4…” 07/02/2023 from 8:00 AM-12:00 PM: “…Note: No international travel, no illness, no contact within 14 days with someone who is ill with covid 19 [sic], covid [sic] screening negative aides temp 98.1…” 07/02/2023 from 6:00 PM-9:00 PM: “…Note: No international travel, no illness, no contact within 14 days with someone who is ill with covid 19 [sic], covid [sic] screening negative aides temp 98.7…” 07/03/2023 from 8:00 AM-12:00 PM: “…Note: No international travel, no illness, no contact within 14 days with someone who is ill with covid 19 [sic], covid [sic] screening negative aides temp 98.4…” 07/03/2023 from 6:00 PM-9:00 PM: “…Note: No international travel, no illness, no contact within 14 days with someone who is ill with covid 19 [sic], covid [sic] screening negative aides temp 98.2…” The notes did not include sufficient documentation to show Patient 1 was turned every 1-2 hours while in bed during waking hours, incontinence care was provided, the condition of the patient’s skin, bathing activities, skin care, and shaving was offered or provided, or to indicate complete care was provided to the dependent patient between 06/29/2023 and 07/03/2023. A communications note authored by RN 2, dated 07/05/2023 at 12:23 PM, indicated, “Office received a message yesterday while closed for the holiday that client (Patient #1) had expired. The family was unsure of the reason and the coroner was arriving at the time of the message. Client chart to be closed at this time.” The clinical record failed to evidence any home health aide visit notes after 7/3/23 that could have been beneficial to identify if the patient had been displaying any signs and symptoms of a decline leading up to this sentinel death. During an interview, on 08/15/2023 at 12:56 PM, the Administrator indicated the agency did not provide family/caregiver (the agency-paid caregiver was a family member of the deceased patient) education or training for precautions identified in the plans of care because the agency would not expect the family/caregiver to provide care when they were not working as a HHA. The plan of care indicated the patient needed 24-hour care but failed to identify what hours the HHA/Caregiver was being offered on the clock from the agency and what hours were off the clock. During an interview, on 08/16/2023 at 10:41 AM, HHA 2 indicated they were the legal guardian of Patient #1, and provided HHA services to Patient #. They found Patient #1 unresponsive and without respirations, on 07/04/2023 at approximately 8:00 AM, Emergency services were initiated. HHA 2 indicated they were "off the clock" when Patient #1 was found. Patient #1 expired, on 07/04/2023, unexpectedly without a known cause. They indicated they had provided care to Patient #1 for many years, had not performed return skill demonstration while employed at the agency, and had not received education or training from the agency regarding safety precautions in accordance with the plan of care The personnel record of HHA 2 did not include documentation to show the agency provided training in regard to safety precautions for falls, transfers, seizures, or aspiration as identified in the plan of care for Patient 1. The agency provided an orientation checklist, dated 11/21/2013, and an HHA skills checklist, dated 11/22/2013, from Entity 5 indicating HHA 2 successfully demonstrated HHA skills and received orientation, but did not provide documentation to determine the skills of HHA 2 were effectively evaluated by the agency upon hire. 2. During an interview, on 08/16/2023 at 11:50 AM, HHA 1 indicated they were a new HHA, really didn't know what they were supposed to be doing, and they did not receive much training from the agency. HHA 1 indicated they just signed a lot of papers during orientation. An HHA skills checklist, dated 06/20/2023 and signed by RN 2, indicated HHA 1 successfully demonstrated appropriate and safe techniques in performing personal hygiene and grooming tasks that include bed bath, sponge, tub, and shower bath, hair shampooing in sink, tub, and bed, nail and skin care, oral hygiene, toileting and elimination, safe transfer techniques and ambulation, normal range of motion and positioning, adequate nutrition and recognizing and reporting changes in skin condition. The checklist did not include documentation to show skills for adequate fluid intake were evaluated. During an interview, on 08/18/2023 at 9:29 AM, HHA 1 indicated they were not required to demonstrate HHA skills to RN 2, on 06/20/2023, and were not provided education or training specific to safety precautions in accordance with the plans of care. 3. A HHA skill checklist, dated 09/14/2022, did not include documentation to show HHA 6 successfully demonstrated appropriate and safe techniques in performing personal hygiene and grooming tasks that include bed bath, sponge, tub, and shower bath, hair shampooing in sink, tub, and bed, nail and skin care, oral hygiene, toileting and elimination, safe transfer techniques and ambulation, or normal range of motion and positioning. An HHA skill checklist, dated 12/22/2022, indicated HHA 6 successfully demonstrated appropriate and safe techniques in performing personal hygiene and grooming tasks that include bed bath, sponge, tub, and shower bath, hair shampooing in sink, tub, and bed, nail and skin care, oral hygiene, toileting and elimination, safe transfer techniques and ambulation, and normal range of motion and positioning. The checklists did not include documentation to show skills for adequate fluid intake were evaluated. During an interview, on 08/18/2023 at 9:27 AM, HHA 6 indicated they were not required to perform a return demonstration of HHA skills on 09/14/2022 or 12/12/2022 and were not provided education or training specific to patient safety precautions in accordance with the plans of care. 4. An HHA skill checklist, dated 05/02/2023 indicated HHA 8 successfully demonstrated appropriate and safe techniques in performing personal hygiene and grooming tasks that include bed bath, sponge, tub, and shower bath, hair shampooing in sink, tub, and bed, nail and skin care, oral hygiene, toileting and elimination, safe transfer techniques and ambulation, and normal range of motion and positioning. The checklist did not include documentation to show skills for adequate nutrition and fluid intake or recognizing and reporting changes in skin condition were evaluated. During an interview, on 08/21/2022 at 9:07 AM, HHA 8 indicated they were not required to perform a return demonstration of HHA skills for the agency staff, on 05/02/2023, and were not provided education or training specific to patient safety precautions in accordance with the plans of care. 5. A HHA skill checklist, dated 06/20/2023, indicated HHA 21 successfully demonstrated appropriate and safe techniques in performing personal hygiene and grooming tasks that include bed bath, sponge, tub, and shower bath, hair shampooing in sink, tub, and bed, nail and skin care, oral hygiene, toileting, and elimination, safe transfer techniques and ambulation, normal range of motion and positioning, adequate nutrition and recognizing and reporting changes in skin condition. The checklist did not include documentation to show skills for adequate fluid intake were evaluated. During an interview, on 08/18/2023 at 9:25 AM, HHA 21 indicated they were not required to perform a return demonstration of HHA skills for agency staff upon hire and were not provided education or training specific to patient safety precautions in accordance with the plans of care. 6. A HHA skills checklist, dated 06/20/2023, indicated HHA 22 successfully demonstrated appropriate and safe techniques in performing personal hygiene and grooming tasks that include bed bath, sponge, tub, and shower bath, hair shampooing in sink, tub, and bed, nail and skin care, oral hygiene, toileting and elimination, safe transfer techniques and ambulation, normal range of motion and positioning, adequate nutrition and recognizing and reporting changes in skin condition. The checklist did not include documentation to show skills for adequate nutrition and fluid intake or recognizing and reporting changes in skin condition were evaluated. During an interview, on 08/18/2023 at 10:03 AM, HHA 22 indicated they were not required to perform a return demonstration of HHA skills for agency staff upon hire and were not provided education or training specific to patient safety precautions in accordance with the plans of care. 7. A HHA skill checklist, dated 06/20/2023, indicated HHA 23 successfully demonstrated appropriate and safe techniques in performing personal hygiene and grooming tasks that include bed bath, sponge, tub, and shower bath, hair shampooing in sink, tub, and bed, nail and skin care, oral hygiene, toileting, and elimination, safe transfer techniques and ambulation, normal range of motion and positioning, adequate nutrition and recognizing and reporting changes in skin condition. The checklist did not include documentation to show skills for adequate nutrition and fluid intake or recognizing and reporting changes in skin condition were evaluated. During an interview, on 08/18/2023 at 10:19 AM, HHA 23 indicated they were not required to perform a return demonstration of HHA skills for agency staff upon hire and were not provided education or training specific to patient safety precautions in accordance with the plans of care. 8. During an interview, on 08/16/2023 at 3:30 PM, the Administrator indicated the agency did not have a policy regarding return demonstrations of HHA skills, but the agency’s expectation would be for return demonstration to be conducted during skill evaluation prior to the first patient contact. The Administrator indicated RN 2 was responsible for evaluating the competency of HHAs after 03/27/2023, but no documentation could be provided to show the skill competencies were actually completed. 410 IAC 17-13-1(a)

