Every finding on record at Canary Home Healthcare of Indiana Inc

The Indiana Department of Health conducted an Emergency Preparedness survey, conducted in accordance with 42 CFR §484.102, for a Home Health Provider and Suppliers. Survey Dates: 04/06/2026, 04/07/2026, 04/08/2026, 04/09/2026 12 month unduplicated skilled admissions: 35 During this Emergency Preparedness survey, Canary Home Health Care of Indiana INC was found to be out of compliance with Conditions of Participation at 42 CFR §484.102: Emergency Preparedness.

Establishment of the Emergency Program (EP) CFR(s): 484.102 §403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.542, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must establish and maintain a [comprehensive] emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements: * (Unless otherwise indicated, the general use of the terms "facility" or "facilities" in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This CONDITION is not met as evidenced by: Based on record review and interview, the home health agency failed to evidence a comprehensive plan that was updated every two years (see Tag E0004); failed to update delegations of authority and succession plans (see Tag E0007); failed to include a process for cooperation and collaboration with local, state and federal emergency preparedness officials that included documented attempts to contact officials in an effort of collaboration and cooperative planning (see Tag E0009); failed to update an emergency preparedness communication plan (see Tag E0029); failed to update name and contact information for local emergency preparedness staff (see Tag E0031); and failed to provide emergency preparedness training to staff at least every two years (see Tag E0037). Findings include: The cumulative effect of these systemic problems resulted in the home health agency's inability to ensure the provision of quality health care in a safe environment for the Condition of Participation at 42 CFR 484.102 Emergency Preparedness, with the likelihood to affect all 26 current patients receiving Home Health services from this provider.

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on record review and observation, the agency failed to evidence a comprehensive plan that was updated every two years in 1 of 1 agency. Findings include: A review of the agency emergency preparedness plan evidenced a document, titled “Introduction to the Emergency Preparedness Plan”, which indicated that the emergency preparedness plan should be reviewed and updated at least every two years. A document, titled “Administrator Approval & Attestation”, indicated that the agency emergency preparedness policy had been reviewed on 10/30/2025, by the administrator. A review of the agency emergency preparedness plan evidenced the following items: A person identified as the administrator who is no longer employed at the agency.An employee identified as the alternate administrator who no longer holds that position.A person identified as the director of clinical services who is no longer employed at the agency.A person identified as the clinical supervisor who is no longer employed at the agency.An incorrect person listed as the Emergency Management County Coordinator with coordinating incorrect contact information. A person identified in the succession of command who is no longer employed at the agency. A person identified as an official spokesperson for issues pertaining to the emergency preparedness planning who is no longer employed at the agency.A person no longer employed by the agency was identified as a person responsible for providing and/or coordinating education efforts relating to emergency preparedness and planning. During an interview on 04/08/2026 beginning at 1:40 PM, the administrator indicated that the review of the emergency preparedness plan should include updating of contact information and other areas, and this was overlooked during the last review on 10/30/2025.

EP Program Patient Population CFR(s): 484.102(a)(3) §403.748(a)(3), §416.54(a)(3), §418.113(a)(3), §441.184(a)(3), §460.84(a)(3), §482.15(a)(3), §483.73(a)(3), §483.475(a)(3), §484.102(a)(3), §485.68(a)(3), §485.542(a)(3), §485.625(a)(3), §485.727(a)(3), §485.920(a)(3), §491.12(a)(3), §494.62(a)(3). [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (3) Address [patient/client] population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.** *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do all of the following: (3) Address resident population, including, but not limited to, persons at-risk; the type of services the LTC facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. *NOTE: ["Persons at risk" does not apply to: ASC, hospice, PACE, HHA, CORF, CMCH, RHC/FQHC, or ESRD facilities.] This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to update delegations of authority and succession plans for emergency preparedness in 1 of 1 agency. Findings include: A review of the agency emergency preparedness plan evidenced a document, titled “Introduction to the Emergency Preparedness Plan”, which indicated that the emergency preparedness plan should be reviewed and updated at least every two years. A document, titled “Administrator Approval & Attestation”, indicated that the agency emergency preparedness policy had been reviewed on 10/30/2025, by the administrator. A review of the emergency preparedness plan evidenced a document titled “Succession of Command”, that identified a person who is no longer employed by the agency as the administrator and director of clinical services, as well as a current employee listed as the alternate administrator who no longer holds this title. During an interview on 04/08/2026 beginning at 1:40 PM, the administrator indicated that the review of the emergency preparedness plan should include updating of contact information and other areas, and this was overlooked during the last review on 10/30/2025.

Local, State, Tribal Collaboration Process CFR(s): 484.102(a)(4) §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility's needs in the event of an emergency. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to include a process for cooperation and collaboration with local, state and federal emergency preparedness officials that included documented attempts to contact officials in an effort of collaboration and cooperative planning at least every two years in 1 of 1 agency. Findings include: A review of the agency emergency preparedness plan failed to evidence documentation of communication, cooperation, or collaboration with local, regional, state, or federal emergency planning authorities, including documented attempts at contacting officials within the last two years. A document, titled “Coordination with Local Emergency Responders and Resources”, indicated that the agency will maintain working relationships with the following agencies: Fire DepartmentLaw enforcement agencyEmergency medical servicesLocal disaster task forceLocal health departmentLocal flood control agencyLocal utility companies During an interview on 04/09/2026 beginning at 11:24 AM, the administrator indicated that there have been no documented attempts to contact emergency officials regarding emergency preparedness cooperation and collaboration since 08/21/2023.

Development of Communication Plan CFR(s): 484.102(c) §403.748(c), §416.54(c), §418.113(c), §441.184(c), §460.84(c), §482.15(c), §483.73(c), §483.475(c), §484.102(c), §485.68(c), §485.542(c), §485.625(c), §485.727(c), §485.920(c), §486.360(c), §491.12(c), §494.62(c). (c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to update the emergency preparedness communication plan in 1 of 1 agency. Findings include: A review of the agency emergency preparedness communication plan indicated the plan should be reviewed and updated every two years and that contact information for incoming new staff and departing staff will be updated throughout the year as necessary. A document, titled “Communication Plan: Staff Contact Information”, evidenced names and contact information for 2 employees who were no longer employed by the agency and names and contact information for 5 of the 16 employees currently employed by the agency. During an interview on 04/08/2025 beginning at 1:40 PM, the administrator indicated that contact information should be updated every two years and that the incorrect and omitted contact information for current employees was an oversight at the time of review on 10/30/2025.

Emergency Officials Contact Information CFR(s): 484.102(c)(2) §403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.542(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at §483.73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at §483.475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to update name and contact information for local emergency preparedness staff in 1 of 1 agency. Findings include: A review of the agency emergency preparedness plan indicated that contact information is updated every 2 years and throughout the year for changes to information for entities listed on the contacts list. A document, titled “Key Contacts Information”, evidenced an incorrect contact name and contact number for the emergency management county coordinator. The name and contact number is for a coordinator in a neighboring city and not affiliated with the county. During an interview on 04/09/2026 beginning at 11:24 AM, the administrator indicated that the emergency contacts information for state, regional, and local emergency staff is gathered from searching on google, and calls are not made to verify or confirm contact information.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to provide emergency preparedness training to staff at least every two years in 1 of 1 agency. Findings include: A review of the agency emergency preparedness plan indicated that staff training on the emergency preparedness plan would occur during orientation and at least every two years. A review of training records for staff of the agency evidenced that employees had received emergency preparedness training during orientation, but failed to evidence that any employee had received emergency preparedness training every two years thereafter for the four employees that had been employed greater than two years. During an interview on 04/08/2026 beginning at 3:20 PM, the administrator indicated that every employee is trained in emergency preparedness upon hire, and training is only repeated unless there has been a change in the emergency preparedness plan or procedures.

This visit was for a Federal Recertification and State Re-Licensure survey of a home health provider. Survey Dates: 04/06/2026, 04/07/2026, 04/08/2026, 04/09/2026 Unduplicated Skilled Admissions for the last 12 Months: 35 A partially extended survey was announced to the Alternate Administrator on 04/07/2026 at 1:36 PM. An extended survey was announced to the Alternate Administrator on 04/08/2026 at 4:20 PM. During this Federal Recertification Survey, Canary Home Health Care of Indiana INC., was found to be out of compliance with Condition of Participation 42CFR 484.102 Emergency Preparedness; 42 CFR 484.60 Care planning, coordination of services, and quality of care; 42 CFR 484.65 Quality assessment/performance improvement; 42 CFR 484.70 Infection prevention and control; and 42 CFR 484.80 Home Health Aide Services. Based on the Condition-level deficiencies during the 04/09/2026 survey, your agency was subject to an extended survey pursuant to section 1891(c)(2)(D) of the Social Security Act on 04/08/2026. 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 04/09/2026 and continuing through 04/08/2028. Abbreviations used in this survey: Registered Nurse (RN), Licensed Practical Nurse (LPN, Home Health Aide (HHA), Physical Therapy (PT), Occupational Therapy (OT), Clinical Manager (CM), Plan of Care (POC), Start of Care (SOC), Skilled Nurse (SN)

5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the start of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to complete the comprehensive assessment in a timely manner in 1 of 2 clinical record reviews of new admission patients. (Patient #1) Findings include: A policy, titled “Initial and Comprehensive Assessment”, indicated that a comprehensive patient assessment should be completed within 5 calendar days of the patient’s SOC. A clinical record review, for Patient #1, evidenced that the SOC comprehensive assessment was performed on 03/12/2026. The PT comprehensive assessment and the OT comprehensive assessment were both completed 7 days later on 03/19/2026. During an interview on 04/08/2026 beginning at 11:31 AM, the CM indicated that the PT and OT comprehensive assessment should be performed within 24 to 48 hours of SOC. The CM indicated that if the family of Patient #1 had refused the PT and OT comprehensive assessment, there was no documentation as such.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) 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: (1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment included the physical, mental, and psychosocial status in 2 of 3 active clinical records reviewed with a wound present at time of the comprehensive assessment. (Patient #2, 5) The findings include: 1. A clinical record review for Patient #2 evidenced a comprehensive assessment for recertification dated 03/26/2026 which indicated the patient had a pressure ulcer (wounds to the skin and underlying tissue resulting from prolonged pressure to the skin) stage II (a pressure ulcer with partial thickness loss of skin) to the right side of the sacrum (lower back above the buttocks). The assessment failed to evidence the assessment of the depth of the wound. The assessment indicated the patient complained of “achy” legs and failed to evidence an assessment of the pain to include intensity, duration, frequency, character, aggravating and alleviating factors, and impact on function. On 04/07/2026 at 2:03 PM, the CM indicated the comprehensive assessment did not include the depth of the wound and a complete pain assessment. 2. A clinical record review for Patient #5 evidenced a comprehensive assessment at the recertification dated 02/13/2026 completed by the CM which indicated the patient had a stage II pressure ulcer to the right buttocks and failed to evidence an assessment of the wound depth. The assessment indicated patient had a gastrostomy (GT, a type of feeding tube surgically inserted through the abdomen and into the stomach) and failed to evidence the assessment included the size of the GT. On 04/08/2026 and 1:34 PM, the CM indicated the wound was open and the assessment did not include the depth. The CM indicated the assessment did not include the size of the GT. 410 IAC 17-14-1(a)(1)(B)

Patient's needs CFR(s): 484.55(c)(4) The patient's medical, nursing, rehabilitative, social, and discharge planning needs; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment included the need for nursing services in 1 of 2 active clinical records reviewed with a feeding tube. (Patient #5) The findings include: A clinical record review for Patient #5 evidenced a POC for the recertification period 02/14/2026-04/04/14/2026 which indicated the agency was to provide SN services 1 time a week for 8 weeks to include instructing the caregiver on the management of the feeding tube. A comprehensive assessment at recertification dated 02/13/2026 indicated patient received care by caregiver who managed the tube feeding. The assessment failed to evidence the need for nursing services related to the feeding tube. On 04/08/2026 at 1:34 PM, the CM indicated the caregiver was able to manage the tube feeding and the need for SN to educate the caregiver on the feeding tube was not documented. 410 IAC 17-14-1(a)(1)(B)

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 the comprehensive assessment included a reconciliation of medications in 3 of 5 active clinical records reviewed. (Patient #2, 4), and failed to ensure the reconciliation of medications included notification of major drug interactions to the provider in 2 of 2 active clinical record reviews of patients who had major drug interactions identified. (Patient #1, Patient #8) The findings include: 1. A clinical record review for Patient #2 evidenced a referral document from the attending nurse practitioner dated 02/02/2025 which indicated a medication list which included Gabapentin (to treat seizure and/or nerve pain), Diazepam (to treat anxiety and/or seizures), and Atorvastatin (to treat high cholesterol). The POC for the initial certification period 02/04/2025-04/04/2025 failed to evidence the patient’s medications included Gabapentin, Diazepam, and Atorvastatin. A comprehensive assessment at the SOC dated 02/04/2025 failed to evidence the review of the medication discrepancy between what was included in the attending physician’s list of ordered medications and what was included in Patient’s POC. On 04/07/2026 at 1:57 PM, the CM indicated the comprehensive assessment did not document the discrepancy of the medications between the medication list on the referral and on the POC. 2. A clinical record review for Patient #4 evidenced an agency document dated 04/07/2026 and titled “Drug-Drug Interactions” which indicated there were 6 drug interactions between Levothyroxine (for underactive thyroid) and Sertraline (for depression); Cyanocobalamin (Vitamin B) and Omeprazole (for reflux); Aspirin (for pain, fever, and/or prevention of blood clots) and Sertraline; Aspirin and Spironolactone (for high blood pressure, heart failure, and/or fluid retention); Aspirin and Furosemide (for fluid retention); and Levothyroxine and Omeprazole. The POC for the initial certification period 03/08/2026-05/06/2026 indicated the patient’s medications included Levothyroxine, Sertraline, Cyanocobalamin, Omeprazole, Aspirin, Spironolactone, and Furosemide. The comprehensive assessment at SOC dated 03/08/2026 completed by the CM indicated no issues were found during the drug review and failed to evidence the review of the drugs to include the drug interactions. On 04/08/2026 at 1:59 PM, the CM indicated the agency only reviews medications for severe interactions and indicated the moderate and minor drug reactions were not included in the drug review at the time of the comprehensive assessment. 1.A policy, titled “Ongoing Assessment”, indicated that the provider should be notified of medications which might interact. 2. A clinical record review for Patient #2 evidenced a referral document from the attending nurse practitioner dated 02/02/2025 which indicated a medication list which included Gabapentin (to treat seizure and/or nerve pain), Diazepam (to treat anxiety and/or seizures), and Atorvastatin (to treat high cholesterol). The POC for the initial certification period 02/04/2025-04/04/2025 failed to evidence the patient’s medications included Gabapentin, Diazepam, and Atorvastatin. A comprehensive assessment at the SOC dated 02/04/2025 failed to evidence the review of the medication discrepancy between what was included in the attending physician’s list of ordered medications and what was included in Patient’s POC. On 04/07/2026 at 1:57 PM, the CM indicated the comprehensive assessment did not document the discrepancy of the medications between the medication list on the referral and on the POC. 2. A clinical record review for Patient #4 evidenced an agency document dated 04/07/2026 and titled “Drug-Drug Interactions” which indicated there were 6 drug interactions between Levothyroxine (for underactive thyroid) and Sertraline (for depression); Cyanocobalamin (Vitamin B) and Omeprazole (for reflux); Aspirin (for pain, fever, and/or prevention of blood clots) and Sertraline; Aspirin and Spironolactone (for high blood pressure, heart failure, and/or fluid retention); Aspirin and Furosemide (for fluid retention); and Levothyroxine and Omeprazole. The POC for the initial certification period 03/08/2026-05/06/2026 indicated the patient’s medications included Levothyroxine, Sertraline, Cyanocobalamin, Omeprazole, Aspirin, Spironolactone, and Furosemide. The comprehensive assessment at SOC dated 03/08/2026 completed by the CM indicated no issues were found during the drug review and failed to evidence the review of the drugs to include the drug interactions. On 04/08/2026 at 1:59 PM, the CM indicated the agency only reviews medications for severe interactions and indicated the moderate and minor drug reactions were not included in the drug review at the time of the comprehensive assessment. 3.A clinical record review for Patient #1, evidenced a referral document from the attending provider dated 03/11/2026 that included a list of current medications to include Metformin (to treat diabetes) and Carvedilol (to treat high blood pressure). The POC for the initial certification period of 03/12/2026 to 05/10/2026 failed to evidence that Patient #1’s medications included Metformin and Carvedilol. Additionally, medications listed on the POC but not listed on the referral document included Aspirin (for anticoagulation), Cardizem (to treat high blood pressure), Mirtazepine (to treat depression), Wound wash (for wound care), Manuka honey (for wound care), and Desitin Paste (to protect skin). A comprehensive assessment at the SOC dated 03/12/2026 failed to evidence the review of the medication discrepancy between what was included on the attending provider’s list of medications and what was included in Patient #1’s POC. During an interview on 04/09/2026 beginning at 11:31 AM, the CM indicated that there was no documentation of medication discrepancies identified at the SOC, or that the discrepancies were discussed with the provider. #.A clinical record review for Patient #1 evidenced a document, titled “Drug-Drug Interactions”, that indicated a major drug interaction between the medications Sertraline (to treat depression) and Mirtazepine (to treat depression). The record failed to evidence that the physician was notified of the major drug-drug interaction. During an interview on 04/09/2026 beginning at 11:31 AM, the CM indicated that there was no documentation of a conversation with the provider regarding the major drug interactions. #.A clinical record review for Patient #8 evidenced a document, titled “Drug-Drug Interactions”, that indicated two major drug interactions: between the medications Clopidogrel (used as an anticoagulant) and Esomeprazole (used to decrease stomach acid), and Trelegy Elipta (to treat chronic obstructive pulmonary disease) and Carvedilol (to treat blood pressure). During an interview on 04/09/2026 beginning at 9:25 AM, RN 1 indicated that there was no conversation with the provider to discuss the major drug interactions, and that the only communication with the provider is the faxed medication reconciliation.

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 record review and interview, the agency failed to update the comprehensive assessment with changes in the patient’s condition in 1 of 1 active clinical record reviewed with an onset of a new wound after the SOC in a total sample. (Patient #4) The findings include: A clinical record review for Patient #4 evidenced a SN visit note dated 04/02/2026 completed by the CM which indicated new pressure ulcers (wounds to the skin and underlying tissue resulting from prolonged pressure to the skin) to the buttocks. The record failed to evidence an update to the comprehensive assessment for the change in status due to the new wounds. On 04/07/2026 at 4:23 PM, the CM indicated the comprehensive assessment was not updated for the new wounds. 410 IAC 17-14-1(a)(1)(B)

Discharge Planning CFR(s): 484.58(a) Standard: Discharge planning. An HHA must develop and implement an effective discharge planning process. For patients who are transferred to another HHA or who are discharged to a SNF, IRF or LTCH, the HHA must assist patients and their caregivers in selecting a post-acute care provider by using and sharing data that includes, but is not limited to HHA, SNF, IRF, or LTCH data on quality measures and data on resource use measures. The HHA must ensure that the post-acute care data on quality measures and data on resource use measures is relevant and applicable to the patient's goals of care and treatment preferences. This STANDARD is not met as evidenced by: Based on record review, the agency failed to implement its transfer/discharge policy in 1 of 2 closed clinical records reviewed. (Patient #6) The findings include: A 2022 policy titled “Transfer/Referral Criteria and Process” indicated the agency will document all communication with the receiving provider and patient/caregiver in the clinical record and complete a transfer summary within 48 hours of notification of transfer. A clinical record review for Patient #6 indicated a comprehensive assessment for transfer/discharge dated 02/27/2026 which indicated the patient was transferred to the hospital for shortness of breath and was admitted for congestive heart failure (chronic weakening of heart causing fluid overload in lungs). The clinical record failed to evidence documentation of how and when it was notified of the patient’s transfer and failed to evidence any communication with the hospital and patient’s caregiver related to discharging patient due to caregiver’s request to seek an alternative place of residence for the patient upon discharge from the hospital. On 04/09/2026 at 12:40 PM, the CM indicated there was no documentation of how and when the agency was notified of patient’s transfer to the hospital. The CM indicated once the agency found out about the patient’s transfer to the hospital, the agency communicated with the caregiver who indicated they were going to seek an alternative place of residence for the patient such as a skilled nursing facility upon discharge from the hospital. The CM indicated there was no documentation of the communication with the patient’s caregiver related to the discharge and need to find alternative living arrangements for the patient and no communication documented with the receiving facility on the agency’s plan to discharge and not resume home health care upon hospital discharge. 410 IAC 17-12-2(i)

Discharge or Transfer Summary Content CFR(s): 484.58(b)(1) Standard: Discharge or transfer summary content. The HHA must send all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to send all necessary information pertaining to patient’s current course of illness and post-discharge goals of care to the practitioner (or receiving facility) upon discharge within 48 hours of notification of transfer in 2 of 2 closed clinical records reviewed. (Patient #6, Patient #7) The findings include: 2.A clinical record review for Patient #7 indicated a comprehensive assessment for transfer/discharge dated 03/02/2026 which indicated that Patient #7 was transferred to the hospital for acute respiratory failure and was admitted. During an interview on 04/09/2026 beginning at 2:14 PM, the CM indicated that there was no documentation or record of how, when, and by whom the agency was notified of Patient #7’s transfer to the hospital. Additionally, the CM indicated that while a transfer summary should be sent to the receiving facility within 48 hours of the comprehensive assessment completion, a transfer summary was never sent to the receiving facility for Patient #7. A 2022 policy titled “Transfer Summary” indicated the transfer summary including medications will be sent to the receiving facility within 2 business days of becoming aware of an unplanned transfer. A clinical record review for Patient #6 indicated a comprehensive assessment for transfer/discharge dated 02/27/2026 which indicated the patient was transferred to the hospital for shortness of breath and was admitted On 04/09/2026 at 12:40 PM, the CM indicated the agency was not notified of the transfer to the hospital until 03/02/2026 when the comprehensive assessment at discharge was created in the electronic medical record. The CM indicated the transfer summary was not sent to the receiving facility until 03/13/2026. 410 IAC 17-13-2(a)(b)(9)

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, observation, and interview, the agency failed to ensure services were provided as directed in the POC (see tag G0572); failed to ensure the POC included all medical equipment, patient-specific interventions, and measurable goals (see tag G0574); failed to ensure services were provided only as ordered by a physician (see tag G0580); failed to ensure physician’s verbal orders were documented in the clinical record per agency policy and signed and dated by the physician (see tag G0584); failed to notify the physician with changes in patient’s condition or needs that suggest the POC should be altered (see tag G0590); failed to update the POC with changes as needed (see tag G0592); and failed to ensure care was coordinated with all disciplines providing care (see tag G0606). The cumulative effect of these systemic problems resulted in the home health agency’s inability to ensure the provision of quality health care in a safe environment for the condition of participation 42 CFR §484.60 Condition: Care Planning, Coordination, Quality of Care 410 IAC 17-13-1(a)