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure all medications, diagnosis, and all pertinent information were included on the plan of care for 3 of 11 record reviews (Patient #3, #4, #10); and failed to ensure 6 of 6 actively employed home health aides (HHA) and 1 of 1 former HHA were competent to carry out assigned patient care tasks in a safe, effective, and efficient manner. (Patient #1, HHA 2, HHA 1, HHA 6, HHA 8, HHA 21, HHA 22, HHA 23) Findings include: 1. A 2022 policy titled Client Plan of Care was provided by the Administrator on 08/15/2023 at 12:10 PM. The policy indicated, but was limited to, “4. Changes in the plan of care are documented through written and signed modifications to the plan of care. …” 2. The clinical record for Patient #3, start of care (SOC) date 11/20/2019, certification period 07/02/2023 to 08/30/2023, included a plan of care (POC) that did not indicate who was to assess, measure, and manage Patient #3’s wound. Review of the Comprehensive Assessment dated 02/27/2023 indicated Patient #3 had a right abdominal fold abscess and a pressure ulcer on coccyx that was reported by the mother. The note indicated the agency was waiting for physician orders for the patient to see the wound clinic but did not specify who made the call to the physician. During a home visit on 08/15/2023 at 11:00 AM Registered Nurse (RN) 2 asked the caregiver from Entity 1 what the skin around Patient #3’s ostomy bag looked like, the color of urine in the foley catheter bag, and if Patient #3 had any new skin breakdown. RN 2 then documented Entity 1’s caregiver assessment. RN 2 stated it depends on the patient’s payer source as to what kind of assessment was to be performed. RN 2 was asked if Patient #3’s wound was open or closed and would only repeatedly reply that our job was only intervention and prevention. RN 2 stated he/she does not coordinate care with the wound center or Entity 1. RN 2 failed to visual assess Patient #3’s ostomy, urine, and skin assessment. During an interview on 08/19/2023 at 9:40 AM the Administrator was unaware Patient #3’s wound was not measured during nursing visits. The Administrator stated the agency does not have any orders to treat wounds from the physician therefore they have no patients with wounds on census. The Administrator stated the expectation was for the nurse to visually assess the patient’s skin and urine in a catheter bag while in the patient’s home. The Administrator stated the expectation was for the skilled nurse to measure the patients wound weekly. The Administrator stated the agency does not have a specific wound care policy. 3. The clinical record for Patient #4, start of care (SOC) date 10/24/2022, certification period 06/21/2023 to 08/19/2023, included a plan of care (POC) that did not indicate Patient #4 was taking Levothyroxine or a supporting diagnosis for the medication. During a home visit in 08/15/2023 at 8:30 AM Registered Nurse (RN) 2 provided medication set-up for Patient #4. RN 2 placed Levothyroxine 75 mcg (medication for underactive thyroid) into Patient #4’s weekly medication planner. RN 2 stated Patient #4 had been on Levothyroxine for a while but was unsure why the medication or the supporting diagnosis for the medication was not listed on the current plan of care. The agency failed to ensure all medications and pertinent diagnosis were included on the plan of care. Patient #4 was asked if he/she receives services from anyone else to which he/she respond “yes, but I don’t know who”. RN 2 stated he/she receives services from Entity 1. RN 2 stated additional information such as duration and frequency of Entity 1 were not included on the plan of care and the agency does not coordinate services with Entity 1. 3. During an interview on 08/15/2023 at 9:40 AM the Administrator stated all medications, diagnoses, and anything pertinent should be included on the plan of care. 4. The clinical record for Patient #5, SOC date 12/27/2022, certification period 06/27/2023 to 08/25/2023, that included a POC indicating fall / ambulation precautions and to keep pathways clear. Review of Communication Notes dated 07/31/2023, 08/10/2023, and 08/23/2023 indicated Patient #5 was in a motor vehicle accident and was experiencing pain from a mass in the pelvis. During a home visit on 08/16/2023 at 12:00 PM the Home Health Aide (HHA) 1 stated Patient #5’s walker and electric wheelchair are in storage due to lack of space from temporarily living in a 2 bedroom hotel room with 2 children and 4 adults. HHA 1 stated the patient uses a cane. Review of the POC failed to include all the durable medical equipment / supplies Patient #5 uses. The POC indicated no family social problems and no transportation needs. The agency failed to be updated the POC to include Patient #5’s current living condition. The POC did not indicate the frequency of a shower or partial bath. The POC did not address the risk for emergency department / hospital readmission. HHA 1 stated he/she had some training but does not know what he/she was doing. 5. A communications note authored by RN 2, dated 07/05/2023 at 12:23 PM, indicated, “Office received a message yesterday while closed for the holiday that client had expired. Family unsure of reason and coroner was arriving at time of message. Client chart to be closed at this time.” During an interview, on 08/15/2023 at 12:56 PM, the Administrator indicated the agency did not provide family/caregiver education or training for precautions identified in the plans of care, because the agency would not expect the family/caregiver to provide care when they were not working as an Home Health Aide (HHA). 6. During an interview, on 08/16/2023 at 10:41 AM, HHA 2 indicated they were the legal guardian of Patient #1, provided HHA services to Patient #1, and they were not CPR (Cardio-Pulmonary Resuscitation) certified. HHA 2 indicated they found Patient #1 unresponsive and without respirations, on 07/04/2023 at approximately 8:00 AM, Emergency services were initiated, but CPR was not started. HHA 2 indicated they were "off the clock" when Patient #1 was found. Patient #1 expired on 07/04/2023 unexpectedly without a known cause. HHA 2 was unaware Patient #1's code status was full code. They indicated they had provided care to Patient #1 for many years, had not performed return skill demonstration while employed at the agency, and had not received education or training from the agency regarding safety precautions in accordance with the plan of care The personnel record of HHA2 indicated they were not CPR certified and provided care to a patient who was a full code. The record did not include documentation to show the agency provided training in regard to safety precautions for falls, transfers, seizures, or aspiration as identified in the plan of care for Patient 1. The agency provided an orientation checklist, dated 11/21/2013, and an HHA skills checklist, dated 11/22/2013, from Entity 5 indicating HHA 2 successfully demonstrated HHA skills and received orientation, but did not provide documentation to determine the skills of HHA 2 were effectively evaluated by the agency upon hire. 7. During an interview, on 08/16/2023 at 11:50 AM, HHA 1 indicated they were a new HHA, really didn't know what they were supposed to be doing, and they did not receive much training from the agency. HHA 1 indicated they just signed a lot of papers during orientation. An HHA skills checklist, dated 06/20/2023 and signed by RN 2, indicated HHA 1 successfully demonstrated appropriate and safe techniques in performing personal hygiene and grooming tasks that include bed bath, sponge, tub, and shower bath, hair shampooing in sink, tub, and bed, nail and skin care, oral hygiene, toileting and elimination, safe transfer techniques and ambulation, normal range of motion and positioning, adequate nutrition and recognizing and reporting changes in skin condition. The checklist did not include documentation to show skills for adequate fluid intake were evaluated. During an interview, on 08/18/2023 at 9:29 AM, HHA 1 indicated they were not required to demonstrate HHA skills to RN 2, on 06/20/2023, and were not provided education or training specific to safety precautions in accordance with the plans of care. 8. A HHA skill checklist, dated 09/14/2022, did not include documentation to show HHA 6 successfully demonstrated appropriate and safe techniques in performing personal hygiene and grooming tasks that include bed bath, sponge, tub, and shower bath, hair shampooing in sink, tub, and bed, nail and skin care, oral hygiene, toileting and elimination, safe transfer techniques and ambulation, or normal range of motion and positioning. An HHA skill checklist, dated 12/22/2022, indicated HHA 6 successfully demonstrated appropriate and safe techniques in performing personal hygiene and grooming tasks that include bed bath, sponge, tub, and shower bath, hair shampooing in sink, tub, and bed, nail and skin care, oral hygiene, toileting and elimination, safe transfer techniques and ambulation, and normal range of motion and positioning. The checklists did not include documentation to show skills for adequate fluid intake were evaluated. During an interview, on 08/18/2023 at 9:27 AM, HHA 6 indicated they were not required to perform a return demonstration of HHA skills on 09/14/2022 or 12/12/2022 and were not provided education or training specific to patient safety precautions in accordance with the plans of care. 9. An HHA skill checklist, dated 05/02/2023 indicated HHA 8 successfully demonstrated appropriate and safe techniques in performing personal hygiene and grooming tasks that include bed bath, sponge, tub, and shower bath, hair shampooing in sink, tub, and bed, nail and skin care, oral hygiene, toileting and elimination, safe transfer techniques and ambulation, and normal range of motion and positioning. The checklist did not include documentation to show skills for adequate nutrition and fluid intake or recognizing and reporting changes in skin condition were evaluated. During an interview, on 08/21/2022 at 9:07 AM, HHA 8 indicated they were not required to perform a return demonstration of HHA skills for the agency staff, on 05/02/2023, and were not provided education or training specific to patient safety precautions in accordance with the plans of care. 10. A HHA skill checklist, dated 06/20/2023, indicated HHA 21 successfully demonstrated appropriate and safe techniques in performing personal hygiene and grooming tasks that include bed bath, sponge, tub, and shower bath, hair shampooing in sink, tub, and bed, nail and skin care, oral hygiene, toileting and elimination, safe transfer techniques and ambulation, normal range of motion and positioning, adequate nutrition and recognizing and reporting changes in skin condition. The checklist did not include documentation to show skills for adequate fluid intake were evaluated. During an interview, on 08/18/2023 at 9:25 AM, HHA 21 indicated they were not required to perform a return demonstration of HHA skills for agency staff upon hire and were not provided education or training specific to patient safety precautions in accordance with the plans of care. 11. A HHA skills checklist, dated 06/20/2023, indicated HHA 22 successfully demonstrated appropriate and safe techniques in performing personal hygiene and grooming tasks that include bed bath, sponge, tub, and shower bath, hair shampooing in sink, tub, and bed, nail and skin care, oral hygiene, toileting and elimination, safe transfer techniques and ambulation, normal range of motion and positioning, adequate nutrition and recognizing and reporting changes in skin condition. The checklist did not include documentation to show skills for adequate nutrition and fluid intake or recognizing and reporting changes in skin condition were evaluated. During an interview, on 08/18/2023 at 10:03 AM, HHA 22 indicated they were not required to perform a return demonstration of HHA skills for agency staff upon hire and were not provided education or training specific to patient safety precautions in accordance with the plans of care. 12. A HHA skill checklist, dated 06/20/2023, indicated HHA 23 successfully demonstrated appropriate and safe techniques in performing personal hygiene and grooming tasks that include bed bath, sponge, tub, and shower bath, hair shampooing in sink, tub, and bed, nail and skin care, oral hygiene, toileting and elimination, safe transfer techniques and ambulation, normal range of motion and positioning, adequate nutrition and recognizing and reporting changes in skin condition. The checklist did not include documentation to show skills for adequate nutrition and fluid intake or recognizing and reporting changes in skin condition were evaluated. During an interview, on 08/18/2023 at 10:19 AM, HHA 23 indicated they were not required to perform a return demonstration of HHA skills for agency staff upon hire and were not provided education or training specific to patient safety precautions in accordance with the plans of care. During an interview, on 08/16/2023 at 3:30 PM, the Administrator indicated the agency did not have a policy regarding return demonstrations of HHA skills, but the agency’s expectation would be for return demonstration to be conducted during skill evaluation prior to the first patient contact. The Administrator indicated RN 2 was responsible for evaluating the competency of HHAs after 03/27/2023, but no documentation could be provided to show the skill competencies were actually completed. 13. The clinical record for Patient #10, SOC date 08/19/2022, certification period 08/14/2023 to 10/12/2023, that included a POC that did not indicate the patient’s risk for emergency department visits or hospital re-admission. 17-13-1(a)(1)(B) 17-13-1(a)(1)(C ) 17-13-1(a)(1)(D)(i-xiii) 410 IAC 17-14-1(l)(1)(A)

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the agency failed to effectively integrate and coordinate the care provided by an outside agency to assure patients’ needs were met for 2 of 2 skilled nursing home visits. (Patients #3, #4); and failed to ensure services were provided in accordance with the plan of care for 22 of 23 visits missed between 03/07/2023 and 04/25/20232. (Patient #6) 4. The clinical record for Patient 6, SOC date 03/29/2018, certification period 03/03/2023 to 04/26/2023, included POC that indicated the patient should receive SN (Skilled Nurse) services three times a week for eight weeks The clinical record indicated 22 of 23 missed visits occurred between 03/03 and 04/25/2023. A communication note, dated 03/09/2023 at 10:47 AM, indicated the physician was notified missed visits occurred on 03/07/2023 and 03/08/2023 because no SN was available. A communication note, dated 03/15/2023 at 8:33 AM, indicated the physician was notified four missed visits occurred on 03/102023, 3/14/2023, 03/15/2023, 03/17/2023 because no SN was available. A communication note, dated 03/28/2023 at 9:57 AM, indicated the physician was notified six missed visits occurred between 03/21/2023, 03/22/2023, 03/24/2023, 03/28/2023, 03/29/2023, and 03/21/2023 because no SN was available. A communication note, dated 04/10/2023 at 12:52 PM, indicated three missed visits occurred on 04/04/2023, 04/05/2023, and 04/07/2023 because no SN was available. A communication note, dated 04/13/2023 at 11:35 AM, indicated three missed visits occurred on 04/11/2023, 04/12/2023, and 04/14/2023 because no SN was available. A communication note, dated 04/24/2023 at 1:49 PM, indicated three missed visits occurred on 04/18/2023, 04/19/2023, and 04/21/2023 because no skilled nurse was available. A communication note, dated 05/02/2023 at 9:31 AM, indicated one missed visit occurred on 04/25/2023 was available. A discharge summary, dated 04/26/2023, indicated the patient was discharged from the agency due to skilled nursing staff not available to provide services. The summary indicated, “…Mother…is working with (Entity 6) to find another agency to provide these services...” During an interview, on 08/21/2023 at 2:00 PM, the Administrator indicated the agency tries to obtain the necessary services to provide care to each patient, but if services can not be provided the usual practice of the agency is to wait until the end of the certification period to discharge the patient. The Administrator indicated the patient’s family usually coordinates with their case manager to obtain services from a new agency, but the agency would assist if necessary. The Administrator indicated no documentation could be provided to show the agency actively participated in discharge planning for Patient #6 prior to 04/26/2023. 410 IAC 17-12-2(g)(h) 1. A 2022 policy titled Care Coordination was provided by the Administrator on 08/15/2023 at 12:10 PM. The policy indicated, but was not limited to, “3. The clinician responsible for coordination of care will: A. Communicate with all personnel caring for the client including the physician. … C. Update the plan of care. … F. Communicate between multiple disciplines to optimize visit schedules for the benefit of the client. … 5. Written evidence of care coordination will be documented in the client’s clinical record.” 2. The clinical record for Patient #3, start of care (SOC) date 11/20/2019, certification period 07/02/2023 to 08/30/2023, included a plan of care (POC) that did not indicate the name of an outside Entity or frequency that provided care for Patient #3. During a home visit on 08/15/2023 at 11:00 AM a caregiver from Entity 1 was providing care for Patient #3. The current plan of care was reviewed along with RN 2 and acknowledged the name of Entity 1 and Entity 1’s frequency was not included on the plan of care. Registered Nurse (RN) 2 stated the agency does not communicate with other outside agencies. RN 2 stated the agency would call SWIRCA’s case manager if needed. 3. The clinical record for Patient #4, SOC date 10/24/2022, certification period 06/21/2023 to 08/19/2023, included a POC that did not indicate the name of outside Entity or frequency that provided care for Patient #4. During a home visit on 08/15/2023 at 8:30 AM Patient #4 stated he/she receives attendant care services from another agency when asked. RN 2 stated the agency does not communicate with other outside agencies directly. RN 2 stated the agency would communicate with SWIRCA’s case manager and that would be noted in the patient’s chart. The agency failed to integrate and coordinate the care provided by an outside agency. 410 IAC 17-14-1(a)(1)(F)

Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This STANDARD is not met as evidenced by: Based on record review and interview, the agency’s Administration and Governing Body failed to ensure data was collected, measured, analyzed, and tracked regarding wounds and adverse / sentinel (unexpected death) events within the Quality Assurance Performance Improvement (QAPI) program for 1 of 1 QAPI program review. (Patients #1, #3) Findings include: 1. An Administrator evaluation dated 07/08/2022 and 07/07/2021 signed by the Administrator and Governing Body indicated, but was not limited to, “Oversees the HHAs Information Management and Quality Assessment and Performance Improvement programs. … Professional Requirements: … Attends committee, QAPI and management meetings, as appropriate.” 2. During an interview, on 08/14/2023 at 10:45 AM, the Administrator indicated HHA 2 had not immediately reported the unanticipated death of Patient #1 to the agency, an investigation of the event was not conducted because HHA 2 was “…not on the clock…”, and they did not know the details of the event. 3. The clinical record for Patient #3, start of care (SOC) date 11/20/2019, certification period 07/02/2023 to 08/30/2023, included a Comprehensive Assessment that indicated Patient #3 had a pressure wound to the coccyx (tailbone). During an interview on 08/19/2023 at 9:40 AM the Administrator was unaware Patient #3’s wound was not measured during nursing visits. The Administrator stated the agency does not have any orders to treat wounds from the physician therefore they have no patients with wounds on census. The Administrator stated the expectation was for the nurse to visually assess the patient’s skin and urine in a catheter bag while in the patient’s home. The Administrator stated the expectation was for the skilled nurse to measure the patients wound weekly. The Administrator stated the agency does not have a specific wound care policy. 4. Review of the agency 2023 QAPI program on 08/21/2023 failed to collect data, measure, analyze, and track wounds and adverse /sentinel events (unexpected occurrence involving death or serious physical or psychological injury) with in the QAPI program. 5. During an interview on 08/21/2023 at 10:30 AM the Administrator stated the former director of nursing (DON) and RN 2 did not address or track wounds and adverse events. The Administrator was unsure why wounds and adverse events were not addressed in the QAPI program. 410 IAC 17-12-2(a)

Home health aide services CFR(s): 484.80 Condition of participation: Home health aide services. All home health aide services must be provided by individuals who meet the personnel requirements specified in paragraph (a) of this section. This CONDITION is not met as evidenced by: Based on record review and interview, the agency failed to ensure home health aides were aware of patient code status or what an advance directive entailed. The agency failed to ensure HHAs were competent to provide patient care prior to first patient contact, failed to ensure HHAs were provided education and training for advanced directives and safety precautions in accordance with plans of care, and failed to ensure the HHA visit notes were thorough and complete to promote effective oversight. (See tag G0800); and the agency failed to ensure the competency program included the required HHA subject areas and effective evaluation of HHA skills. (See tag G0768) The cumulative effect of the deficient practice resulted in the agency being out of compliance with Condition of Participation §484.80 Home Health aide services and has the likelihood to affect all current patients receiving services from the provider.

Competency evaluation CFR(s): 484.80(c)(1)(2)(3) Standard: Competency evaluation. An individual may furnish home health services on behalf of an HHA only after that individual has successfully completed a competency evaluation program as described in this section. (1) The competency evaluation must address each of the subjects listed in paragraph (b)(3) of this section. Subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section must be evaluated by observing an aide's performance of the task with a patient or pseudo-patient. The remaining subject areas may be evaluated through written examination, oral examination, or after observation of a home health aide with a patient, or with a pseudo-patient as part of a simulation. (2) A home health aide competency evaluation program may be offered by any organization, except as specified in paragraph (f) of this section. (3) The competency evaluation must be performed by a registered nurse in consultation with other skilled professionals, as appropriate. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the competency program for 6 of 6 actively employed home health aides (HHA) and 1 of 1 former HHA included the required HHA subject areas and effective evaluation of HHA skills. (HHA 2, HHA 1, HHA 6, HHA 8, HHA 21, HHA 22, HHA 23) Findings include: 1. The personnel record of HHA 2 indicated date of hire was 03/27/2019 and the first patient contact occurred on 04/05/2023. The record did not include sufficient documentation to show the agency provided education and training or evaluation upon hire or prior to first patient contact for appropriate and safe techniques in performing personal hygiene and grooming tasks that include, bed bath, sponge, tub, and shower bath, hair shampooing in sink, tub, and bed, nail and skin care, oral hygiene, toileting and elimination, safe transfer techniques and ambulation, normal range of motion and positioning, adequate nutrition and fluid intake, or recognizing and reporting changes in skin condition. During an interview, on 08/16/2023 at 10:41 AM, HHA 2 indicated they had not received education or training from the agency. They indicated they had not performed return skill demonstration while employed at the agency 2. The personnel record of HHA 1 indicated the date of hire was 06/20/2019 and the first patient contact occurred on 06/27/2023. The record did not include sufficient documentation to show education or training regarding adequate fluid intake was provided. A HHA skill checklist, dated 06/20/2023, did not include documentation to show skills for adequate fluid intake were evaluated. During an interview, on 08/16/2023 at 11:50 AM, HHA 1 indicated they were a new HHA, really didn't know what they were supposed to be doing, they did not receive much training from the agency, and they just signed a lot of papers during orientation. During an interview, on 08/18/2023 at 9:29 AM, HHA 1 indicated they were not required to demonstrate HHA skills to RN 2, on 06/20/2023. 3. The personnel record of HHA 6 indicated the date of hire was 09/14/2022 and the first patient contact occurred on 09/21/2022. The record did not include sufficient documentation to show education or training regarding adequate fluid intake was provided. The HHA skill checklists, dated 09/14/2022 and 12/22/2022, did not include documentation to show education or training regarding adequate fluid intake was provided or evaluated by the agency. During an interview, on 08/18/2023 at 9:27 AM, HHA 6 indicated they were not required to perform a return demonstration of HHA skills on 09/14/2022 or 12/12/2022. 4. The personnel record of HHA 8 indicated the date of hire was 05/02/2023 and the first patient contact occurred on 05/15/2023. The record did not include sufficient documentation to show education or training regarding adequate nutrition and fluid intake or recognizing and reporting changes in skin condition was provided. A HHA skill checklist, dated 05/02/2023, did not include documentation to show education or training regarding adequate nutrition and fluid intake or recognizing and reporting changes in skin condition was provided or evaluated by the agency. During an interview, on 08/21/2022 at 9:07 AM, HHA 8 indicated they were not required to perform a return demonstration of HHA skills for the agency staff, on 05/02/2023. 5. The personnel record of HHA 21 indicated the date of hire was 06/20/2023 and the first patient contact occurred on 06/26/2023. The record did not include sufficient documentation to show education or training regarding adequate fluid intake was provided. A HHA skill checklist, dated 06/20/2023, did not include documentation to show education or training regarding adequate fluid intake was provided or evaluated by the agency. During an interview, on 08/18/2023 at 9:25 AM, HHA 21 indicated they were not required to perform a return demonstration of HHA skills for agency staff upon hire. 6. The personnel record of HHA 22 indicated the date of hire was 06/20/2023 and the first patient contact occurred on 06/27/2023. The record did not include sufficient documentation to show education or training regarding adequate nutrition and fluid intake or recognizing and reporting changes in skin condition were provided or evaluated. A HHA skill checklist, dated 06/20/2023, did not include documentation to show education or training regarding adequate nutrition and fluid intake or recognizing and reporting changes in skin condition were provided or evaluated by the agency. During an interview, on 08/18/2023 at 10:03 AM, HHA 22 indicated they were not required to perform a return demonstration of HHA skills for agency staff upon hire. 7. The personnel record of HHA 23 indicated the date of hire was 06/06/2023 and the first patient contact occurred on 06/12/2023. The record did not include sufficient documentation to show education or training regarding adequate nutrition and fluid intake or recognizing and reporting changes in skin condition were provided or evaluated. A HHA skill checklist, dated 06/20/2023, did not include documentation to show education or training regarding adequate nutrition and fluid intake or recognizing and reporting changes in skin condition were provided or evaluated by the agency. During an interview, on 08/18/2023 at 10:19 AM, HHA 23 indicated they were not required to perform a return demonstration of HHA skills for agency staff upon hire. During an interview, on 08/16/2023 at 3:30 PM, the Administrator indicated the agency’s expectation would be for education and training of all required subject areas of HHA skills to be provided and evaluated prior to first patient contact for all HHAs and RN 2 was responsible for the provision and evaluation of HHA education and training after 03/27/2023, but no supporting documentation could be provided. 410 IAC 17-14-1(l)(1)(A)