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure services were provided as directed in the POC in 2 of 5 active clinical records reviewed. (Patient #4, 5) The findings include: 410 IAC 17-13-1A 1. A clinical record review for Patient #4 evidenced a PT POC for the initial certification period 03/08/2026-05/06/2026 signed by the PT on 03/11/2026 which indicated the agency was to provide PT services 1 time a week for 1 week, 2 times a week for 2 weeks, and 1 time a week for 5 weeks. The clinical record failed to evidence the agency provided PT services during week 2 beginning 03/15/2026 and week 3 beginning 03/22/2026. On 04/07/2026 at 4:25 PM, the CM indicated the agency did not provide PT services as directed in the POC. 2. A clinical record review for Patient #5 evidenced a POC for the recertification period 02/14/2026-04/14/2026 which indicated the agency would provide SN services 1 time a week for 8 weeks to include a complete physical assessment and wound care to the pressure ulcer (wounds to the skin and underlying tissue resulting from prolonged pressure to the skin) on the right buttock. Record review failed to evidence the agency provided a SN visit during the week of 02/15/2026. The SN visit note dated 02/26/2026 indicated wound care was already provided by the caregiver and failed to evidence an assessment of the wound. The record failed to evidence an assessment of the wound to the right buttock from 02/13/2026 until 03/06/2026. SN visit notes completed by the CM dated 03/12/2026, 03/19/2026, 03/26/2026, and 04/03/2026 evidenced the patient had non-blanching areas to the right buttocks and failed to evidence the assessment of the wound to include measurements and surrounding skin appearance. During the entrance conference on 04/06/2026 beginning at 12:20 PM, the Administrator indicated the nurse would assess and measure the wounds at every visit. On 04/08/2026 beginning at 1:40 PM, the CM indicated the agency did not provide a SN visit during the week of 02/15/2026 and there was no wound assessment between 02/13/2026 and 03/06/2026. The CM indicated the wound to the right buttocked was no longer open but was non-blanching which was a pressure ulcer stage 1 (pressure-related tissue damage with intact, non-blanching skin) and indicated there were no measurements of the Stage 1 pressure ulcer on 03/12/2026, 03/19/2026, 03/26/2026, and 04/03/2026.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure the POC included all medical equipment, patient-specific interventions, and measurable goals in 4 of 7 clinical records reviewed. (Patient #2, 4, 5 ,6) The findings include: 410 IAC 17-13-1 (a)(1)(D)(i-xiii) 1. During an observation of care at the home of Patient #2 on 04/07/2026 beginning at 11:05 AM, the patient was observed lying on an air mattress. A comprehensive assessment for recertification dated 03/26/2026 indicated the patient took an Ensure supplement (nutritional supplement) at breakfast and dinner daily. A clinical record review evidenced a POC for recertification period 03/31/2026-05/29/2026 which failed to include the air mattress and Ensure supplement. The POC indicated the patient’s medications included a lidocaine (pain relieving medication) patch topically to the affected area daily and failed to evidence what area was affected. The POC indicated blood sugar parameters for when to notify the physician, and the POC failed to evidence blood sugars were supposed to be checked and a diagnosis for diabetes (a chronic disease affecting blood sugar). The POC indicated goals that the patient would reach optimal effectiveness of pain and maintain appropriate body weight and would reach optimal nutrition and hydration. The POC did not include the patient-specific optimal level of pain, nutrition, and hydration and failed to evidence what was the appropriate body weight. On 04/07/2026 at 11:22 AM, the patient’s caregiver indicated the lidocaine patches were applied as needed to the patient’s neck and forehead. On 04/07/2026 beginning at 1:57 PM, the CM indicated the POC did not include the air mattress and Ensure supplement. The CM indicated the affected area for the lidocaine patch was not included on the POC. The CM indicated the patient was not diabetic and the blood sugar parameter was not patient-specific but a generic intervention. The CM indicated the goals on the POC were generic and not patient specific. 2. A clinical record review for Patient #4 evidenced a comprehensive assessment at SOC dated 03/08/2026 and completed by the CM which indicated the patient had an acute exacerbation of congestive heart failure (chronic, progressive condition where the heart cannot pump efficiently and causes fluid to back-up in the lungs and body) and had difficulty breathing with minimal exertion. The patient had a recent increase of Furosemide (medication to decrease the swelling caused by fluid overload in the tissues) and had swelling to both legs. The POC for the initial certification period 03/08/2026-05/06/2026 failed to evidence interventions and goals for the swelling. On 04/07/2026 at 4:23 PM, the CM indicated specific interventions such as educating the patient to elevate legs and measuring legs were not included as patient-specific interventions in the POC. The CM indicated there was no patient-specific goal for the patient’s edema. 3. A clinical record review for Patient #5 evidenced a comprehensive assessment for the recertification dated 02/13/2026 which indicated the patient used a purewick (an external catheter that uses suction and a tube to drain urine away from the body) for bladder incontinence. A SN visit dated 03/26/2026 indicated the patient had heel protectors and an air mattress. The POC for the recertification 02/14/2026-04/14/2026 failed to evidence the external catheter. The POC indicated the patient had a gastrostomy (GT, a type of feeding tube surgically inserted through the abdomen and into the stomach) and had a pressure ulcer (wounds to the skin and underlying tissue resulting from prolonged pressure to the skin) stage II (a pressure ulcer with partial thickness loss of skin) to the right buttock. The POC indicated the goals included patient was to have effective tube feeding management and optimal wound healing. The POC failed to include measurable goals related to tube feeding management and wound healing. The POC failed to evidence the size of the GT. The POC failed to evidence the heel boots and air mattress. On 04/08/2026 beginning at 1:32 PM, the CM indicated the goals were generated by the program used to develop the POC according to the interventions, so the goals were not measurable. The CM indicated the POC did not include the size of the GT. The CM indicated the purewick external catheter, heel boots, and air mattress were not included in the POC. 4. A clinical record review for Patient #6 evidenced a comprehensive assessment for recertification dated 01/27/2026 which indicated the patient’s diagnoses included heart failure and indicated the patient had edema (swelling) to both legs. A SN visit note dated 02/11/2026 completed by LPN 1 indicated the caregiver complained the patient was becoming more short of breath and indicated the patient was assessed to have difficulty breathing. The visit note indicated LPN 1 instructed the patient to use a spirometer (a handheld medical device used to improve lung function and improve deep breathing capacity). The POC for the recertification period 01/31/2026-03/31/2026 failed to evidence the use of a spirometer and failed to evidence interventions and goals related to the edema. On 04/09/2026 at 2:53 PM, the CM indicated the spirometer and interventions related to the edema were not included in the POC.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure services were provided only as ordered by a physician in 4 of 5 active clinical records reviewed. (Patient #2, Patient #4, Patient #5, Patient #1) The findings include: 7. A clinical record review for Patient #1 evidenced a POC for the certification period of 03/12/2026 to 05/10/2026 which was not signed by the physician until 03/27/2026. The record evidenced that the agency provided HHA services on 03/13/2026, 03/21/2026, and 03/23/2026; SN services on 03/12/2026 and 03/19/2026. The record failed to evidence an order for home health services from the SOC until the POC was signed on 03/27/2026. During an interview on 04/09/2026 beginning at 11:31 AM, the CM indicated that the provider is not typically contacted for orders at the SOC unless there are immediate needs, and that the order for services is the POC that may remain unsigned initially. 1. A 2022 policy titled “Physician Participation in Plan of Care” indicated the physician would direct the patient care and care would be provided in compliance with orders. The physician orders for care would include diagnoses, treatments to include type and frequency, and medications. Verbal orders will be obtained at the time the POC is established and documented in the clinical record. 2. A 2022 policy titled “Verification of Physician Orders” indicated verbal orders would be documented on an agency form, dated and signed by the professional receiving the order, and the original of the order form would be delivered to the physician for signature. 3. A 2022 policy titled “Care Planning Process” indicated the plan of care will be based on the physician’s (or other licensed practitioner’s) orders. 4. During an observation of care at the home of Patient #2 on 04/07/2026 from 11:05 AM to 11:45 AM, RN 1 was observed providing a head-to-toe assessment, patient/caregiver education, and medication management. A clinical record review evidenced a POC for recertification period 03/31/2026-05/29/2026, which was not yet signed by the physician. The record failed to evidence an order for home health services after the physician-signed POC ending 03/30/2026. On 04/07/2026 at 1:52 PM, the CM indicated the POC was the agency’s order for recertification and continuation of home health services and the POC beginning 03/31/2026 was not yet signed by the physician. 5. A clinical record review for Patient #4 evidenced an order from the nurse practitioner dated 03/05/2026 which indicated the agency was to evaluate and treat for SN, HHA, PT, and OT. The comprehensive assessment at SOC dated 03/08/2026 and completed by the CM indicated the patient had rashes to both legs and under both breasts that required topical medication. The assessment indicated the patient had an acute exacerbation of congestive heart failure (chronic, progressive condition where the heart can not pump efficiently and causes fluid to back-up in the lungs and body) and had difficulty breathing with minimal exertion. The patient had a recent increase of Furosemide (medication to decrease the swelling caused by fluid overload in the tissues) and had swelling to both legs. The record indicated the agency provided PT services on 03/11/2026; HHA services on 03/12/2026, 03/14/2026, and 03/17/2026, and SN services on 03/18/2026. The clinical record indicated the POC for the initial certification period 03/08/2026-05/06/2026 was not signed until 03/20/2026 and no other orders for care were provided before 03/20/2026. On 04/07/2026 at 4:19 PM, the CM indicated the POC is order for care. The CM indicated she did not speak to the nurse practitioner at SOC and was unsure of the name of the person she spoke to at the nurse practitioner’s office when she left a message regarding the SOC. The CM indicated the nurse practitioner did not return the phone call regarding the SOC. 6. A clinical record review for Patient #5 evidenced a POC for recertification period 02/14/2026-04/14/2026, which was not by the physician until 02/25/2026. The record evidenced the agency provided HHA services on 02/16/2026, 02/20/2026, and 02/23/2026. The record failed to evidence an order for home health services after the physician-signed POC ending 02/13/2026. On 04/08/2026 at 1:29 PM, the CM indicated there was no additional orders from the physician after the ending of the certification period on 02/13/2026 and before the POC for the certification beginning 02/14/2026 was signed by the physician on 02/25/2026. The CM indicated she did not recall speaking to the physician to get verbal orders for the recertification of the patient at the time of the comprehensive assessment on 02/13/2026. 410 IAC 17-13-1(a)

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure physician’s verbal orders were documented in the clinical record per agency policy and signed and dated by the physician in 1 of 1 clinical record with a change in attending physicians. (Patient #5) The findings include: A clinical record review for Patient #5 evidenced a referral order from Person 1 (physician) for home health services for SN, PT, and HHA services dated 08/20/2024. The comprehensive assessment at SOC dated 08/23/2024 completed by the CM which indicated the CM contacted Person 1 regarding the SOC and the SN and HHA services. A communication note dated 09/03/2024 completed by the CM indicated the patient’s caregiver requested to change the attending physician from Person1 to Person 2 (physician). The POC for the initial certification period 08/23/2024-10/21/2024 was signed by Person 2. The record failed to evidence a verbal order was written and signed by the physician for home care services as discussed at the comprehensive assessment with the CM on 08/23/2024. On 04/08/2026 at 4:32 PM, the CM indicated there was no documentation of the verbal order or the SOC by Person 1. 410 IAC 17-14-1(a)(H)

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to notify the physician with changes in patient’s condition or needs that suggest the POC should be altered in 5 of 8 clinical records reviewed. (Patient #2, Patient #4, Patient #5, Patient #6, Patient #3) The findings include: 6. A policy, titled “Scope of Services”, indicated that nursing services provided to patients includes informing the physician and other staff of changes in the patient’s needs. A clinical record review for Patient #3, evidenced the following: A SN visit note, dated 03/20/2026, by RN 2, indicated that Patient #3 was in need of refills of medications and that RN 2 attempted to call refills into the pharmacy, but the pharmacy was closed due to power outage. The note failed to evidence that the physician was notified of the pharmacy unable to refill the medications.A SN visit note, dated 03/27/2027, indicated that the pharmacy was closed due to power outage for the day. The note failed to evidence that the physician was notified of the pharmacy unable to refill the medications.A SN visit note, dated 04/03/3036, indicated that RN 2 attempted to reorder medications into the pharmacy, but the pharmacy was closed. The record failed to evidence that the physician was notified of the pharmacy unable to refill the medications.During an interview on 04/09/2026 beginning at 9:42 AM, RN 2 indicated that the pharmacy was closed and she was unable to have medications refilled for 4 weeks. Additionally, she indicated that the physician was not notified of the inability to have Patient #3’s medications refilled. During an interview on 04/09/2026 beginning at 12:45 PM, the pharmacy manager at Patient #3's pharmacy confirmed that Patient #3 has their medications filled through this pharmacy and that the only closure in the last 60 days had been on 03/13/2026 due to a power outage. 1. A 2022 policy titled “Admission Documents” indicated the agency will notify the physician or other licensed practitioner of refusal of services. 2. A clinical record review for Patient #2 evidenced a referral order from the ordering nurse practitioner dated 02/02/2025 for OT services. The clinical record failed to evidence OT services were provided. The referral document evidenced a medication list which included Gabapentin (to treat seizure and/or nerve pain), Diazepam (to treat anxiety and/or seizures), and Atorvastatin (to treat high cholesterol). The POC for the initial certification period 02/04/2025-04/04/2025 failed to evidence the patient’s medications included Gabapentin, Diazepam, and Atorvastatin. On 04/07/2026 beginning at 12:37 PM, the CM indicated the agency did not provide OT services, because the agency did offer OT services at the time of referral. The CM indicated there was no documentation the agency notified the ordering nurse practitioner that the agency was not able to provide the OT services as ordered. The CM indicated there was no documentation the agency notified the attending nurse practitioner of the discrepancy in medications. 3. A clinical record review for Patient #4 evidenced a referral order from the ordering nurse practitioner dated 03/05/2026 which indicated the agency was to provide OT services. The clinical record failed to evidence the agency provided OT services and failed to evidence the agency notified the nurse practitioner that OT services were not provided. On 04/07/2026 at 4:17 PM, the CM indicted the patient refused OT and there was no documentation the agency notified the ordering nurse practitioner that the patient refused OT services as ordered. 4. A clinical record review for Patient #5 evidenced a referral order from the physician dated 08/20/2024 which indicated the agency was to provide SN, HHA, and PT services. The consent form dated 08/23/2026 and signed by the patient’s caregiver indicated the patient/caregiver refused PT services. The clinical record failed to evidence the agency notified the physician the patient/caregiver refused PT services as ordered. On 04/08/2026 at 4:25 PM, the CM indicated there was no documentation the physician was notified the patient/caregiver refused PT services. 5. A clinical record review for Patient #6 evidenced the POC for the recertification period 01/31/2026-03/31/2026 which indicated patient’s diagnoses included heart failure. The POC failed to evidence the use of a spirometer. A SN visit note dated 02/11/2026 completed by LPN 1 indicated caregiver complained the patient was becoming more short of breath and indicated the patient was assessed to have difficulty breathing. The visit note indicated LPN 1 instructed the patient to use a spirometer (a handheld medical device used to improve lung function and improve deep breathing capacity) and indicated the patient’s weight increased by 6 pounds from the previous visit on 02/04/2026. A SN visit note dated 02/19/2026 completed by LPN 1 indicated the patient complained of being short of breath with just sitting and indicated the patient was assessed to have difficulty breathing. A PT visit note dated 02/24/2026 completed by PT 2 indicated the patient complained of dizziness, had a blood pressure higher than usual of 170/80, and a reported blood sugar of over 200. A SN visit note dated 02/24/2026 completed by LPN 1 indicated the patient’s caregiver was more short of breath and was assessed to have difficulty breathing. A discharge summary dated 02/27/2026 indicated the patient was transferred to the hospital due to shortness of breath and admitted for congestive heart failure (weakness of the heart causing fluid to back up in the lungs and other parts of the body). The record failed to evidence the agency notified the physician related to the patient’s complaints of shortness of breath and dizziness, weight gain, difficulty breathing, spirometer use, and elevated blood pressure and blood sugar prior to the patient’s transfer to the hospital. On 04/09/2026 at 2:28 PM, the CM indicated the agency did not notify the physician related to the changes in the patient’s condition.

Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient's updated comprehensive assessment, and contain information concerning the patient's progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the agency failed to update the POC with changes as needed in 1 of 2 home visits with a RN. (Patient #2) The findings include: During an observation of care at the home of Patient #2 with RN 1 on 04/07/2026 at 11:25 AM, a dry dressing was observed to the patient’s sacrum (lower back above the buttocks). The patient’s caregiver was observed to remove the dressing, and the patient’s sacrum and buttocks were observed without an open area. A clinical record review evidenced a POC for the recertification period 03/31/2026-05/29/2026 which indicated a diagnosis of a pressure ulcer (wounds to the skin and underlying tissue resulting from prolonged pressure to the skin) stage II (a pressure ulcer with partial thickness loss of skin) to the sacral region. The POC failed to evidence it was updated to reflect the wound was healed and pure honey and a dry dressing was applied daily to the sacral area. On 04/07/2026 at 11:25 AM, RN 1 indicated the wound to the coccyx/buttocks was healed. On 04/07/2025 at 11:28 AM, the patient’s caregiver indicated they were still applying “pure honey” to the wound and covering with a dry dressing daily for protection to the area. On 04/07/2026 at 2:55 PM, RN 1 indicated the wound to the sacrum was healed in the last few weeks and the family was applying honey to the wound for 3 months. RN 1 indicated she did not update the POC to reflect the healed wound and use of honey.

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 agency failed to ensure care was coordinated with all disciplines providing care in 1 of 2 active clinical records reviewed with PT services (Patient #4) and in 1 of 2 closed clinical record reviewed. (Patient #6) The findings include: 1. A clinical record review for Patient #4 evidenced a PT POC for the initial certification period 03/08/2026-05/06/2026 which indicated the agency was to provide PT services 1 time a week for 1 week, 2 times a week for 2 weeks, and 1 time a week for 5 weeks. A missed visit note dated 03/17/2026 and completed by PT 1 indicated the patient was not feeling well and cancelled PT. The record failed to evidence PT 1 notified the RN case manager the patient was not feeling well. Missed visit notes dated 03/20/2026, 03/24/2026, and 03/27/2026 completed by PT 1 indicated PT services were cancelled. The clinical record failed to evidence PT services were provided week 2 beginning 03/15/2026 and week 3 beginning 03/22/2026, and the record failed to evidence PT 1 coordinated care with the RN case manager regarding the PT frequency directed by the POC was not able to be met. On 04/07/2026 at 4:25 PM, the CM (and RN case manager) indicated PT 1 did not inform her of the patient’s report of not feeling well. The CM indicated there was no documentation the PT notified the CM of the missed PT visits prior to 04/01/2026. 2. A clinical record review for Patient #6 evidenced the POC for the recertification period 01/31/2026-03/31/2026 which indicated patient’s diagnoses included heart failure. The POC failed to evidence the use of a spirometer. A SN visit note dated 02/11/2026 completed by LPN 1 indicated caregiver complained the patient was becoming more short of breath and indicated the patient was assessed to have difficulty breathing. The visit note indicated LPN 1 instructed the patient to use a spirometer (a handheld medical device used to improve lung function and improve deep breathing capacity) and indicated the patient’s weight increased by 6 pounds from the previous visit on 02/04/2026. A SN visit note dated 02/19/2026 completed by LPN 1 indicated the patient complained of being short of breath with just sitting and indicated the patient was assessed to have difficulty breathing. A PT visit note dated 02/24/2026 completed by PT 2 indicated the patient complained of dizziness, had a blood pressure higher than usual of 170/80, and a reported blood sugar of over 200. A SN visit note dated 02/24/2026 completed by LPN 1 indicated the patient’s caregiver was more short of breath and was assessed to have difficulty breathing. A discharge summary dated 02/27/2026 indicated the patient was transferred to the hospital due to shortness of breath and admitted for congestive heart failure (weakness of the heart causing fluid to back up in the lungs and other parts of the body). The record failed to evidence LPN 1 and PT 2 notified the RN case manager in efforts to coordinate care related to the patient’s complaints of shortness of breath and dizziness, weight gain, difficulty breathing, spirometer use, and elevated blood pressure and blood sugar prior to the patient’s transfer to the hospital. On 04/09/2026 at 2:28 PM, the CM indicated LPN 1 and PT 2 did not notify the RN case manager related to the changes in the patient’s condition. 410 IAC 17-12-2(g)

Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA's governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA's performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This CONDITION is not met as evidenced by: Based on record review and interview, the agency failed to ensure: the quality assessment and performance improvement (QAPI) program was capable of showing measurable improvement in indicators affecting health outcomes, patient safety, and quality of care (G0642); the program utilized quality indicator data to include measures from OASIS (Outcome and Assessment Information Set) data to identify opportunities for improvement (G0644); the performance improvement activities focused on high risk and high volume areas (G0646); the program tracked adverse events, analyzed their causes, and implemented preventative actions (G0654); performance improvement actions are tracked and measured to ensure improvements are sustained (G0656); and the reason the improvement project was chosen and the measurable progress achieved was documented (G0568). The cumulative effect of these systemic problems resulted in the home health agency’s inability to ensure the provision of quality health care in a safe environment for the condition of participation 42 CFR §484.65 Condition: Quality Assessment/Performance Improvement. The findings include: Review of the agency’s hospitalization log indicated the following hospitalizations: 1 (5%) for Quarter 1 2024, 2 (10%) for Quarters 2 and 3 2024, 1 (5%) for Quarter 4 2024, 4 (20%) for Quarter 1 2025, 6 (30%) for Quarter 2 2025, 7 (35%) for Quarter 3 2025, 1 (5%) for Quarter 4 2025, and 7 (35%) for Quarter 1 2026. The hospitalization log did not include relevant data to track and trend data such as length of stay and admitting diagnosis. Review of the agency’s infection log indicated the following infections: 0 for Quarters 1, 2, and 3 2025, 1 (5%) for Quarter 4 2025, 4 (20%) for Quarter 1 2026, and 3 (15%) for the month of April 2026. The infection log was missing information for tracking and trending data such as type of infection for patient infections with a date of onset of 11/18/2024 and 04/03/2026. A review of the incident log indicated the following falls: 1 (5%) for Quarters 3 and 4 2024 and Quarter 1 2025, 2 (10%) Quarters 2 and 3 2025, 5 (25%) for Quarter 4 2025, and 4 (20%) for Quarter 1 2026. Review of the QAPI program and meeting minutes dated 06/26/2024, 09/25/2024, 12/30/2024, 03/26/2025, and 12/31/2025 failed to evidence indicators and documented improvements affecting health outcomes, patient safety, and quality of care. The program failed to evidence quality indicator data from OASIS and failed to evidence data, data analysis, and performance improvement activities related to hospitalizations, falls, and infections. The program failed to evidence the reason why the improvement project was chosen and measurable progress achieved. On 04/09/2026 beginning at 1:40 PM, the Administrator indicated the average census for 2024 and 2025 was 18-22. The Administrator indicated the QAPI program did not have any data compiled related to OASIS data outcomes. The Administrator indicated there were no performance improvement actions set in place, because the agency did not go over a threshold value of more than 10% variance in any comparison and indicated there was no data included in the program for the comparison of the variance in threshold value. The Administrator indicated the reason the improvement project was chosen was not documented. The Administrator indicated the QAPI program did not include data related to falls, hospitalizations, and infections. 410 IAC 17-12-2(a)

Infection prevention and control CFR(s): 484.70 Condition of Participation: Infection prevention and control. The HHA must maintain and document an infection control program which has as its goal the prevention and control of infections and communicable diseases. This CONDITION is not met as evidenced by: Based on record review and interview, the agency failed to: follow standards of practice, including the use of standard precautions, to prevent the transmission of infections (See tag G0682); maintain program for the surveillance, prevention, control, and investigation of infections (See tag G0684); and follow agency policy to provide infection control education to staff (See tag G0686). The cumulative effect of these systemic problems resulted in the home health agency's inability to ensure the provision of quality health care for the Condition of Participation 42 CFR 484.70 Infection Prevention and Control. Other unrelated conditions of participation and findings will be cited.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on record review, observation, and interview, the agency failed to follow standards of practice including the use of environmental cleaning and disinfection to prevent the transmission of infections and communicable diseases in 2 of 2 home visit observations with a RN. (Patient #2, Patient #3) The findings include: 2.During a home visit for Patient #3 on 04/07/2026 beginning at 11:36 AM, RN 2 was observed using a stethecope, blood pressure cuff, and pulse oximeter (medical device to measure oxygetn saturation and pulse). RN 2 was observed to wipe the equipment with wipes from an unmarked, plastic bag that she obtained from the nursing bag. No label that stated disinfection solution for the wipes or directions for use was present on the plastic bag. RN 2 was observed wiping the equipment and placing it directly in the nursing bag without a saturation time or dry time. During an interview on 04/09/2026 beginning at 9:42 AM, RN 2 indicated that she provides her own disinfecting wipes and does not use agency provided disinfection wipes. RN 2 additionally indicated that she places them in a small plastic bag because the original container is too large for the nursing bag and that she was unaware of the directions for use in regard to saturation and dry time for effective disinfection. A 2022 policy titled “Standard Precautions” indicated that non-disposable equipment used by the clinician would be disinfected by an approved disinfectant. During a home visit observation for Patient #2 on 04/07/2026 beginning at 11:33 AM, RN 1 was observed using a stethoscope, blood pressure cuff, and pulse oximeter (medical device to measure oxygen saturation and pulse). RN 1 was observed wiping the equipment with a disposable wipe from a container which noted the cleaned surfaces must remain wet for 4 minutes and allowed to air dry for disinfection. RN 1 was observed wiping the equipment and immediately placing it in the nursing bag without allowing the surfaces to remain wet for 4 minutes or allowing equipment to air dry. On 04/07/2026 at 11:34 AM, when queried what the dry time was for the disinfecting wipes, RN 1 asked “Is there anything special I’m supposed to do?” RN 1 indicated she probably should have left the equipment out before putting it right back into the nurse bag. 410 IAC 17-12-1(m)

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure a program was developed for the surveillance, identification, prevention, and control of infectious and communicable diseases specific to care and services provided in the home setting and was included in the agency’s Quality Assurance and Performance Improvement (QAPI) program. The findings include: 1. A clinical record review for Patient #1 evidenced the patient was admitted to the hospital on 03/23/2026 for a complex urinary tract infection per the hospital admission documents. 2. A clinical record review for Patient #2 evidenced a SN visit note dated 03/17/2026 which indicated the patient had a urinary tract infection and started antibiotics. The infection was not logged on the infection log. 3. A clinical record review for Patient #8 evidenced a comprehensive assessment for recertification dated 12/16/2025 which indicated the patient had cellulitis (bacterial infection affecting deep tissue layers of the skin). 4. Review of the agency’s infection log failed to evidence the infections for Patient #1, #2, and #8. The infection log was missing information for tracking and trending data such as type of infection for logged patient infections with a date of onset of 11/18/2024 and 04/03/2026. The infection log indicated 5 patient infections in 2024, 1 in 2025, and 7 for year-to-date 2026. The agency failed to evidence an infection control program to include the surveillance of infections to include the aggregations of data to track and trend the patient infections. 5. A review of the QAPI program failed to evidence the data related to the patient infections. 6. On 04/09/2026 at 2:17 PM, the Administrator indicated there was no data aggregation of infections and no infections data was included in the QAPI program.

Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to provide infection control education to staff annually per its policy in 3 of 3 personnel records reviewed of licensed personnel that have been hired for greater than 1 year (CM, RN 1, PT 3) and failed to provide infection control education at time of hire in 1 of 2 personnel records reviewed of licensed personnel that have been hired for under 1 year (PT 1). The findings include: 1. A 2022 policy titled “Training/Inservice Education” indicated mandatory inservices would be attended by all disciplines and would include annual training for infection control. 2. A 2022 policy titled “Infection Control Plan” indicated new personnel receive a copy of the standard precautions at time of orientation and staff will receive infection control training no less than annually. The policy indicated attendance would be documented and maintained in the personnel files. 3. A personnel record review for the CM, date of hire 12/26/2022, failed to evidence infection control education since hire. 4. A personnel record review for RN 1, date of hire 08/19/2024, failed to evidence infection control education since hire. 5. A personnel record review for PT 3, date of hire 04/25/2024, failed to evidence infection control education since hire. 6. A personnel record review for PT 1, date of hire 02/06/2026, failed to evidence infection control education. 7. Review of the agency inservice binder failed to evidence any education other than OASIS (Outcome and Assessment Information Set) dated 03/25/2026. 8. On 04/08/2026 at 2:06 PM, the CM indicated there was no specific annual inservice provided to staff and infection control education was only provided at time of hire. 9. On 04/08/2026 beginning at 2:39 PM, the Administrator indicated the agency had not yet provided refresher training related to hand hygiene and bag technique. The Administrator indicated there was not any infection control training for PT 1.