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure home health aides were aware of patient code status or what an advance directive entailed. The agency failed to ensure HHAs were competent to provide patient care prior to first patient contact, failed to ensure HHAs were provided education and training for advanced directives and safety precautions in accordance with plans of care for 6 of 6 active HHAs (HHA 1, 6, 8, 21, 22, 23) and 1 of 1 former HHA (HHA 2), and failed to ensure the HHA visit notes were thorough and complete to promote effective oversight. Findings include: 1. The clinical record for Patient #1, SOC date 05/31/2017, indicated Patient #1 was a full code with the diagnoses including, but not limited to, epilepsy, fetal alcohol syndrome, and cerebral palsy. A review of the plan of care dated 06/29/2023 to 08/27/2023 indicated Patient #1 should receive HHA services 2-3 times per week for one week, then 5-6 times per week for eight weeks. The plan indicated the HHA should provide the following services: Turn patient every 1-2 hours while in bed during waking hours; Change adult diapers as needed during the shift, and skincare with each change; Bath-sponge/bed bath 5x/week and as needed, plus skincare and shave as needed (2 to 3 times a week); Provide complete care, the client totally dependent and requires 24-hour supervision. The HHA visit narrative notes, dated from 06/29/2023 through 07/03/2023, indicated the following: 06/29/2023 from 8:00 AM-12:00 PM and another note from 6:00 PM-9:00 PM “…Note: No international travel, no illness, no contact within 14 days with someone who is ill with covid 19 [sic], covid screening negative aides temp 98.2…” 06/30/2023 from 8:00 AM-12:00 PM: “…Note: No international travel, no illness, no contact within 14 days with someone who is ill with covid 19 [sic], covid screening negative aides temp 98.3…” 06/30/2023 from 6:00 PM-9:00 PM: “…Note: No international travel, no illness, no contact within 14 days with someone who is ill with covid 19 [sic], covid screening negative aides temp 98.1…” 07/01/2023 from 8:00 AM-12:00 PM and again from 6:00 PM-9:00 PM “…Note: No international travel, no illness, no contact within 14 days with someone who is ill with covid 19 [sic], covid screening negative aides temp 98.4…” 07/02/2023 from 8:00 AM-12:00 PM: “…Note: No international travel, no illness, no contact within 14 days with someone who is ill with covid 19 [sic], covid screening negative aides temp 98.1…” 07/02/2023 from 6:00 PM-9:00 PM: “…Note: No international travel, no illness, no contact within 14 days with someone who is ill with covid 19 [sic], covid screening negative aides temp 98.7…” 07/03/2023 from 8:00 AM-12:00 PM: “…Note: No international travel, no illness, no contact within 14 days with someone who is ill with covid 19 [sic], covid screening negative aides temp 98.4…” 07/03/2023 from 6:00 PM-9:00 PM: “…Note: No international travel, no illness, no contact within 14 days with someone who is ill with covid 19 [sic], covid screening negative aides temp 98.2…” The notes did not include sufficient documentation to show Patient 1 was turned every 1-2 hours while in bed during waking hours, incontinence care was provided, the condition of the patient’s skin, bathing activities, skin care, and shaving was offered or provided, or to indicate complete care was provided to the dependent patient between 06/29/2023 and 07/03/2023. A communications note authored by RN 2, dated 07/05/2023 at 12:23 PM, indicated, “Office received a message yesterday while closed for the holiday that client (pt #1) had expired. The family was unsure of the reason and the coroner was arriving at the time of the message. Client chart to be closed at this time.” The clinical record failed to evidence any home health aide visit notes after 7/3/23 that could have been beneficial to identify if the patient had been displaying any signs and symptoms of a decline leading up to this sentinel death. During an interview, on 08/15/2023 at 12:56 PM, the Administrator indicated the agency did not provide family/caregiver (the agency-paid caregiver was a family member of the deceased patient) education or training for precautions identified in the plans of care because the agency would not expect the family/caregiver to provide care when they were not working as an Home Health Aide(HHA). The plan of care indicated the patient needed 24-hour care but failed to identify what hours the HHA/Caregiver was being offered on the clock from the agency and what hours were off the clock. During an interview, on 08/16/2023 at 10:41 AM, HHA 2 indicated they were the legal guardian of Patient #1, provided HHA services to Patient #1, and indicated they found Patient #1 unresponsive and without respirations, on 07/04/2023 at approximately 8:00 AM, Emergency services were initiated. HHA 2 indicated they were "off the clock" when Patient #1 was found. Patient #1 expired on 07/04/2023 unexpectedly without a known cause. They indicated they had provided care to Patient #1 for many years, had not performed return skill demonstration while employed at the agency, and had not received education or training from the agency regarding safety precautions in accordance with the plan of care The personnel record of HHA 2 did not include documentation to show the agency provided training in regard to safety precautions for falls, transfers, seizures, or aspiration as identified in the plan of care for Patient 1. The agency provided an orientation checklist, dated 11/21/2013, and an HHA skills checklist, dated 11/22/2013, from Entity 5 indicating HHA 2 successfully demonstrated HHA skills and received orientation, but did not provide documentation to determine the skills of HHA 2 were effectively evaluated by the agency upon hire. 2. During an interview, on 08/16/2023 at 11:50 AM, HHA 1 indicated they were a new HHA, really didn't know what they were supposed to be doing, and they did not receive much training from the agency. HHA 1 indicated they just signed a lot of papers during orientation. An HHA skills checklist, dated 06/20/2023 and signed by RN 2, indicated HHA 1 successfully demonstrated appropriate and safe techniques in performing personal hygiene and grooming tasks that include bed bath, sponge, tub, and shower bath, hair shampooing in sink, tub, and bed, nail and skin care, oral hygiene, toileting and elimination, safe transfer techniques and ambulation, normal range of motion and positioning, adequate nutrition and recognizing and reporting changes in skin condition. The checklist did not include documentation to show skills for adequate fluid intake were evaluated. During an interview, on 08/18/2023 at 9:29 AM, HHA 1 indicated they were not required to demonstrate HHA skills to RN 2, on 06/20/2023, and were not provided education or training specific to safety precautions in accordance with the plans of care. 3. A HHA skill checklist, dated 09/14/2022, did not include documentation to show HHA 6 successfully demonstrated appropriate and safe techniques in performing personal hygiene and grooming tasks that include bed bath, sponge, tub, and shower bath, hair shampooing in sink, tub, and bed, nail and skin care, oral hygiene, toileting and elimination, safe transfer techniques and ambulation, or normal range of motion and positioning. An HHA skill checklist, dated 12/22/2022, indicated HHA 6 successfully demonstrated appropriate and safe techniques in performing personal hygiene and grooming tasks that include bed bath, sponge, tub, and shower bath, hair shampooing in sink, tub, and bed, nail and skin care, oral hygiene, toileting and elimination, safe transfer techniques and ambulation, and normal range of motion and positioning. The checklists did not include documentation to show skills for adequate fluid intake were evaluated. During an interview, on 08/18/2023 at 9:27 AM, HHA 6 indicated they were not required to perform a return demonstration of HHA skills on 09/14/2022 or 12/12/2022 and were not provided education or training specific to patient safety precautions in accordance with the plans of care. 4. An HHA skill checklist, dated 05/02/2023 indicated HHA 8 successfully demonstrated appropriate and safe techniques in performing personal hygiene and grooming tasks that include bed bath, sponge, tub, and shower bath, hair shampooing in sink, tub, and bed, nail and skin care, oral hygiene, toileting and elimination, safe transfer techniques and ambulation, and normal range of motion and positioning. The checklist did not include documentation to show skills for adequate nutrition and fluid intake or recognizing and reporting changes in skin condition were evaluated. During an interview, on 08/21/2022 at 9:07 AM, HHA 8 indicated they were not required to perform a return demonstration of HHA skills for the agency staff, on 05/02/2023, and were not provided education or training specific to patient safety precautions in accordance with the plans of care. 5. A HHA skill checklist, dated 06/20/2023, indicated HHA 21 successfully demonstrated appropriate and safe techniques in performing personal hygiene and grooming tasks that include bed bath, sponge, tub, and shower bath, hair shampooing in sink, tub, and bed, nail and skin care, oral hygiene, toileting, and elimination, safe transfer techniques and ambulation, normal range of motion and positioning, adequate nutrition and recognizing and reporting changes in skin condition. The checklist did not include documentation to show skills for adequate fluid intake were evaluated. During an interview, on 08/18/2023 at 9:25 AM, HHA 21 indicated they were not required to perform a return demonstration of HHA skills for agency staff upon hire and were not provided education or training specific to patient safety precautions in accordance with the plans of care. 6. A HHA skills checklist, dated 06/20/2023, indicated HHA 22 successfully demonstrated appropriate and safe techniques in performing personal hygiene and grooming tasks that include bed bath, sponge, tub, and shower bath, hair shampooing in sink, tub, and bed, nail and skin care, oral hygiene, toileting and elimination, safe transfer techniques and ambulation, normal range of motion and positioning, adequate nutrition and recognizing and reporting changes in skin condition. The checklist did not include documentation to show skills for adequate nutrition and fluid intake or recognizing and reporting changes in skin condition were evaluated. During an interview, on 08/18/2023 at 10:03 AM, HHA 22 indicated they were not required to perform a return demonstration of HHA skills for agency staff upon hire and were not provided education or training specific to patient safety precautions in accordance with the plans of care. 7. A HHA skill checklist, dated 06/20/2023, indicated HHA 23 successfully demonstrated appropriate and safe techniques in performing personal hygiene and grooming tasks that include bed bath, sponge, tub, and shower bath, hair shampooing in sink, tub, and bed, nail and skin care, oral hygiene, toileting, and elimination, safe transfer techniques and ambulation, normal range of motion and positioning, adequate nutrition and recognizing and reporting changes in skin condition. The checklist did not include documentation to show skills for adequate nutrition and fluid intake or recognizing and reporting changes in skin condition were evaluated. During an interview, on 08/18/2023 at 10:19 AM, HHA 23 indicated they were not required to perform a return demonstration of HHA skills for agency staff upon hire and were not provided education or training specific to patient safety precautions in accordance with the plans of care. 8. During an interview, on 08/16/2023 at 3:30 PM, the Administrator indicated the agency did not have a policy regarding return demonstrations of HHA skills, but the agency’s expectation would be for return demonstration to be conducted during skill evaluation prior to the first patient contact. 9. During an interview, on 08/16/2023 at 3:30 PM the Administrator was asked about the signed and completed competencies forms indicating the HHAs were deemed competent and observed performing the required skills by an RN and why all of the HHAs interviewed denied demonstrating the skills or having any type of competency evaluation, the Administrator indicated RN 2, who was also the current Clinical Manager, was responsible for evaluating their skills and completing the competencies as of 03/27/2023 but had no documentation to indicate the skill competency assessments were actually performed.

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: Based on record review and interview, the Governing Body, the Administrator, and the agency failed to investigate an unanticipated patient death, failed to monitor the accuracy of HHA competency evaluation forms to ensure HHAs were competent to provide patient care prior to first patient contact, failed to ensure HHAs were provided education and training for advanced directives and safety precautions in accordance with plans of care for 6 of 6 active HHAs ( HHA 1, 6, 8, 21, 22, 23) and 1 of 1 former HHA (HHA 2), and failed to ensure the HHA visit notes were thorough and complete to promote effective oversight. The deficient practice puts all patients receiving services at risk of receiving ineffective care from the agency (See tag G942); receiving services that were not effectively overseen by the Administrator (See G948); and receiving services from incompetent staff (See tag G952). The cumulative effect of the deficient practice resulted in the agency being out of compliance with Condition of Participation §484.105 Organization and administration of services and has the likelihood to affect all current patients receiving services from the provider.

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, the Administrator, and the agency failed to provide effective management of the provision of home health services to ensure an investigation was initiated after a patient was found without pulse and respirations, failed to ensure the accuracy of HHA competency evaluation forms were monitored to ensure HHAs were competent to provide patient care prior to first patient contact, the provision of HHA education and training for advanced directives and safety precautions in accordance with plans of care were monitored for 6 of 6 active HHAs ( HHA 1, 6, 8, 21, 22, 23) and 1 of 1 former HHA (HHA 2), and failed to monitor to ensure the HHA visit notes were thorough and complete to promote effective oversight. Findings include: 1. A policy and procedure for “Assessment of possible abuse/neglect” was provided, on 08/14/2023 at 3:04 PM, by the Administrator who indicated it was the most current version. The policy indicated, “Purpose [sic] To ensure that all suspected cases of client abuse and/or neglect are reported under the appropriate laws and regulations…The agency reports al suspected cases of abuse and /or neglect in compliance with appropriate state statutes to appropriate protection organizations…Definitions… Neglect: Failure of a caretaker to supply the client with necessary …health care [sic]…Report: any report received by the…licensing agency…of neglect that states the following (see suspected abuse and or neglect investigation report, addendum 3-3C)…What has happened…To Whom it happened…When it happened…Where it happened…Who did the abusing or was responsible for the neglect…2. The clinician will complete a suspected abuse and/or neglect investigation report with the addition of the following information…name of alleged perpetrator…The clinician will complete a suspected…neglect investigation report with the addition of the following information…name of alleged perpetrator…relations to client…information regarding suspected…neglect…date of occurrence…witness to occurrence…nature of occurrence…description of the…neglect…3. The suspected…neglect investigation report with specific information relating to the occurrence is forward [sic] to the RN/Case Manager who will…A. conduct an immediate initial investigation into the suspected…neglect [sic] B. Reviews the documentation for completeness and objectivity [sic] C. Consult the Director of Clinical Services/Administrator. 4. The Director of Clinical Services/Administrator will…A. Authorize a verbal report of the suspected…neglect to the proper authorities in accordance with state law to be filed by RN/Case Manager. B. Review all reports (incident report and follow-up investigation) [sic] C. Conducts any further review if necessary…” The addendum was requested of the Administrator, on 08/14/2023 at 3:08 PM, and was not received prior to survey exit on 08/22/2023. 2. A 07/28/2020 Administrator job description was provided by the Administrator on 08/16/2023 at 8:15 AM. The job description indicated, but was not limited to, “Responsibilities and Duties 1. Organize and direct day-to-day functions all direct and indirect services provided by agency personnel. 2. Maintain ongoing liaison between governing body and staff. … 4. Ensures adequacy of staff education …5. Assures that a Clinical Manager is available during all operating hours. … 10. Ensures agency meets all required rules and regulations. … 11. Responsible for the quality assurance and performance improvement program. … 14. Evaluates performance of clinical staff. … 19. … Assures for the quality and safe delivery of home health services … 23. … development of … standard of care, policies, and procedures … 31. Other duties as assigned by the governing body. …” 3. The clinical record for Patient #1, SOC date 05/31/2017, indicated Patient #1 was a full code with the diagnoses including, but not limited to, epilepsy, fetal alcohol syndrome, and cerebral palsy. A review of the plan of care dated 06/29/2023 to 08/27/2023 indicated Patient #1 should receive HHA services 2-3 times per week for one week, then 5-6 times per week for eight weeks. The plan indicated the HHA should provide the following services: Turn patient every 1-2 hours while in bed during waking hours; Change adult diapers as needed during the shift, and skincare with each change; Bath-sponge/bed bath 5x/week and as needed, plus skincare and shave as needed (2 to 3 times a week); Provide complete care, the client totally dependent and requires 24-hour supervision. The HHA visit narrative notes, dated from 06/29/2023 through 07/03/2023, indicated the following: 06/29/2023 from 8:00 AM-12:00 PM and another note from 6:00 PM-9:00 PM “…Note: No international travel, no illness, no contact within 14 days with someone who is ill with covid 19 [sic], covid screening negative aides temp 98.2…” 06/30/2023 from 8:00 AM-12:00 PM: “…Note: No international travel, no illness, no contact within 14 days with someone who is ill with covid 19 [sic], covid screening negative aides temp 98.3…” 06/30/2023 from 6:00 PM-9:00 PM: “…Note: No international travel, no illness, no contact within 14 days with someone who is ill with covid 19 [sic], covid screening negative aides temp 98.1…” 07/01/2023 from 8:00 AM-12:00 PM and again from 6:00 PM-9:00 PM “…Note: No international travel, no illness, no contact within 14 days with someone who is ill with covid 19 [sic], covid screening negative aides temp 98.4…” 07/02/2023 from 8:00 AM-12:00 PM: “…Note: No international travel, no illness, no contact within 14 days with someone who is ill with covid 19 [sic], covid screening negative aides temp 98.1…” 07/02/2023 from 6:00 PM-9:00 PM: “…Note: No international travel, no illness, no contact within 14 days with someone who is ill with covid 19 [sic], covid screening negative aides temp 98.7…” 07/03/2023 from 8:00 AM-12:00 PM: “…Note: No international travel, no illness, no contact within 14 days with someone who is ill with covid 19 [sic], covid screening negative aides temp 98.4…” 07/03/2023 from 6:00 PM-9:00 PM: “…Note: No international travel, no illness, no contact within 14 days with someone who is ill with covid 19 [sic], covid screening negative aides temp 98.2…” The notes did not include sufficient documentation to show Patient 1 was turned every 1-2 hours while in bed during waking hours, incontinence care was provided, the condition of the patient’s skin, bathing activities, skin care, and shaving was offered or provided, or to indicate complete care was provided to the dependent patient between 06/29/2023 and 07/03/2023. A communications note authored by RN 2, dated 07/05/2023 at 12:23 PM, indicated, “Office received a message yesterday while closed for the holiday that client (pt #1) had expired. The family was unsure of the reason and the coroner was arriving at the time of the message. Client chart to be closed at this time.” The clinical record failed to evidence any home health aide visit notes after 7/3/23 that could have been beneficial to identify if the patient had been displaying any signs and symptoms of a decline leading up to this sentinel death. During an interview, on 08/15/2023 at 12:56 PM, the Administrator indicated the agency did not provide family/caregiver (the agency-paid caregiver was a family member of the deceased patient) education or training for precautions identified in the plans of care because the agency would not expect the family/caregiver to provide care when they were not working as an Home Health Aide(HHA). The plan of care indicated the patient needed 24-hour care but failed to identify what hours the HHA/Caregiver was being offered on the clock from the agency and what hours were off the clock. During an interview, on 08/16/2023 at 10:41 AM, HHA 2 indicated they found Patient #1 unresponsive and without respirations, on 07/04/2023 at approximately 8:00 AM, Emergency services were initiated, but CPR was not started. HHA 2 indicated they were "off the clock" when Patient #1 was found. Patient #1 expired on 07/04/2023 unexpectedly without a known cause. They indicated they had provided care to Patient #1 for many years, had not performed return skill demonstration while employed at the agency, and had not received education or training from the agency regarding safety precautions in accordance with the plan of care The personnel record of HHA 2 did not include documentation to show the agency provided training in regard to safety precautions for falls, transfers, seizures, or aspiration as identified in the plan of care for Patient 1. The agency provided an orientation checklist, dated 11/21/2013, and an HHA skills checklist, dated 11/22/2013, from Entity 5 indicating HHA 2 successfully demonstrated HHA skills and received orientation, but did not provide documentation to determine the skills of HHA 2 were effectively evaluated by the agency upon hire. 4. During an interview, on 08/16/2023 at 11:50 AM, HHA 1 indicated they were a new HHA, really didn't know what they were supposed to be doing, and they did not receive much training from the agency. HHA 1 indicated they just signed a lot of papers during orientation. An HHA skills checklist, dated 06/20/2023 and signed by RN 2, indicated HHA 1 successfully demonstrated appropriate and safe techniques in performing personal hygiene and grooming tasks that include bed bath, sponge, tub, and shower bath, hair shampooing in sink, tub, and bed, nail and skin care, oral hygiene, toileting and elimination, safe transfer techniques and ambulation, normal range of motion and positioning, adequate nutrition and recognizing and reporting changes in skin condition. The checklist did not include documentation to show skills for adequate fluid intake were evaluated. During an interview, on 08/18/2023 at 9:29 AM, HHA 1 indicated they were not required to demonstrate HHA skills to RN 2, on 06/20/2023, and were not provided education or training specific to safety precautions in accordance with the plans of care. 5. A HHA skill checklist, dated 09/14/2022, did not include documentation to show HHA 6 successfully demonstrated appropriate and safe techniques in performing personal hygiene and grooming tasks that include bed bath, sponge, tub, and shower bath, hair shampooing in sink, tub, and bed, nail and skin care, oral hygiene, toileting and elimination, safe transfer techniques and ambulation, or normal range of motion and positioning. An HHA skill checklist, dated 12/22/2022, indicated HHA 6 successfully demonstrated appropriate and safe techniques in performing personal hygiene and grooming tasks that include bed bath, sponge, tub, and shower bath, hair shampooing in sink, tub, and bed, nail and skin care, oral hygiene, toileting and elimination, safe transfer techniques and ambulation, and normal range of motion and positioning. The checklists did not include documentation to show skills for adequate fluid intake were evaluated. During an interview, on 08/18/2023 at 9:27 AM, HHA 6 indicated they were not required to perform a return demonstration of HHA skills on 09/14/2022 or 12/12/2022 and were not provided education or training specific to patient safety precautions in accordance with the plans of care. 6. An HHA skill checklist, dated 05/02/2023 indicated HHA 8 successfully demonstrated appropriate and safe techniques in performing personal hygiene and grooming tasks that include bed bath, sponge, tub, and shower bath, hair shampooing in sink, tub, and bed, nail and skin care, oral hygiene, toileting and elimination, safe transfer techniques and ambulation, and normal range of motion and positioning. The checklist did not include documentation to show skills for adequate nutrition and fluid intake or recognizing and reporting changes in skin condition were evaluated. During an interview, on 08/21/2022 at 9:07 AM, HHA 8 indicated they were not required to perform a return demonstration of HHA skills for the agency staff, on 05/02/2023, and were not provided education or training specific to patient safety precautions in accordance with the plans of care. 7. A HHA skill checklist, dated 06/20/2023, indicated HHA 21 successfully demonstrated appropriate and safe techniques in performing personal hygiene and grooming tasks that include bed bath, sponge, tub, and shower bath, hair shampooing in sink, tub, and bed, nail and skin care, oral hygiene, toileting, and elimination, safe transfer techniques and ambulation, normal range of motion and positioning, adequate nutrition and recognizing and reporting changes in skin condition. The checklist did not include documentation to show skills for adequate fluid intake were evaluated. During an interview, on 08/18/2023 at 9:25 AM, HHA 21 indicated they were not required to perform a return demonstration of HHA skills for agency staff upon hire and were not provided education or training specific to patient safety precautions in accordance with the plans of care. 8. A HHA skills checklist, dated 06/20/2023, indicated HHA 22 successfully demonstrated appropriate and safe techniques in performing personal hygiene and grooming tasks that include bed bath, sponge, tub, and shower bath, hair shampooing in sink, tub, and bed, nail and skin care, oral hygiene, toileting and elimination, safe transfer techniques and ambulation, normal range of motion and positioning, adequate nutrition and recognizing and reporting changes in skin condition. The checklist did not include documentation to show skills for adequate nutrition and fluid intake or recognizing and reporting changes in skin condition were evaluated. During an interview, on 08/18/2023 at 10:03 AM, HHA 22 indicated they were not required to perform a return demonstration of HHA skills for agency staff upon hire and were not provided education or training specific to patient safety precautions in accordance with the plans of care. 9. A HHA skill checklist, dated 06/20/2023, indicated HHA 23 successfully demonstrated appropriate and safe techniques in performing personal hygiene and grooming tasks that include bed bath, sponge, tub, and shower bath, hair shampooing in sink, tub, and bed, nail and skin care, oral hygiene, toileting, and elimination, safe transfer techniques and ambulation, normal range of motion and positioning, adequate nutrition and recognizing and reporting changes in skin condition. The checklist did not include documentation to show skills for adequate nutrition and fluid intake or recognizing and reporting changes in skin condition were evaluated. During an interview, on 08/18/2023 at 10:19 AM, HHA 23 indicated they were not required to perform a return demonstration of HHA skills for agency staff upon hire and were not provided education or training specific to patient safety precautions in accordance with the plans of care. 10. During an interview, on 08/16/2023 at 3:30 PM, the Administrator indicated the agency did not have a policy regarding return demonstrations of HHA skills, but the agency’s expectation would be for return demonstration to be conducted during skill evaluation prior to the first patient contact. The Administrator indicated RN 2 was responsible for evaluating the competency of HHAs after 03/27/2023, but no documentation could be provided to show the skill competencies were actually completed. 410 IAC 17-12-1(b)