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 agency failed to ensure the SN provided services ordered by the provider as indicated in the plan of care in 1 of 4 active clinical record reviews of patients who had received services for greater than 60 days. (Patient #1) Findings include: A policy, titled “Care Planning Process”, indicated that the POC should contain patient specific interventions. A clinical record review for Patient #3, evidenced a POC, dated 02/26/2026, that indicated the physician should be notified of a diastolic blood pressure less than 60mmhg. A SN visit note, by RN 2, dated 03/06/2026, evidenced a blood pressure reading of 92/56mmhg. The visit note failed to evidence communication that the physician had been notified of the diastolic blood pressure of less than 60mmhg. During an interview on 04/09/2026 beginning at 9:42 AM, RN 1 indicated that she did not notify the physician of the blood pressure of Patient #3 that was outside of parameters because the patient was not symptomatic, and would have notified the physician if the patient was symptomatic. 410 IAC 17-14-1(a)(1)(C)

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 filed to ensure accurate preparation of clinical notes in 1of 4 active clinical record reviews of patients who received services more than 60 days. (Patient #8) Findings include: A policy, titled “Contents of Clinical Record”, indicated that the clinical record will be maintained for each patient and that each clinical record should accurately documented. A clinical record review for Patient #8 evidenced the following: A comprehensive assessment dated 02/11/2026, that indicated that Patient #8 uses a nasal cannula for oxygen administration and did not indicate an assessed need for occupational therapy.A SN visit note, dated 02/17/2026, indicated that Patient #8 uses a simple mask for oxygen use, and required occupational therapy services.A SN visit note, dated 03/03/2026, indicated that Patient #8 uses a simple mask for oxygen use, and required occupational therapy services.A SN visit note, dated 03/17/2026, indicated that Patient #8 uses a simple mask for oxygen use, and required occupational therapy services.A SN visit note, dated 03/31/2026, indicated that Patient #8 uses a simple mask for oxygen use, and required occupational therapy services. During an interview on 04/09/2026 beginning at 9:25 AM, RN 1 indicated that she uses a copy and paste feature to prepare the clinical notes and the documentation of a need for occupational therapy and simple mask use for oxygen was an error and oversight to be placed on multiple SN notes. 410 IAC 17-14-1(a)(1)(E)

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 home health agency failed to ensure: the home health aide provide services that were included in the plan of care (see tag G0800); the RN completed a supervisory assessment of HHA services every 14 days (see tag G0808); and the home health aide supervision ensured the care provided followed the plan of care (see tag G0818). The cumulative effect of these systemic problems resulted in the home health agency's inability to ensure the provision of quality health care for the Condition of Participation 42 CFR 484.80 Home Health Aide Services.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the HHA provided the tasks as directed in the POC in 3 of 4 active clinical records reviewed with HHA services. (Patient #4, Patient #5, Patient #3) The findings include: 3. A clinical record review for Patient #3, evidenced an HHA care plan, dated 03/01/2026, that indicated the HHA tasks to be performed by the HHA every visit included combing of hair, oral care, assisting with bedside commode use, and meal preparation. The HHA care plan additionally indicated that the HHA was to report refusal of care. HHA visit notes indicated Patient #3 refused combing of hair on 03/03/2026, 03/06/2026, 03/10/2026, 03/13/2026, 03/17/2026, 03/20/2026, 03/24/2026, 03/27/2026, 03/31/2026, and 04/03/2026; refused oral care on 03/10/2026, 03/13/2026, 03/17/2026, 03/20/2026, 03/24/2026, 03/27/2026, 03/31/2026, and 04/03/2026; assistance with bedside commode on 03/03/2026, 03/10/2026, 03/17/2026, 03/20/2026, 03/24/2026, 03/27/2026, 03/31/2026, and 04/03/2026; and meal preparation on 03/03/2026, 03/06/2026, 03/10/2026, 03/13/2026, 03/17/2026, 03/20/2026, 03/24/2026, 03/27/2026, 03/31/2026, and 04/03/2026. The record failed to evidence the HHA reported the refusals of care as directed in the HHA care plan. During an interview on 04/09/2026 beginning at 9:42 AM, RN 2 indicated that she was the primary RN for Patient #3 and had not been notified of refusals from Patient #3 by the HHA. 1. A clinical record review for Patient #4 evidenced a HHA care plan dated 03/09/2026 which indicated the HHA was to provide oral care, nail care, comb hair, and shampoo the patient at every visit and indicated the HHA was to report refusal of care. HHA visit notes indicated the patient refused oral care on 03/12/2026, 03/17/2026, 03/20/2026, 03/23/2026, 03/27/2026, 03/30/2026, 04/02/2026, and 04/06/2025; refused shampoo on 03/20/2026, 04/02/2026, and 04/06/2026; refused comb hair on 03/20/2026, 04/02/2026, and 04/06/2026; and refused nail care on 04/02/2026. The record failed to evidence the HHA reported the refusals of care as directed in the HHA care plan. On 04/07/2026 at 4:32 PM, the CM indicated there was no documentation the HHA reported the refusals of care. 2. A clinical record review for Patient #5 evidenced a HHA care plan dated 02/14/2026 which indicated the HHA was to provide visits 2 times a week to include provide a shampoo at every visit and indicated the HHA was to report refusal of care. HHA visit notes indicated the patient refused a shampoo at 13 HHA visits dated from 02/16/2026 and 04/03/2026. The record failed to evidence the HHA reported the refusals of care as directed in the HHA care plan. On 04/08/2026 at 1:54 PM, the CM indicated the HHA should provide the tasks as directed on the care plan and there was not any documentation the HHA reported the refusals of care.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the RN completed a supervisory assessment of HHA services every 14 days in 3 of 4 active clinical records reviewed with HHA and skilled services. (Patient #2, Patient #1, Patient #3) The findings include: A clinical record review for Patient #2 evidenced POCs for recertification periods of 01/30/2026-03/30/2026 and 03/31/2026-05/29/2026 which indicated the agency would provide SN and HHA services. The record failed to evidence a supervisory assessment of HHA services since 03/17/2026. On 04/07/2026 at 1:34 PM, the CM indicated there was not a supervisory assessment for HHA services since 03/17/2026. A policy, titled “Home Health Aide Plan of Care”, indicated that the RN will complete a supervisory assessment of the home health aide no less frequently than every 14 days. 2.A clinical record review, for Patient #3, evidenced a POC for the episode period of 03/03/2026 to 05/01/2026 that indicated the agency would provide SN and HHA services. The clinical record evidenced an HHA supervisory visit was performed on 03/17/2026, with the next HHA supervisory visit performed 17 days later on 03/28/2026. During an interview on 04/09/2026 beginning at 12:05 PM, the CM indicated that HHA supervisory visits should be conducted no less than every 14 days. 3.A clinical record review, for Patient #1, evidenced a POC for the episode period of 03/12/2026 to 05/10/2026 that indicated the agency would provide SN, HHA, PT, and OT services. The clinical record failed to evidence that any HHA supervisory visit was performed as of survey date of 04/09/2026. During an interview on 04/08/2026 beginning at 11:31 AM, the CM indicated that while Patient #1 was hospitalized from 03/23/2026 to 04/01/2026, an HHA supervisory visit should have been completed upon Patient #1’s resumption of care on 04/02/2026 and was not completed at that time.

HH aide supervision elements CFR(s): 484.80(h)(4)(i-vi) Home health aide supervision must ensure that aides furnish care in a safe and effective manner, including, but not limited to, the following elements: (i) Following the patient's plan of care for completion of tasks assigned to a home health aide by the registered nurse or other appropriate skilled professional; (ii) Maintaining an open communication process with the patient, representative (if any), caregivers, and family; (iii) Demonstrating competency with assigned tasks; (iv) Complying with infection prevention and control policies and procedures; (v) Reporting changes in the patient's condition; and (vi) Honoring patient rights. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the HHA was supervised to ensure the aides furnished care that followed the patient’s plan of care in 3 of 4 active clinical records reviewed with HHA services. (Patient #4, Patient #5, Patient #3) The findings include: 3. A clinical record review for Patient #3, evidenced an HHA care plan, dated 03/01/2026, that indicated the HHA tasks to be performed by the HHA every visit included combing of hair, oral care, assisting with bedside commode use, and meal preparation. Tasks to be performed weekly included changing linen, shampooing hair, and cleaning/filing nails. The HHA care plan additionally indicated that the HHA was to report refusal of care. HHA visit notes indicated Patient #3 refused combing of hair on 03/03/2026, 03/06/2026, 03/10/2026, 03/13/2026, 03/17/2026, 03/20/2026, 03/24/2026, 03/27/2026, 03/31/2026, and 04/03/2026; refused oral care on 03/10/2026, 03/13/2026, 03/17/2026, 03/20/2026, 03/24/2026, 03/27/2026, 03/31/2026, and 04/03/2026; assistance with bedside commode on 03/03/2026, 03/10/2026, 03/17/2026, 03/20/2026, 03/24/2026, 03/27/2026, 03/31/2026, and 04/03/2026; and meal preparation on 03/03/2026, 03/06/2026, 03/10/2026, 03/13/2026, 03/17/2026, 03/20/2026, 03/24/2026, 03/27/2026, 03/31/2026, and 04/03/2026. The record failed to evidence the HHA reported the refusals of care as directed in the HHA care plan. HHA visit notes indicated that the weekly tasks of changing linen, shampooing hair, and cleaning/filing nails had been completed with on 03/03/2026, 03/06/2026, 03/10/2026, 03/13/2026, 03/17/2026, 03/20/2026, 03/24/2026, 03/27/2026, 03/31/2026, and 04/03/2026 which was twice weekly. A review of the HHA supervisory visit notes dated 03/03/2026, 03/17/2026, and 04/03/2026, completed by RN 2, indicated the HHA followed the patient’s plan of care for completion of tasks assigned. The review failed to evidence the RN provided HHA supervision to ensure the HHA followed the care plan as directed. During an interview on 04/09/2026 beginning at 9:42 AM, RN 2 indicated that she had not been notified by the HHA of refusals by Patient #3, but if tasks were not completed, completed more often than ordered, and refusals were not reported, then it would have been incorrect to document that the patient plan of care was being followed by the HHA. 1. A clinical record review for Patient #4 evidenced a HHA care plan dated 03/09/2026 which indicated the HHA was to provide oral care, nail care, comb hair, and shampoo the patient at every visit and indicated the HHA was to report refusal of care. HHA visit notes indicated the patient refused oral care on 03/12/2026, 03/17/2026, 03/20/2026, 03/23/2026, 03/27/2026, 03/30/2026, 04/02/2026, and 04/06/2025; refused shampoo on 03/20/2026, 04/02/2026, and 04/06/2026; refused comb hair on 03/20/2026, 04/02/2026, and 04/06/2026; and refused nail care on 04/02/2026. The record failed to evidence the HHA reported the refusals of care as directed in the HHA care plan. Review of the HHA supervisory visits dated 03/23/2026 and 04/02/2026 completed by the CM indicated the HHA followed the patient’s plan of care for completion of tasks as assigned. Review failed to evidence the RN provided HHA supervision to ensure the HHA followed the care plan as directed. On 04/07/2026 at 4:32 PM, the CM indicated there was no documentation the RN provided supervision of the HHA regarding the POC not being followed. 2. A clinical record review for Patient #5 evidenced a HHA care plan dated 02/14/2026 which indicated the HHA was to provide visits 2 times a week to include provide a shampoo at every visit and indicated the HHA was to report refusal of care. HHA visit notes indicated the patient refused a shampoo 13 times at HHA visits dated from 02/16/2026 and 04/03/2026. The record failed to evidence the HHA reported the refusals of care as directed in the HHA care plan. Review of the HHA supervisory visits dated 02/26/2026, 03/12/2026, and 03/26/2026 completed by the CM indicated the HHA followed the patient’s plan of care for completion of tasks as assigned. Review failed to evidence the RN provided HHA supervision to ensure the HHA followed the care plan as directed. On 04/08/2026 at 1:55 PM, the CM indicated there was no documentation the RN provided supervision of the HHA regarding the POC not being followed. 410 IAC 17-14-1(n)

Coordinate patient care CFR(s): 484.105(c)(2) Coordinating patient care, This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to coordinate patient care with other agencies servicing patients in 1 of 2 clinical record reviews of active patients on service less than 60 days. (Patient #1) Findings include: A policy, titled “Scope of Services”, indicated that the agency will be responsible for coordination of services to meet patient needs. During an observation of a home visit on 04/07/2026, for Patient #1, a staff member from Entity 3 was present. The staff member indicated that Entity 3 provides services including bathing, positioning, feeding, meal preparation, incontinent care, and housekeeping 6 days per week. The staff member indicated that when the agency HHA comes twice weekly, on the days that Entity 3 is scheduled. Entity 3 indicated that there was no communication with Entity 3 regarding duties performed or scheduling. A clinical record review for Patient #1 failed to evidence communication or coordination of care with Entity 3. During an interview on 04/09/2026 beginning at 11:31 AM, the CM indicated that care coordination with other agencies should be performed upon knowledge of other entities in the home. The CM indicated that there was no care coordination with Entity 3 at the time of record review.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure clinical records were accurate in 1 of 3 active clinical records reviewed with an infection. (Patient #2) The findings include: 410 IAC 17-15-1 (a)(7) A 2022 policy titled “Clinical/Service Data Collection” indicated documentation in the clinical record would be accurate and reflect the care provided. A clinical record review for Patient #2 evidenced SN visit notes dated 03/17/2026 and 03/31/2026 which indicated the patient had a urinary tract infection and started antibiotics “today” on 03/17/2026. On 04/07/2026 at 2:09 PM, the CM indicated the SN visit note dated 03/31/2026 was not accurate but a carry-over from the SN visit note dated 03/17/2026.