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on record review and interview, the Administrator failed to be responsible for all day to day operations for 1 of 1 home health agency. Findings include: A 07/28/2020 Administrator job description was provided by the Administrator on 08/16/2023 at 8:15 AM. The job description indicated but was not limited to, “Responsibilities and Duties 1. Organize and direct day-to-day functions all direct and indirect services provided by agency personnel. 2. Maintain ongoing liaison between governing body and staff. … 4. Ensures adequacy of staff education …5. Assures that a Clinical Manager is available during all operating hours. … 10. Ensures agency meets all required rules and regulations. … 11. Responsible for the quality assurance and performance improvement program. … 14. Evaluates performance of clinical staff. … 19. … Assures for the quality and safe delivery of home health services … 23. … development of … standard of care, policies, and procedures … 31. Other duties as assigned by the governing body. …” The agency Administrator failed to initiate an investigation of the event for a patient reviewed for unanticipated death. (See tag G488) The agency Administrator failed to ensure the skilled nurse performed a wound assessment and measurements for patients with open wounds and failed to visually assess patients for skin integrity issues on home visits. The agency failed to ensure skin assessments, catheter monitoring, and health status assessments were not delegated to an outside Entity. The agency Administrator, skilled nurse, and human resource personnel indicated the care and assessment depended on the patient’s payer source. This puts all patients with active wounds at risk for infection and further deterioration based on their payer source. (See tag G510) The agency Administrator failed to ensure an ongoing visual assessment of skin, catheters, and ostomies was performed on home visits and documented in the comprehensive / updated assessment. (See tag G536) The agency Administrator failed to ensure the comprehensive assessment was updated to accurately reflect the patient status of a wound. (See tag G544) The agency Administrator failed to ensure effective discharge planning was implemented when sufficient nursing staff services could not be obtained for Patient #6 and 22 of 23 skilled nursing visits were missed. (See tag G562) The agency Administrator failed to ensure the training program for actively employed home health aides (HHA) and for a former HHA included the required subject areas. (See tag G564) The agency Administrator failed to ensure HHA education and training for advanced directives and safety precautions were provided to family caregivers in accordance with plans of care for active HHAs and for a former HHA and failed to ensure the HHA visit notes were thorough and complete to promote effective oversight. (See tag G570) The agency Administrator failed to ensure that actively employed home health aides (HHA) were competent to carry out assigned patient care tasks in a safe, effective, and efficient manner. (See tag G574) The agency Administrator failed to ensure services were provided in accordance with the plan of care. (See tag G606) The agency Administrator failed to ensure data was collected, measured, analyzed, and tracked regarding wounds and adverse / sentinel (unexpected death) events within the Quality Assurance Performance Improvement (QAPI) program. (See tag G642) The agency Administrator failed to ensure the skilled nurse met the agency's expectations and followed agency policy regarding patient assessments. (See tag G700) The agency failed to ensure HHAs were competent to provide patient care prior to first patient contact and failed to ensure HHAs were provided education and training for advanced directives and safety precautions in accordance with plans of care. (See tag G750) The agency Administrator failed to ensure the competency program for employed home health aides and for a former HHA included the required HHA subject areas and effective evaluation of HHA skills. (See tag G768) The agency Administrator failed to ensure that actively employed home health aides were qualified to provide safety precautions for patients in accordance with the plan of care. (See tag 952) 410 IAC 17-12-1(b)(3) 410 IAC 17-12-1 (c)(1) 410 IAC 17-12-2(a)

Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure 6 of 6 actively employed home health aides (HHA) were qualified to provide safety precautions for patients in accordance with the plan of care. (HHA 2, HHA 1, HHA 6, HHA 8, HHA 21, HHA 22, HHA 23) Findings include: 1. A communications note authored by RN 2, dated 07/05/2023 at 12:23 PM, indicated, “Office received a message yesterday while closed for the holiday that client had expired. Family unsure of reason and coroner was arriving at time of message. Client chart to be closed at this time.” During an interview, on 08/15/2023 at 12:56 PM, the Administrator indicated the agency did not provide family/caregiver education or training for precautions identified in the plans of care, because the agency would not expect the family/caregiver to provide care when they were not working as an Home Health Aide (HHA). 2. The personnel record of HHA 2 indicated date of hire was 03/27/2019 and the first patient contact occurred on 04/05/2023. The record did not include sufficient documentation to show the agency provided education and training or evaluation upon hire or prior to first patient contact for appropriate and safe techniques in performing personal hygiene and grooming tasks that include, bed bath, sponge, tub, and shower bath, hair shampooing in sink, tub, and bed, nail and skin care, oral hygiene, toileting and elimination, safe transfer techniques and ambulation, normal range of motion and positioning, adequate nutrition and fluid intake, or recognizing and reporting changes in skin condition. During an interview, on 08/16/2023 at 10:41 AM, HHA 2 indicated they were the legal guardian of Patient #1, and provided HHA services to Patient #1. HHA 2 indicated they found Patient #1 unresponsive and without respirations, on 07/04/2023 at approximately 8:00 AM, Emergency services were initiated. HHA 2 indicated they were "off the clock" when Patient #1 was found. Patient #1 expired on 07/04/2023 unexpectedly without a known cause. HHA 2 indicated they had provided care to Patient #1 for many years, had not performed return skill demonstration while employed at the agency, and had not received education or training from the agency regarding safety precautions in accordance with the plan of care. 3. The personnel record of HHA 1 indicated the date of hire was 06/20/2019 and the first patient contact occurred on 06/27/2023. The record indicated HHA 1 provided HHA services to a family member but did not include sufficient documentation to show education or training regarding adequate fluid intake, or fall and ambulation precautions was provided. During an interview, on 08/16/2023 at 11:50 AM, HHA 1 indicated they were a new HHA, really didn't know what they were supposed to be doing, they did not receive much training from the agency, they provided care were a family member of Patient #5, and they just signed a lot of papers during orientation. During an interview, on 08/18/2023 at 9:29 AM, HHA 1 indicated they were not required to demonstrate HHA skills to RN 2, on 06/20/2023, they couldn't remember receiving education or training on adequate fluid intake, and they did not receive training related to fall or ambulation precautions. 4. The personnel record of HHA 6 indicated the date of hire was 09/14/2022 and the first patient contact occurred on 09/21/2022. The record indicated HHA 6 provided HHA services to a family member, but did not include sufficient documentation to show education or training regarding adequate fluid intake or patient-specific safety precautions were provided. The HHA skill checklists, dated 09/14/2022 and 12/22/2022, did not include documentation to show education or training regarding adequate fluid intake was provided or evaluated by the agency. During an interview, on 08/18/2023 at 9:27 AM, HHA 6 indicated they were provided HHA care to a family member, they were not required to perform a return demonstration of HHA skills on 09/14/2022 or 12/12/2022, and they had not received education or training regarding patient-specific safety precautions. 5. The personnel record of HHA 8 indicated the date of hire was 05/02/2023 and the first patient contact occurred on 05/15/2023. The record indicated HHA 8 provided HHA services to a family member, but did not include sufficient documentation to show education or training regarding adequate nutrition and fluid intake, recognizing and reporting changes in skin condition, or patient-specific safety precautions was provided. A HHA skill checklist, dated 05/02/2023, did not include documentation to show education or training regarding adequate nutrition and fluid intake or recognizing and reporting changes in skin condition was provided or evaluated by the agency. During an interview, on 08/21/2022 at 9:07 AM, HHA 8 indicated they were not required to perform a return demonstration of HHA skills for the agency staff, on 05/02/2023 and education or training on patient-specific safety precautions were not provided. 6. The personnel record of HHA 21 indicated the date of hire was 06/20/2023 and the first patient contact occurred on 06/26/2023. The record indicated HHA 21 provided HHA services to a family member, but did not include sufficient documentation to show education or training regarding adequate fluid intake was provided or patient specific safety precautions was provided. A HHA skill checklist, dated 06/20/2023, did not include documentation to show education or training regarding adequate fluid intake was provided or evaluated by the agency. During an interview, on 08/18/2023 at 9:25 AM, HHA 21 indicated they were not required to perform a return demonstration of HHA skills for agency staff upon hire and education or training on patient-specific safety precautions was provided. 7. The personnel record of HHA 22 indicated the date of hire was 06/20/2023 and the first patient contact occurred on 06/27/2023. The record indicated HHA 22 provided HHA services to a family member, but did not include sufficient documentation to show education or training regarding adequate nutrition and fluid intake, recognizing and reporting changes in skin condition, or patient-specific safety precautions was provided. A HHA skill checklist, dated 06/20/2023, did not include documentation to show education or training regarding adequate nutrition and fluid intake or recognizing and reporting changes in skin condition were provided or evaluated by the agency. During an interview, on 08/18/2023 at 10:03 AM, HHA 22 indicated they were not required to perform a return demonstration of HHA skills for agency staff upon hire and education or training on patient-specific safety precautions was not provided. 8. The personnel record of HHA 23 indicated the date of hire was 06/06/2023 and the first patient contact occurred on 06/12/2023. The record indicated HHA 23 provided HHA services to a family member, but did not include sufficient documentation to show education or training regarding adequate nutrition and fluid intake, recognizing and reporting changes in skin condition or patient-specific safety precautions was provided. A HHA skill checklist, dated 06/20/2023, did not include documentation to show education or training regarding adequate nutrition and fluid intake or recognizing and reporting changes in skin condition were provided or evaluated by the agency. During an interview, on 08/18/2023 at 10:19 AM, HHA 23 indicated they were not required to perform a return demonstration of HHA skills for agency staff upon hire and education or training on patient-specific safety precautions was not provided. 9. During an interview, on 08/16/2023 at 3:30 PM, the Administrator indicated the agency’s expectation would be for education and training of all required subject areas of HHA skills to be provided and evaluated prior to first patient contact for all HHAs and RN 2 was responsible for the provision and evaluation of HHA education and training after 03/27/2023, but no supporting documentation could be provided. 410 IAC 17-12-1(d)(3)

This visit was for a Federal and State complaint survey of a Home Health Provider. 04/17/2023-04/18/2023 12 Month Unduplicated Skilled Census: 21 These deficiencies reflect State findings in accordance with 410 IAC 17 QA completed on 4/24/2023 by A4.

Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure all services outlined in the plan of care were provided for 1 of 3 active record reviews. (Patient #5) Findings include: An undated Home Health Care Patient Bill of Rights was provided on 04/17/2023 at 1:50 PM. The policy indicated, but was not limited to, “You have the right to file complaints with the home health agency and/or the Indiana State Department of Health: Regarding treatment or care that is (or fails to be) furnished … You have the right to: … The care to be furnished … any factors that could impact treatment effectiveness … receive all services outlined in the plan of care.” The clinical record for patient #5, start of care (SOC) date 02/05/2023, certification date 03/21/2023 to 05/19/2023, was reviewed on 04/17/2023 which included a plan of care (POC) with orders for home health aide services two times a week for one week and three times a week for eight weeks. The agency failed to ensure home health aide visits were conducted on 03/29/2023, 03/31/2023, 04/03/2023, 04/05/2023, 04/07/2023, and 04/12/2023. Review of a fax to the physician dated 04/05/2023 and 04/14/2023 indicated the agency was unable to provide a caregiver. During an interview on 04/18/2023 at 11:30 AM the Administrator indicated the agency was unable to provide a caregiver on the above dates and are currently hiring for home health aides. 410 IAC 17-13-1(a)

Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure complaints were recorded in the complaint log for 1 of 1 home health agency. Findings include: A 2022 policy titled Client Concerns was provided by the Administrator on 04/17/2023 at 1:50 PM. The policy indicated, but was not limited to, “(Better Living) staff members encourage clients to express their concerns about their care or services freely … 6. The VP of Professional Services of Better Living: A. Reviews all completed and reviewed client concerns forms. … D. Files completed client concerns forms in Better Living’s client concerns administrative file.” During an interview on 04/17/2023 at 11:50 AM Patient #1 indicated he/she voiced a complaint with past employee Registered Nurse (RN) 1 about not receiving treatment supplies. On 04/17/2023 review of the 2023 Complaint Logbook did not evidence patient #1’s complaint. During an interview on 04/17/2023 at 12:45 PM the Administrator indicated he/she was aware of patient #1’s complaint and was aware Patient #1 was filing a complaint with the Office of the Attorney General. At that time, the Administrator indicated the complaint form should have been filed out by past employee RN #1 and on file at the agency but wasn’t. The Administrator acknowledged he/she failed to follow up to ensure the complaint was on file. 410 IAC 17-12-3(c)(2)

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the initial assessment was completed within 48 hours of referral for 1 of 2 closed record reviews. (Patient #1) Findings include: A 2022 policy titled Client Plan of Care was provided on 04/17/2023 at 1:50 PM. The policy indicated, but was not limited to, “1. Better Living Services are furnished to clients: … B. Following a written plan of care established and periodically reviewed by a Doctor of Medicine … 7. If a physician refers a client with a verbal order for a plan of care that cannot be completed until after an evaluation, the physician is contacted to approve any additions or modifications …” The clinical record for Patient #1, start of care (SOC) date 02/14/2023, certification date 02/14/2023 to 03/31/2023, was reviewed on 04/17/2023. The clinical record included a referral date 02/01/2023 and a start of care date 02/14/2023. The agency failed to include documentation of the reason why a physician’s order was not obtained for a delayed start of care date from the referral date. During an interview on 04/17/2023 at 3:15 PM the Administrator indicated the agency was waiting for Patient #1 to be discharged from another agency and confirmed there was no documentation in the record regarding a delayed start of care date. 410 IAC 17-14-1(a)(1)(A)

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure all medications and treatments were specified and included on the plan of care and medication profile for 1 of 2 closed record reviews. (Patient #1) Findings include: An undated Home Health Care Patient Bill of Rights was provided on 04/17/2023 at 1:50 PM. The policy indicated, but was not limited to, “ … You have the right to file complaints with the home health agency and / or the Indiana State Department of Health: Regarding treatment or care that is (or fails to be) furnished … You have the right to: … The care to be furnished … any factors that could impact treatment effectiveness … receive all services outlined in the plan of care … Before care is furnished you have the right to be advised of : The extent to which payment for home health services may be expected from Medicare, Medicaid … known to the Agency.” The clinical record for Patient #1, start of care (SOC) date 02/14/2023, certification date 02/14/2023 to 03/31/2023, was reviewed on 04/17/2023 which included a plan of care (POC). Review of the plan of care failed to include the specific type of medication that was to be prescribed for Patient #1’s bilateral lower legs. Review of the Medication Profile indicated the agency failed to include the anatomical location of where Nystatin (antifungal medication) was to be applied, failed to include a stop date for Sulfamethoxazole-Trimethoprim DS (antibiotic), and failed to add Oxygen orders/instructions. During an interview on 04/17/2023 at 3:15 PM the Administrator was unsure as to why all medications were not specified or included on the plan of care or medication profile. 410 IAC 17-14-1(a)(1)(B)

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the plan of care specified orientation, a psychosocial assessment, and cognitive status on the plan of care 4 of 5 record reviews, with the potential to affect all active records (Patients #1, #3, #4, #5) and failed to ensure all Durable Medical Equipment (DME) were included on the plan of care for 1 of 2 closed record reviews. (Patient #1) Findings include: 1. A 2022 policy titled Client Plan of Care was provided on 04/17/2023 at 1:50 PM. The policy indicated; but was not limited to, “1. Better Living Services are furnished to clients: … B. Following a written plan of care established and periodically reviewed by a Doctor of Medicine … 4. Changes in the plan of care are documented through written and signed modifications to the plan of care … 5. Clients … are notified of modifications in the plan of care. Documentation of the notification is included in the clinical record. “ 2. The clinical record for Patient #1, start of care (SOC) date 02/14/2023, certification date 02/14/2023 to 03/31/2023, was reviewed on 04/17/2023. The clinical record included a plan of care (POC) that described Patient #1’s mental status, psychosocial, and cognitive status as “oriented”. The agency failed to specify Patient #1’s mental status on the POC as indicated, but not limited to, the patient’s orientation to person, place, and time. The agency failed to complete a psychosocial assessment (interpersonal relationships in the immediate family, financial status, homemaker/household needs, family social problems, and transportation needs) and cognitive status assessment (reasoning, remembering, learning) on Patient #1’s POC. Review of Patient #1’s Skilled Nursing Visit Note dated 02/20/2023 indicated Patient #1 had a wheelchair, wound care, oxygen, and a trach (opening through the neck to breathe). Review of the POC dated 02/14/2023 failed to indicate the listed DME supplies that were on the Skilled Nursing Note. 3. The clinical record for Patient #3, start of care (SOC) date 09/25/2018, certification date 03/03/2023 to 05/01/2023, was reviewed on 04/17/2023 which included a plan of care (POC) that described Patient #3’s mental status, psychosocial, and cognitive status as “oriented”. The agency failed to specify Patient #3’s mental status on the POC as indicated, but not limited to, the patient’s orientation to person, place, and time. The agency failed to complete a psychosocial assessment (interpersonal relationships in the immediate family, financial status, homemaker/household needs, family social problems, and transportation needs) and cognitive status assessment (reasoning, remembering, learning) on Patient #3’s POC. 4. The clinical record for Patient #4, start of care (SOC) date 11/20/2019, certification date 03/04/2023 to 05/02/2023, was reviewed on 04/17/2023 which included a plan of care (POC) that described Patient #4’s mental status, psychosocial, and cognitive status as “oriented”. The agency failed to specify Patient #4’s mental status on the POC as indicated, but not limited to, the patient’s orientation to person, place, and time. The agency failed to complete a psychosocial assessment (interpersonal relationships in the immediate family, financial status, homemaker/household needs, family social problems, and transportation needs) and cognitive status assessment (reasoning, remembering, learning) on Patient #4’s POC. 5. The clinical record for Patient #5, start of care (SOC) date 02/05/2023, certification date 03/21/2023 to 05/19/2023, was reviewed on 04/17/2023 which included a plan of care (POC) that described Patient #5’s mental status, psychosocial, and cognitive status as “oriented, forgetful”. The agency failed to specify Patient #5’s mental status on the POC as indicated, but not limited to, the patient’s orientation to person, place, and time. The agency failed to complete a psychosocial assessment (interpersonal relationships in the immediate family, financial status, homemaker/household needs, family social problems, and transportation needs) and cognitive status assessment (reasoning, remembering, learning) on Patient #5’s POC. 6. During an interview on 04/18/2023 at 12:00 PM the Administrator confirmed the mental status, psychosocial, and cognitive status on the plan of care specified orientation but did not go into detail on mental status, psychosocial, and cognitive status. 410 IAC 17-13-1(a)(1)(D)(i-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 ensure staff followed physician orders for 1 of 2 closed record reviews. (Patient #1) Findings include: A revised 01/02/2019 Registered Nurse job description was provided by the Administrator on 04/17/2023 at 12:45 PM. The job description indicated; but was not limited to, “4. Administers medication and treatment as prescribed by the physician. … 6. Completes, maintains, and submits accurate and relevant clinical notes regarding clients’ condition and care given.” Review of Prep Notes Communication dated 03/06/2023 by past employee RN 1 indicated a call was placed to the physician regarding the need for new leg wraps to complete Patient #1’s treatment. RN 1 requested new orders if AccuWraps (2 layer compression system delivers therapeutic compression to manage swelling) could not be obtained. RN 1 indicated the home visit was moved to 03/07/2023 due to lack of supplies to complete the treatment. Review of Prep Notes Communication dated 03/07/2023 by past employee RN 1 indicated a home visit was conducted but failed to indicate physician treatment orders were followed or new treatment orders were obtained to complete Patient #1’s treatment. During an interview on 04/17/2023 at 3:15 PM the Administrator confirmed there was no follow-up orders or documentation of new treatment orders or instructions received on Patient #1. The Administrator indicated past employee RN 1 obtained AccuWrap supplies from Entity 2. 410 IAC 17-13-1(a)