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102. Survey Dates: 8/1/2023-8/3/2023 Facility ID: 015944 Active Census: 10 At this Emergency Preparedness survey, Canary Home Health Care was found not to be in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 484.102.

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure they developed and implemented an individualized comprehensive emergency preparedness plan to include hazard vulnerability assessment, employee contact information, collaboration with local officials, employee training, and arrangements made with other agencies to ensure staffing for all patients. The findings include: Record review on 8/3/2023, of the agency’s emergency preparedness plan was reviewed from 4:13 PM – 5:29 PM, with the administrator and owner/governing body member. Review of the hazard vulnerability assessment (HVA) indicated Canary Home Health would perform an agency based and community-based risk assessment utilizing an all-hazards approach. Review of the agency’s HVA documents (agency based and community based) evidenced the analysis was blank and incomplete. Review of the emergency response section evidenced information about tropical storms and hurricanes, which are likely to occur along the coastal states. Review failed to evidence the emergency plan was individualized to the area the agency serves. Review failed to evidence a full scale or tabletop exercise was performed with staff. Review failed to evidence collaboration with other agencies or volunteers in the area to service patients in an emergency. Review failed to evidence staff contact information located in the agency’s emergency plan. Review failed to evidence the agency provided Emergency Preparedness training at time of employee hire. During an interview on 8/3/2023, at 4:13 PM, the Administrator indicated the agency was planning emergency preparedness “drills” for staff in September of 2023. When queried about the plan for a tabletop exercise performed, the Administrator indicated they were not familiar with that term. The Owner/governing body member indicated they were planning a full event because there was a district meeting every 2 years. At 4:16 PM, the Owner/governing body member indicated they did not see coordination with local officials, but the agency received the “OK” to list agencies in the policies and procedures but was not included in the emergency plan. At 4:22 PM, the Administrator indicated there was no documentation of emergency preparedness training. The Owner/ governing body member revealed a document with the name of the emergency preparedness coordinator and failed to evidence what topics were covered upon hire. At 5:08 PM, the Owner/ governing body member queried the relevance for the tropical storm and hurricane information in the agency’s emergency plan. When queried if that weather information applied to the agency, the Owner/governing body member stated “No.” At 5:20 PM, the Owner/governing body member indicated in an emergency, the agency would transfer patients to a licensed agency to assume care but failed to provide the name of a specific agency they had made arrangements with.

HHA Comprehensive Assessment in Disaster CFR(s): 484.102(b)(1) §484.102(b)(1) Condition for Participation: [(b) Policies and procedures. The HHA 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. At a minimum, the policies and procedures must address the following:] (1) The plans for the HHA's patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. This STANDARD is not met as evidenced by: Based on observation, record review, and interview, the agency failed to develop and implement individualized emergency preparedness plans for the patients which provided appropriate instructions, in the event of an emergency in 3 of 3 home visits conducted. (Patient #1, 4, 5) The findings include: *. Record review of an agency policy retrieved on 8/3/2023, titled “Introduction to the Emergency Preparedness Plan” evidenced a section subtitled “Mitigation Activities” that indicated the agency should develop an individual emergency preparedness as part of the comprehensive assessment in an effort to reduce the risk for potential harm to the patient. *. An observation of a home visit was conducted on 8/2/2023, from 9:43 AM – 10:15 AM, for patient #4, start of care 6/13/2023, with PT 1. During the visit, the patient’s information folder was reviewed and failed to evidence an individualized emergency plan in the patient’s home to include the patient's pharmacy contact information, an evacuation location and medical equipment needed for daily care, such as a glucometer needed to assess a blood sugar. On 8/3/2023, at 2:58 PM, the patient's individualized emergency preparedness plan was discussed with the Clinical Manager. *. An observation of a home visit was conducted on 8/2/2023, from 11:02 AM – 12:05 AM, for patient #5, start of care 6/7/2023, with RN 1. During the visit, the patient’s information folder was reviewed and failed to evidence an individualized emergency plan in the patient’s home to include an evacuation location, medical equipment needed for daily care, such as a glucometer, and required durable medical equipment (DME) needed outside the home such as a cane or walker. On 8/3/2023, at 2:51 PM, the patient's individualized emergency preparedness plan was discussed with the Clinical Manager. 1. Clinical record on 8/1/2023, for Patient #1 evidenced an agency document titled “Home Health Certification and Plan of Care” for certification period 6/20/2023-8/18/2023, which indicated the patient was allergies included coumadin (a medication used to thin the blood) and pollen. Review indicated the patient’s medications included, but were not limited to, Xarelto (a medication used to thin the blood to prevent/treat strokes) and indicated the patient’s safety measures included bleeding precautions. Review of an agency document titled “Patient In-Home Clinical Emergency Plan” dated 4/21/2023, indicated the patient had no allergies. Review indicated the form had a section for special precautions which failed to evidence the patient’s bleeding precautions were included. During an interview on 8/2/2023, at 3:23 PM, the Clinical Manager indicated the individualized emergency plan should include the patient’s allergies. 2. During an interview on 8/2/2023, at 3:59 PM, the Clinical Manager indicated the patient's emergency preparedness plan should be available to the patient in the patient's home and should be individualized to include safety precautions, the patient's evacuation plan, and medical supplies/equipment needed.

This survey was an initial Medicaid Certification and State Licensure survey of a home health provider. Survey Dates: 8/1/2023-8/3/2023 Facility ID: 015944 Unduplicated admission for the past 12 months: 10 Survey was fully extended on 8/3/2023. This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Quality Review Completed 08/15/2023, Area 1

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on record review an interview, the home health agency failed to ensure all patients were informed of changes to services as consented for 1 of 2 active clinical records reviewed with physical therapy services. (Patient #6) The findings include: Clinical record review on 8/1/2023, for patient #6, evidenced an agency document titled “Admission Consent” signed by the patient on 7/19/2023, which indicated the patient agreed to home health aide (HHA) services twice a week for 9 weeks and physical therapy (PT) services once a week for 8 weeks. Record review of the plan of care indicated PT frequency once a week for 6 weeks and HHA once a week for one week and twice a week for 8 weeks. Review evidenced the plan of care frequencies for PT and HHA services differed from the frequencies consented by the patient. During an interview on 8/3/2023, at 2:26 PM, the Clinical Manager indicated PT felt only 6 weeks was warranted and did not see that information documented. At 2:29 PM, when queried if the patient was notified of the changes, RN 1 stated “I don’t believe so.” The Clinical Manager indicated the patient was notified verbally but the conversation was not documented. 410 IAC 17-12-3(b)(2)(D)(ii)(AA)

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 the comprehensive assessment included a review of the patient’s medications to identify any potential adverse effects and drug reactions in 1 of 1 clinical record reviewed with a hospitalization. (Patient #2) The findings include: Clinical record review on 8/3/2023, for Patient #2, evidenced an agency document titled “Home Health Certification and Plan of Care” for certification period 5/23/2023-7/21/2023, which indicated the patient’s medications included, but were not limited to, furosemide (medication used to treat reflux), atenolol (medication used to treat high blood pressure), albuterol (medication used to treat wheezing and shortness of breath), aspirin (medication used to treat pain and/or fever or to thin the blood), gabapentin (medication to treat seizures and/or nerve pain), Cymbalta (antidepressant), oxycodone (a narcotic pain reliever), Plavix (medication used to prevent clots), and Amaryl (medication used to treat high blood sugar). Review indicated interactions between to include, but not limited to, the following medications: furosemide and atenolol, atenolol and albuterol, atenolol and aspirin, gabapentin and Cymbalta, Cymbalta and Plavix, Cymbalta and oxycodone, aspirin and Plavix, oxycodone and albuterol, aspirin and Amaryl, Cymbalta and gabapentin, and gabapentin and oxycodone. Review of an agency document titled “Start of Care” completed by the Clinical Manager and dated 5/23/2023, indicated the drug review at the initial comprehensive assessment identified no issues. Review failed to evidence the agency identified the potential drug interactions. During an interview on 8/3/2023, at 3:38 PM, the Clinical Manager indicated she did not see any indication in the clinical record the potential medication interactions were identified and indicated they should have been documented. 410 IAC 17-14-1(a)(1)(B)

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 record review and interview, the agency failed to update the comprehensive assessment in 1 of 1 clinical record reviewed with wounds. (Patient #2) The findings include: Review of an agency policy revised November 2021, titled “Initial and Comprehensive Assessment” stated, “… This assessment will measure patient outcomes from data collected at the start of care and at the following defined intervals thereafter: … Significant change in condition ….” Clinical record review on 8/3/2023, for Patient #2, evidenced an agency document titled “Skilled Nurse Visit” completed by the Clinical Manager and dated 7/15/2023, which indicated the patient had a new wound to the left thigh, a pressure ulcer (wounds to the skin and underlying tissue resulting from prolonged pressure to the skin) stage II (some skin loss or damage involving the top-most skin layers), that was not present at the last skilled nursing visit. Review indicated the wound had moderate drainage with a foul odor. Review failed to evidence the agency updated the comprehensive assessment with the significant change related to the new wound. During an interview at the entrance conference on 8/1/2023, at 12:13 PM, the Clinical Manager indicated the comprehensive assessment would need to be updated for a new wound. During an interview on 8/3/2023, at 3:34 PM, the Clinical Manager indicated the comprehensive assessment was not revised to include the new wound to the left thigh. 410 IAC 17-14-1(a)(1)(B)

Discharge Planning CFR(s): 484.58(a) Standard: Discharge planning. An HHA must develop and implement an effective discharge planning process. For patients who are transferred to another HHA or who are discharged to a SNF, IRF or LTCH, the HHA must assist patients and their caregivers in selecting a post-acute care provider by using and sharing data that includes, but is not limited to HHA, SNF, IRF, or LTCH data on quality measures and data on resource use measures. The HHA must ensure that the post-acute care data on quality measures and data on resource use measures is relevant and applicable to the patient's goals of care and treatment preferences. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to follow its policy for discharge planning in 1 of 1 clinical record reviewed with a planned discharge. (Patient #3) The findings include: Review of an agency policy revised November 2021, titled “Discharge Criteria and Process” stated, “… When the patient’s plan of care changes and this change results in a discharge or reduction of services, the patient or his/her representative, as well as his/her primary physician … will be notified and involved in the planning decisions. … The organization will verbally notify the patient of the decision to terminate or reduce services within one (1) visit prior to the time the change in service is to occur … The decision to terminate or reduce services must be documented in the clinical record citing the circumstances and notification to the patient … and the patient’s physician … Efforts to resolve problems prior to discharge will also be documented in the patient's record. The patient shall be provided contact information for other home health agencies and providers if continued care is needed….” Clinical record review on 8/2/2023, for Patient #3, start of care 6/9/2023, evidenced an agency document titled “Home Health Certification and Plan of Care” for certification period 6/9/2023-8/7/2023, which indicated the agency was to provide skilled nursing services 1 time every other week for 9 weeks and home health aide services 1 time a week for 9 weeks. Review evidenced a discharge assessment completed by the registered nurse and dated 7/6/2023, which indicated the patient was discharged due to not having seen the physician within 30 days of start of care and not having a face-to-face encounter completed per agency policy. Review indicated the patient was requesting to continue services and instructed to call the physician to schedule an appointment for a face-to-face encounter and then the physician may send an admission order to start skilled services again. Review failed to evidence documentation the patient was informed prior to the time of discharge of the termination of services from the agency per agency policy. Review failed to evidence the agency provided contact information for other home health agencies per agency policy. Review failed to evidence the agency documented any attempts to obtain the face-to-face encounter with the physician prior to discharge per agency policy. Review failed to evidence documentation the agency notified the patient and the physician of the discharge planning if the face-to-face encounter was not obtained per agency policy. During an interview on 8/3/2023, at 1:17 PM, the Clinical Manager indicated the agency had not received the face to face from the physician since the patient was not seen by the physician within 90 days prior or 30 days after the start of care. The Clinical Manager indicated the agency would not get paid without a face-to-face encounter so the patient needed to be discharged until the physician saw the patient and could complete a face-to-face encounter form. At 1:23 PM, the Clinical Manager indicated there was no documentation prior to discharge of the plan to discharge. During an interview on 8/3/2023, at 1:23 PM, Administrative Staff 2 indicated there was not a policy regarding the face-to-face encounter. Administrative Staff 2 indicated the patient was readmitted for home care services on 7/25/2023 because the physician sent an order for home care services and indicated the agency did not yet have a face-to-face encounter from the physician.