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on record review and interview, the Registered Nurse failed to ensure agency policy was followed regarding documentation for 1 of 2 closed record reviews. (Patient #1) Findings include: A revised 01/02/2019 Registered Nurse job description was provided by the Administrator on 04/17/2023 at 12:45 PM. The job description indicated;, but was not limited to, “6. Completes, maintains, and submits accurate and relevant clinical notes regarding clients’ condition and care given.” Review of Prep Notes Communication dated 03/06/2023 and 03/07/2023 by past employee Registered Nurse 1 (RN 1) failed to ensure complete and accurate clinical notes were maintained regarding follow-up treatment orders and documentation of where he/she found additional AccuWrap (2-layer compression system delivers therapeutic compression to manage swelling) supplies to complete the Patient #1’s treatment. During an interview on 04/17/2023 at 3:15 PM the Administrator confirmed there was no follow-up orders or documentation received on Patient #1’s AccuWraps. The agency failed to follow agency policy regarding the documentation of complete and accurate clinical notes. 410 IAC 17-14-1(a)(1)(H)-RN

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 staff prepared and maintained clinical notes for 1 of 2 closed record reviews. (Patient #1) Finding include: A revised 01/02/2019 Registered Nurse job description was provided by the Administrator on 04/17/2023 at 12:45 PM. The job description indicated; but was not limited to, “4. Administers medication and treatment as prescribed by the physician. … 6. Completes, maintains, and submits accurate and relevant clinical notes regarding clients’ condition and care given.” Review of Prep Notes Communication dated 03/06/2023 by past employee RN 1 indicated a call was placed to the physician regarding the need for new leg wraps to complete Patient #1’s treatment. RN 1 requested new orders if AccuWraps (2 layer compression system delivers therapeutic compression to manage swelling) could not be obtained. RN 1 indicated the home visit was moved to 03/07/2023 due to lack of supplies to complete the treatment. Review of Prep Notes Communication dated 03/07/2023 by past employee RN 1 indicated a home visit was conducted but failed to document specific new treatment orders or where he/she found additional AccuWrap supplies to complete the treatment. During an interview on 04/17/2023 at 3:15 PM the Administrator confirmed there was no follow-up orders or documentation received on Patient #1. The agency staff failed to complete and maintain accurate clinical notes. 410 IAC 17-14-1(a)(1)(E)-RN

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102. Survey Date: January 25-28, 2021 Census = 46 active At this Emergency Preparedness survey, Better Living Home Health Care, Inc. was found not in compliance with Emergency Preparedness Requirements for Medicare Participating Providers and Suppliers, 42 CFR 484.102(b)(5) Volunteers and Staffing.

Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years (annually for LTC).] At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to include the use of volunteers within the emergency preparedness communication plan for the agency. Findings include: An undated policy titled Emergency Preparedness Plan In-Service was provided by the Administrator on 1/27/2021 at 2:30 p.m. The policy indicated, but was not limited to, "Establishes policies and procedures for the agency to follow." A review of the Emergency Preparedness Plan indicated that volunteers were not addressed in any way within the written policy. During an interview on 1/27/2021 at 2:30 p.m. the Administrator and Director of Nursing reviewed the Emergency Plan and acknowledged the plan did not indicate if the agency would use volunteers or emergency staff. The Administrator stated the agency would not be using volunteers.

This visit was for Recertification and State Licensure Survey, in conjunction with a covid-19 infection control survey. Survey Dates: 1/25, 1/26, 1/27, and 1/28 of 2021 Partially Extended Survey Announced 1/25/21 at 1:10 p.m. Facility Number: 012101 Census: 46 active These deficiencies reflect State Findings cited in accordance with 410 IAC 17. Quality Review completed on 2/1/2021 A4

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 observation, record review, and interview, the agency failed to provide in writing an understandable and accessible discharge/transfer policy to patients for 3 of 3 home visits (Patients 1, 4, and 5) which had the potential to affect all patients served by the home health agency. Findings included: 1. A Home Health 2018 policy titled Client Discharge and Transfer Policy (Client Care Policy 3034) was provided by the Director of Nursing (DON) on 1/26/21 at 12:15 p.m. The policy indicated, but was not limited to, "PURPOSE To provide patient with the procedures and policies for transfer and/or discharge ..." 2. During a home visit with Patient 1 on 1/26/2021 at 9:30 a.m. the admission packet of the patient was reviewed. No discharge/transfer policy was available in the home or accessible to the patient. 3. During a home visit with Patient 4 on 1/26/2021 at 7:30 a.m. the admission packet of the patient was reviewed. No discharge/transfer policy was available in the home or accessible to the patient. 4. During a home visit with Patient 5 on 1/27/2021 at 1:54 p.m. the admission packet of the patient was reviewed. No discharge/transfer policy was available in the home or accessible to the patient. 5. An interview was conducted with the Administrator on 1/26/2021 at 10:20 a.m. The Administrator indicated that the policy was given at time of admission but if not that it is available upon request. After further discussion with the DON and case managers, it was determined at admission a written discharge and transfer policy was not given out to patients in the admission packet. 17-12-3(a)(1)(A)

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure standard infection control precautions were followed for 1 of 3 home visit observations. (Patient 1) Findings include: An undated policy titled Universal Body Substance Precaution was provided by the Administrator on 1/25/21 at 1:00 p.m. The policy indicated, but was not limited to, "F. Gloves should not be washed or disinfected for reuse ..." A 3/6/20 policy titled Handwashing was provided by the Director of Nursing on 1/26/21 at 12:32 p.m. The policy indicated, but was not limited to, "Personnel providing care/service in the home setting will wash their hands ... before and after each contact with a patient/client ... before and after gloves are used ... " A 2000 policy titled Bag Technique was provided by the Director of Nursing on 1/27/21 at 8:45 a.m. The policy indicated, but was not limited to, "Keep the bag closed during the visit ... If additional equipment or supplies are needed from the bag during the home visit, the handwashing procedure must be repeated ... " During a home visit on 1/26/2021 at 9:30 a.m. employee B, a registered nurse, was observed applying gloves and using patient 1's tape measure to measure the left arm fistula. Employee B applied hand sanitizer to his/her gloves and proceeded to disinfect the tape measure. Employee B applied more hand sanitizer onto the same gloves and assessed patient 1's lung sounds with a stethoscope then entered into his/her supply bag with gloves on to obtain a disinfectant wipe. Employee B failed to remove his/her gloves and perform hand hygiene before entering the supply bag. Employee B applied more hand sanitizer on the same gloves and rubbed the pill dispenser down. Employee B applied more hand sanitizer on the same pair of gloves and proceeded to handle patient 1's pills with the same gloves and fill the medication dispenser. Employee B failed to remove gloves and perform hand hygiene after filling the medication dispenser. Employee B proceeded to pour peroxide into a container. Employee B washed gloved hands in the sink with water then dried gloved hands with a paper towel. Employee B then opened his/her supply bag to obtain a disinfectant wipe to clean off the vital sign equipment (blood pressure cuff, oxygen saturation device, and stethoscope), placed the equipment back in the supply bag, applied hand sanitizer on gloved hands and proceeded to document on the tablet. Employee B then removed the gloves and reapplied new gloves without performing hand hygiene. Employee B began to clean the trach inner cannula (tube inserted into the body). Employee B failed to follow agency policy on infection control precautions. During an interview on 1/27/2021 at 3:00 p.m. the Administrator stated that gloves should not be disinfected and reused. 17-12-1(m)

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the agency failed to perform tracheostomy care as indicated on the plan of care for 1 of 2 skilled nurse observations. (Patient 1) Finding include: A 2019 revised Registered Nurse job description was provided by the Administrator on 1/27/2021 at 8:05 a.m. The job description indicated, but was not limited to, "Provides professional nursing care by utilizing all elements of nursing process ..." The complete clinical record for patient 1 was reviewed on 1/25/2021, start of care date 9/25/18, with a certification period of 1/12/21 to 3/12/21, with orders for the skilled nurse to perform tracheostomy care and to clean inner cannula (tube inserted into the body) of trachea prn (as needed) as requested by the patient. Patient 1's diagnoses included, but were not limited to, legal blindness and kidney/pancreas transplant. During a home visit observation on 1/26/2021 at 9:30 a.m. employee A, a registered nurse, was observed during patient 1's home visit. Employee A failed to assess for redness, open areas, and drainage, to patient 1's tracheostomy (opening to the air way). During an interview on 1/27/2021 at 10:45 a.m. the Director of Nursing was asked if tracheostomy care included an assessment for skin breakdown, redness, or drainage, given that patient 1 was legally blind. The Director of Nursing indicated the nurse should have assessed the skin around the tracheostomy. 17-14-1(a)(1)(H)

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 care coordination notes between clinicians administering services were documented in the patient's clinical record for 1 of 4 active records reviewed (Patient 5) and 2 of 3 closed records reviewed (Patient 2 and 3). Findings include: 1. A Home Health 2018 policy titled Care Coordination (Client Care Policy 3006) was provided by the Director of Nursing (DON) on 1/27/2021 at 2:50 p.m. The policy indicated, but was not limited to, "PURPOSE To ensure the coordination of services for each client ...POLICY It is the policy of Better Living to utilize a care coordination system to provide comprehensive, coordinated ...It is the responsibility of the RN/Case Manager to assign a clinician to be responsible for the coordination of care ...PROCEDURE 3. K Conduct case conferences and document in progress note ...5. Written evidence of care coordination will be documented in the client's clinical record." 2. The complete closed clinical record for patient 2, start of care date 5/4/2017, was reviewed on 1/25/2021, and included a plan of care for the certification period 10/15/2020 to 12/13/2020. The record lacked case conference and/or communication notes showing collaboration between clinicians on updates/changes found in the electronic medical record for this patient for the entire certification period reviewed. 3. The complete closed clinical record for patient 3, start of care date 4/29/2020, was reviewed on 1/25/2021, and included a plan of care for the certification period 6/28/2020 to 8/26/2020. The record lacked case conference and/or communication notes showing collaboration between clinicians on updates/changes found in the electronic medical record for this patient for the entire certification period reviewed. 4. The complete clinical record for patient 5, start of care date 2/19/2018, was reviewed on 1/26/2021, and included a plan of care for the certification period 11/25/2020 to 1/23/2021. The record lacked case conference and/or communication notes showing collaboration between clinicians on updates/changes found in the electronic medical record for this patient for the entire certification period reviewed. 5. During an interview on 1/27/2021 at 10:25 a.m. the Director of Nursing (DON) stated prior to the pandemic there were weekly meetings between clinicians about patients. Since the pandemic this had been occurring on the phone or via email but not as a group, and instead there was more one on one or individually between clinicians that work with a patient. The DON could not explain why there were not notes documenting these communications for specified patients in the clinical record as stated in the facility policy. The DON acknowledged documentation should occur for all communication taking place. 17-14-1 (a)(1)(E)