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 the transfer summary contained all necessary medical information pertaining to the patient’s current treatment to the receiving facility in 1 of 1 clinical record reviewed with a transfer to the hospital. (Patient #2) The findings include: Review of an agency policy revised November 2021, titled “Transfer Summary” stated, “… Within 48 hours of transfer, the transferring clinician will complete a transfer summary that includes, as appropriate: … Destination of patient transferred … The physical and psychosocial status at time of transfer, including specific medical, psychosocial, or other problems requiring interventions or follow-up … Medication profile … Completed transfer summaries will be given to a clinical records clerk, who will send a copy to the receiving organization … within … two (2) days of becoming aware of an unplanned transfer … A copy of the transfer summary will be sent to the physician … within 48 hours of transfer….” Clinical record review on 8/3/2023, for Patient #2, evidenced an agency document titled “Transfer Discharge” completed by the Clinical Manager and dated 7/19/2023, which indicated on 7/18/2023, the Clinical Manager was notified by the patient of a transfer to Entity D (hospital) on 7/16/2023, where the patient was admitted. Review of an agency document titled “Home Health Transfer Summary (Auto Generated)” completed by the Clinical Manager and dated 7/24/2023, failed to evidence the transfer summary was completed by the clinician within 48 hours and sent to the receiving facility and the physician responsible for the plan of care within 48 hours of being notified of the unplanned transfer per agency policy. Review failed to evidence the patient’s wounds for which the skilled nurse was providing wound treatment and failed to evidence the name of the receiving facility. Review failed to evidence the transfer summary was sent to the receiving facility and physician. During an interview on 8/3/2023, at 3:44 PM, the Clinical Manager indicated the fax log showed a fax was sent to the patient’s physician on 7/23/2023, but failed to evidence what the document was. When queried how the physician could have been faxed the transfer summary on 7/23/2023, when the transfer summary was not completed and signed until 7/24/2023, the Clinical Manager indicated the fax must not have been for the transfer summary. When queried why the transfer summary did not include the name of the receiving facility, the Clinical Manager indicated she would check her copy. No additional documentation or information was provided.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on observation, record review and interview, the agency failed to ensure the plan of care was individualized to include medications, interventions, diagnoses, safety precautions and goals in 6 of 6 clinical records reviewed. (Patients #1, 2, 3, 4, 5, 6) The findings include: 4. Clinical record review on 8/2/2023, for patient #4, start of care 6/13/2023, evidenced an agency document titled “Home Health Certification and Plan of Care” that indicated the patient was prescribed to take Eliquis (blood thinning medication) daily. Review failed to evidence the patient was placed on bleeding precautions to ensure patient safety. Review failed to evidence pertinent information including but not limited to the patient’s homebound status or medical necessity. Review failed to evidence the plan of care was individualized to the patient’s specific needs. During an interview on 8/3/2023, at 2:54 PM, the Clinical Manager indicated the plan of care should have indicated the patient was on bleeding precautions due to the daily Eliquis order. 5. Clinical record review on 8/3/2023, for patient #5, start of care 6/7/2023, evidenced an agency document titled “Home Health Certification and Plan of Care” that indicated the patient was prescribed to apply Voltaren (over the counter topical nonsteroidal anti-inflammatory drug) gel as needed but failed to evidence an indication when. The medication list evidenced the patient was taking Lovastatin (used to treat high cholesterol), Lisinopril (used to treat high blood pressure and heart failure). Review of the diagnoses listed on the plan of care evidenced type 2 diabetes and hypothyroidism only. Review failed to evidence all pertinent diagnoses listed related current medications/treatments. Review of the goals stated the patient “… will demonstrate competence with self-management of [Disease Process] as evidenced by ….” Review failed to evidence what disease process the patient will demonstrate competence. Review of the discharge plan evidenced the patient would be discharged from skilled nursing services to the care of themself but failed to evidence when. During an interview on 8/3/2023, from 2:40 PM – 2:48 PM, the Clinical Manager indicated there should be a diagnosis listed within the brackets. The Clinical Manager agreed and stated “Got it” when prescribed medications used for specific disease processes failed to evidence a coordinating diagnosis on the plan of care. The Clinical Manager indicated the patient should use Voltaren gel for arthritis/pain. The Clinical Manager indicated the plan of care should indicate when discharge would be appropriate. 6. Clinical record review on 8/1/2023, for patient #6, start of care 7/19/2023, with a pertinent diagnosis of diabetes, evidenced an agency document titled “Home Health Certification and Plan of Care” that indicated the patient was prescribed Claritin (antihistamine used to treat allergies or hives) as needed but failed to evidence an indication for when the patient should take it. A section that described goal for the patient indicated the patient’s hemoglobin A1c (a blood test used to determine the patient’s blood sugar over the last 3 months) would be at 6 (below 5.7 is considered normal) by the end of the certification period. During an interview on 8/3/2023, at 2:17 PM, the Clinical Manager indicated they should get an ideal A1c level specific to the patient from the physician. The Clinical Manager indicated the patient would take Claritin when their seasonal allergies were bothering them. 7. During an interview on 8/3/2023, from 2:05 PM - 2:12 PM, the clinical manager indicated the patients' goals were developed based on the patient's assessment of diagnosis, durable medical equipment, patient preferences and disciplines. The Clinical Manager indicated a PRN (as needed) order should include the dose, frequency and indication. The Clinical Manager indicated a patient would be placed on bleeding precautions anytime a patient is taking an anticoagulant (blood thinning medication) which included Eliquis and is assessed at the start of care. The Clinical Manager indicated they believed including a homebound narrative would help describe the patient in a "bigger picture." 1. During an observation of care at the home of Patient #1, a prescription bottle was observed in the home with a label indicating the patient took Baclofen (a medication used for muscle spasms) 3 times a day. Clinical record on 8/1/2023 evidenced an agency document titled “Home Health Certification and Plan of Care” for certification period 6/20/2023-8/18/2023, and signed by the Alternate Clinical Manager, which indicated the patient’s medication included, but were not limited to, Baclofen 3 times a day and as needed. Review failed to evidence the plan of care was individualized to include the correct medication frequency. Review indicated the plan of care included blood sugar parameters and failed to evidence the patient’s diagnosis included diabetes (a chronic condition which affects the way the body processes blood sugar). Review of the plan of care indicated the pathophysiology of an unidentified disease was a degenerative, noninflammatory joint disease with associated risk factors, signs and symptoms, preventative measures, and possible complications. Review failed to evidence the diagnoses included on the plan of care were a degenerative, noninflammatory joint disease. Review indicated the patient’s primary diagnosis was neuromuscular dysfunction of the bladder (damage to the nerves and/or muscles of the bladder causing abnormal function) and failed to evidence interventions and goals in the plan of care related to the primary diagnosis. Review indicated the patient’s rehab potential was blank. During an interview on 8/2/2023, at 3:12 PM, the Clinical Manager could not find the patient’s diagnoses included diabetes and indicated the blood sugar parameters should not be included if the patient did not have a diabetes diagnosis and was not checking blood sugars. The Clinical Manager indicated the pathophysiology of the unidentified joint disease was a default in the program used to develop the plans of care and was not individualized to the patient. At 3:18 PM, the Clinical Manager indicated interventions related to the primary diagnosis such as bladder training and tracking output should have been included in the plan of care. The Clinical Manager indicated the rehab potential should have been completed on the plan of care. During an interview on 8/3/2023, at 4:47 PM, the Alternate Clinical Manager indicated the patient needed bladder training such as Kegel exercises (exercises to strengthen the pelvic floor) and scheduled toileting related to the patient’s primary diagnosis. At 4:52 PM, the Alternate Clinical Manager indicated the medication discrepancy was a documentation error, and the plan of care should include the frequency of Baclofen to be 3 times a day. The Alternate Clinical Manager indicated the blood sugar parameters was automatically added to the plan of care. 2. Clinical record review on 8/3/2023, for Patient #2, evidenced an agency document titled “Home Health Certification and Plan of Care” for certification period 5/23/2023-7/21/2023, which indicated the patient’s medications included, but were not limited to, albuterol (medication used to treat wheezing and shortness of breath) as needed, baclofen (medication to treat muscle spasms) as needed, oxycodone (a narcotic pain medication) as needed, and Plavix (a medication used to prevent blood clots). Review failed to evidence the agency individualized the plan of care to include for what indications the medications were to be taken as needed. Review indicated the skilled nurse was to facilitate the patient’s advanced care planning and facilitate a meeting with the physician for covered services for advanced care planning. Review failed to evidence the safety measures included bleeding precautions for the use of Plavix. Review indicated the skilled nurse was to provide wound treatment as ordered by the physician and failed to evidence to where the wounds were located and what was the individualized ordered wound treatment to be provided. During an interview on 8/3/2023, at 3:38 PM, the Clinical Manager indicated oxycodone was for pain, baclofen was for muscle spasms, and albuterol was for shortness of breath and indicated bleeding precautions should have been included in the safety precautions. At 3:42 PM, the Clinical Manager indicated the advanced care planning intervention was a default intervention that should not be included in the patient’s plan of care. At 3:42 PM, the Clinical Manager indicated the wounds were located to both legs and the ordered wound treatment was for CeraVe (a moisturizing cream) daily. The Clinical Manager indicated the wound location and wound care orders should be included in the plan of care. 3. Clinical record review on 8/2/2023, for Patient #3, evidenced an agency document titled “Home Health Certification and Plan of Care” for certification period 6/9/2023-8/7/2023, which indicated the patient’s medication included Voltaren gel (a topical medicated gel used for pain relief) applied topically 4 times a day and failed to evidence the plan of care was individualized to include to where the Voltaren gel was to be applied. Review failed to evidence the plan of care included the patient’s rehab potential. Review indicated the agency was to provide home health aide services 1 time a week for 9 weeks and failed to evidence the plan of care included interventions and goals related to the home health aide services. During an interview on 8/3/2023, at 1:03 PM, the Clinical Manager indicated the Voltaren gel was to be applied to the patient’s knees and elbows. The Clinical Manager indicated the plan of care should include the patient’s rehab potential was fair and indicated the plan of care should include home health aide services for personal care and activities of daily living. 410 IAC 17-13-1(a)(1)(D)(ii, ix, x, 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 clinical record review and interview, the agency failed to ensure wound care was provided only as ordered by a physician in 1 of 1 clinical record reviewed with a wound. (Patient #2) The findings include: Review of an agency policy revised November 2021, titled “Wound Care” stated, “… Nurse/therapist will provide wound care per physician orders ….” Clinical record review on 8/3/2023, for Patient #2, evidenced an agency document titled “Start of Care” completed by the Clinical Manager/registered nurse (RN) and dated 5/23/2023, which indicated the RN assessed the patient to have two stasis wounds (wounds to the lower extremities caused by damaged veins), one to the right lower leg and a wound to the left lower leg. Review of an agency document titled “Home Health Certification and Plan of Care” for certification period 5/23/2023-7/21/2023, indicated the skilled nurse was to provide wound treatment as ordered by the physician and failed to evidence the specific wound care ordered. Review of agency documents titled “Skilled Nurse Visit” completed by the Clinical Manager and dated 5/25/2023, 6/9/2023, and 7/5/2023, indicated cream was applied daily and as needed. During an interview on 8/3/2023, at 3:42 PM, the Clinical Manager indicated she provided wound care at every visit by cleansing the wound with wound cleanser and applying CeraVe cream to the blisters on the lower extremities. The Clinical Manager indicated she did not have an order for cleansing the wounds with wound cleanser and the patient informed the Clinical Manager the physician wanted the patient to have CeraVe cream applied to the blisters. The Clinical Manager indicated she did not have a wound treatment order from the physician for the CeraVe cream. 410 IAC 17-13-1(a)

Review and revision of the plan of care CFR(s): 484.60(c) Standard: Review and revision of the plan of care. This STANDARD is not met as evidenced by: Based on record review an interview, the agency failed to ensure the plan of care was revised to include all current treatment orders for 2 of 4 active clinical records reviewed. (Patients #4, 5) The findings include: 1. Clinical record review on 8/2/2023, for patient #4, start of care 6/13/2023, evidenced an agency document titled “Skilled Nurse Visit” from 6/28/2023, which indicated the patient reported taking Tylenol. Record review failed to evidence the plan of care for certification period 6/13/2023 – 8/11/2023, included Tylenol. Review failed to evidence the plan of care was revised to include all current medications being taken by the patient. During an interview on 8/3/2023, at 2:57 PM, the Clinical Manager indicated the medication Tylenol should have been added to the plan of care. 2. Clinical record review on 8/3/2023, for patient #5, start of care 6/7/2023, evidenced an agency document titled “Skilled Nurse Visit” from 7/6/2023, which indicated the patient reported taking “Tylenol Arthritis.” Record review failed to evidence the plan of care for certification period 6/7/2023 – 8/5/2023, included Tylenol Arthritis. Review failed to evidence the plan of care was revised to include all current medications being taken by the patient. During an interview on 8/3/2023, at 2:51 PM, RN 1 indicated Tylenol Arthritis was not revised into the plan of care.

Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient's condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed revise the plan of care and ensure the practitioner responsible for the plan of care reviewed the plan of care as frequently as the patient’s condition required in 1 of 1 clinical record reviewed with a wound. (Patient #2) The findings include: Clinical record review on 8/3/2023, for Patient #2, evidenced an agency document titled “Skilled Nurse Visit” completed by the Clinical Manager/registered nurse (RN) and dated 7/15/2023, which indicated the patient had a new wound to the left thigh, a pressure ulcer (wounds to the skin and underlying tissue resulting from prolonged pressure to the skin) stage II (some skin loss or damage involving the top-most skin layers), that was not present at the last skilled nursing visit. Review indicated the wound had moderate drainage with a foul odor. Review indicated the RN cleansed the wound with wound wash, applied a betadine (a skin disinfectant) soaked gauze, and applied ABD (absorbent wound bandage) and gauze wrap. Review failed to evidence the agency updated the plan of care to include the wound and treatment order to the left thigh and failed to ensure the physician reviewed the plan of care for revision due to the change in the patient's condition. During an interview on 8/3/2023, at 3:30 PM, the Clinical Manager indicated she did not revise the plan of care because she did not write the order for the wound treatment until 7/18/2023, and by then the patient had gone to the hospital. 410 IAC 17-13-1(a)(2)

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 ensure coordination of care with all providers servicing the patient in 1 of 1 home visits with a home health aide. (Patient #1) The findings include: Review of an agency policy revised November 2021, titled “Care/Service Coordination” stated, “… Care coordination will include, but not be limited to: … Integration of 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 ….” During an observation of care at the home of Patient #1 on 8/2/2023, at 9:59 AM, Person C was noted at the patient’s home and indicated they were a caregiver for the patient from Entity A and had been servicing the patient for 3 months. During the observation of care, Person C participated without invitation in conversations between the patient and home health aide from the other room where Person C was cleaning. Patient #1 was observed multiple times rolling her eyes when Person C would talk during the care provided by the home health aide. Person C shared unsolicited personal information about the patient with the surveyor and home health aide. Clinical record review on 8/1/2023, failed to evidence any services provided to the patient in the home and failed to evidence any care coordination with Entity A. During an interview on 8/2/2023, at 11:51 AM, Person B, office manager at Entity A, indicated Entity A provided the patient with homemaker and attendant care services and was unaware of any home care services provided by the home health agency. During an interview on 8/2/2023, at 2:15 PM, the Clinical Manager indicated there was no care coordination with Entity A. 17-12-2(h)

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on observation and interview, the home health agency failed to ensure all required information was maintained in the patients home to include a written visit schedule for 3 of 3 home visits conducted (Patient # 1, 4, 5) The findings include: 1. During an observation of care at the home of Patient #1 on 8/2/2023, at 9:59 AM, a written visit schedule was not observed in the patient's home. During an interview on 8/2/2023, at 10:09 AM, Patient #1 indicated they did not get a written visit schedule but is informed verbally of when agency staff will make visits when they call the night before. 2. An observation of a home visit was conducted on 8/2/2023, from 9:43 AM – 10:15 AM, for Patient #4, start of care 6/13/2023, with PT 1. During the visit, the patient’s information folder was reviewed and failed to evidence a written visit schedule for all disciplines providing services on behalf of the agency. Observation and record review failed to evidence a written visit schedule was made available to the patient in their home by the agency. During an interview on 8/2/2023, at 10:12 AM, Patient #4 indicated PT 1 will set up the next visit during their scheduled time together and then calls in the morning of the visit to confirm. 3. An observation of a home visit was conducted on 8/2/2023, from 11:02 AM – 12:05 AM, for patient #5, start of care 6/7/2023, with RN 1. During the visit, the patient’s information folder was reviewed and failed to evidence a written visit schedule for all disciplines providing services on behalf of the agency. Observation and record review failed to evidence a written visit schedule was made available to the patient in their home by the agency.

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on observation and interview, the home health agency failed to ensure all required information was maintained in the patients home to include a a medication list with instructions for 3 of 3 home visits conducted (Patient # 1, 4, 5). The findings include: 2. An observation of a home visit was conducted on 8/2/2023, from 9:43 AM – 10:15 AM, for patient #4, start of care 6/13/2023, with PT 1. During the visit, the patient’s information folder was reviewed and failed to evidence a list of medications being taken by the patient with instructions. Observation and record review failed to evidence a current list of medications with instructions was made available to the patient in their home by the agency. 3. An observation of a home visit was conducted on 8/2/2023, from 11:02 AM – 12:05 AM, for patient #5, start of care 6/7/2023, with RN 1. During the visit, the patient’s information folder was reviewed and failed to evidence a list of medications being taken by the patient with instructions. Observation and record review failed to evidence a current list of medications with instructions was made available to the patient in their home by the agency. 1. During an observation of care at the home of Patient #1 on 8/2/2023, at 9:59 AM, a written medication schedule and instructions was not observed in the patient's home. During an interview on 8/2/2023, at 10:09 AM, Patient #1 indicated they did not remember getting a patient home folder from the agency.

Treatments and therapy services CFR(s): 484.60(e)(3) Any treatments to be administered by HHA personnel and personnel acting on behalf of the HHA, including therapy services. This ELEMENT is not met as evidenced by: Based on observation and interview, the home health agency failed to ensure all required information was maintained in the patients home to include a plan for treatments provided for 3 of 3 home visits conducted (Patient #1, 4, 5). The findings include: 2. An observation of a home visit was conducted on 8/2/2023, from 9:43 AM – 10:15 AM, for patient #4, start of care 6/13/2023, with PT 1. During the visit, the patient’s information folder was reviewed and failed to evidence a current, individualized plan of treatment. Observation and record review failed to evidence a current plan of treat was made available to the patient in their home by the agency. 3. An observation of a home visit was conducted on 8/2/2023, from 11:02 AM – 12:05 AM, for patient #5, start of care 6/7/2023, with RN 1. During the visit, the patient’s information folder was reviewed and failed to evidence a current, individualized plan of treatment. Observation and record review failed to evidence a current plan of treat was made available to the patient in their home by the agency. 1. During an observation of care at the home of Patient #1 on 8/2/2023, at 9:59 AM, written treatments to be provided by the agency were not observed in the patient's home. During an interview on 8/2/2023, at 10:09 AM, Patient #1 indicated they did not remember getting a patient home folder from the agency.

Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This ELEMENT is not met as evidenced by: Based on observation, record review and interview, the home health agency failed to ensure all required information was maintained in the patients home to include the name of the clinical manager for 3 of 3 home visits conducted (Patient #1, 4, 5). The findings include: 2. An observation of a home visit was conducted on 8/2/2023, from 9:43 AM – 10:15 AM, for patient #4, start of care 6/13/2023, with PT 1. During the visit, the patient’s information folder was reviewed and failed to evidence contact information to include the name of the clinical manager. Observation and record review failed to evidence the clinical manager’s contact information was made available to the patient in their home buy the agency. 3. An observation of a home visit was conducted on 8/2/2023, from 11:02 AM – 12:05 AM, for patient #5, start of care 6/7/2023, with RN 1. During the visit, the patient’s information folder was reviewed and failed to evidence contact information to include the name of the clinical manager. Observation and record review failed to evidence the clinical manager’s contact information was made available to the patient in their home buy the agency. 1. During an observation of care at the home of Patient #1 on 8/2/2023, at 9:59 AM, the name and contact information of the clinical manager was not observed in the patient's home. During an interview on 8/2/2023, at 10:09 AM, Patient #1 indicated they did not remember getting a patient home folder from the agency.

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 home health agency failed to ensure all employees practiced standard/universal precautions to prevent the transmission of infections and failed to follow agency infection control policies and procedures in 2 of 3 home visits. (Patients #1, #5) The findings include: 3. An observation of a home visit was conducted on 8/2/2023, at 11:00 AM, for Patient #5, start of care 6/7/2023, with RN 1. At 11:02 AM, RN 1 placed a barrier on the patient’s coffee table and set their bad and tablet on the barrier. RN 1 used alcohol-based hand rub (ABHR) went into their bag and donned a pair of gloves. Patient #5 was sitting on the couch for the skilled nurse assessment which included assessment of blood pressure, temperature, and pulse oximetry. At 11:13 AM, RN 1 indicated they were listening as their stethoscope was place to the patient’s back, chest and stomach. At 11:24 AM, RN 1 reviewed medications with the patient verbally while documenting in the tablet. At 11:26 AM, RN 1 assessed the patient’s feet by removing the shoes and socks, then assessed a new injury to the patient’s toe. At 11:31 AM, RN 1 documented in the tablet and asked the patient about life saving methods, pharmacy information, and emergency contact information. At 11:51 AM, RN 1 removed their gloves and used ABHR. Observation failed to evidence glove changes and hand hygiene performed after patient assessments, documentation in the tablet, or moving from dirty/soiled areas to clean. Observation failed to evidence hand hygiene and glove changes were performed to prevent the spread of possible infectious diseases. 4. During an interview on 8/2/2023, at 2:07 PM, the Clinical Manager indicated hand hygiene should be performed between every glove change and gloves should be changed after any contact made with the patient or when moving to a new procedure. 1. Review of an agency policy revised November 2021, titled “Hand Hygiene” stated, “… Hand decontamination using an alcohol-based hand rub should be performed: … After contact with body fluids or excretions … When moving from a contaminated body site to a clean body site during patient care … After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient … After removing gloves….” 2. During an observation of care at the home of Patient #1 on 8/2/2023, at 10:33 AM, Home Health Aide (HHA) 1 was observed with gloved hands wiping the patient’s anus and in between the patient’s buttocks with a disposable wipe and a brown substance was observed smeared on the wipe. HHA 1 was observed disposing of the wipe in a plastic bag and then picking up the wipe container with the gloved hands, removing a wipe, placing the wipe container back on the bed, and wiping the patient’s anus and in between the patient’s buttocks with the disposable wipe. HHA 1 was observed picking up the wipe container, removing a new wipe, placing it on the bed, and wiping in between the patient’s buttocks 4 additional times. HHA 1 was then observed to pick up a washcloth out of the soapy water basin with gloved hands and wash the exterior of the patient’s buttocks. HHA 1 was not observed to have removed gloves and performed hand hygiene after cleaning the patient’s anus and in between the buttocks and prior to picking up the wipe container and placing it on the patient’s bed and before washing the exterior of the patient’s buttocks. During an interview on 8/2/2023, at 2:07 PM, the Clinical Manager indicated clinicians should change gloves and apply hand sanitizer after cleaning in between a patient’s buttocks before picking up any objects and washing any other area of the body. 410 IAC 17-12-1(m)

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on record review the home health agency failed to ensure all infections were tracked for 1 of 1 clinical record reviewed where an infection was identified. (Patient #5). The findings include: Clinical record review on 8/3/2023, for Patient #5, start of care 6/7/2023, evidenced a skilled nurse visit performed on 7/18/2023, by RN 1, that indicated the patient was exhibiting signs and symptoms of a urinary tract infection (UTI). This document indicated the patient called the physician and antibiotics were ordered to treat the UTI. Record review on 8/3/2023, of the agency’s tracking logs failed to evidence any infections since April 2023. Record review failed to evidence all infections were tracked and documented. On 8/3/2023, at 4:04 PM, the Administrator was notified an infection was identified for Patient #5 and was not included in the infection log.

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 skilled professional failed to provide the services as directed in the plan of care in 5 of 6 clinical records reviewed. (Patients #1, 2, 3, 4, 5) The findings include: 5. Clinical record review on 8/2/2023, for patient #4, start of care 6/13/2023, evidenced an agency document titled “Home Health Certification and Plan of Care” that stated “SN to assess surgical site or healing/ complications; teach patient/ caregiver care of incision to prevent infection, S/ S [signs and symptoms] to report immediately and who to contact. Per physician orders, care of incision is as follows: open to air, no scrubbing to site, monitor for bleeding or excessive bruising ….” Record review of agency documents titled “Skilled Nursing Visit” failed to evidence documentation for an assessment and teaching to the patient on 6/14/2023, 6/28/2023, 7/12/2023, and 7/26/2023, for surgical site healing as ordered on the plan of care. During an interview on 8/3/2023, at 2:55 PM, when queried about the surgical site and documentation of assessment, the Clinical Manager indicated the patient had a cardiac procedure where the doctor inserted a catheter through the right groin. The clinical manager indicated that would not count as a wound and described the site as a puncture with some bruising. 6. Clinical record review on 8/3/2023, for Patient #5, start of care 6/7/2023, evidenced an agency document titled “Home Health Certification and Plan of Care” for certification period 6/7/2023 – 8/5/2023, indicated orders for the skilled nurse to notify the physician if the patient’s pain level was greater than 6, on a 1 – 10 pain scale. Record review of a skilled nurse visit document from 7/6/2023, electronically signed by RN (Registered Nurse) 1 indicated the patient rated their current pain level as 7 out of 10. Review failed to evidence the physician was notified of the out-of-range pain level as ordered on the plan of care. Record review of a skilled nurse visit document from 7/18/2023, electronically signed by RN 1 indicated the patient rated their current pain level as 8 out of 10. Review failed to evidence the physician was notified of the out-of-range pain level as ordered on the plan of care. During an interview on 8/3/2023, at 2:51 PM, RN 1 indicated the pain levels were not reported to the physician from 7/6/2023 and 7/18/2023. During an interview on 8/3/2023, at 2:13 PM, the Clinical Manager indicated when a physician established parameters for vital signs on the plan of care, the clinician should call the physician while still in the patient's home and document the communication within the visit or on a follow up communication note. 1. Review of an agency policy revised November 2021, titled “Wound Care” stated, “… the wound assessment and documentation will include measurement of length, width, depth and undermining and tunneling if present….” 2. Clinical record on 8/1/2023, for Patient #1, evidenced an agency document titled “Home Health Certification and Plan of Care” for certification period 6/20/2023-8/18/2023, which indicated the skilled nurse was to review the patient’s increased nutrition risk behaviors, caloric intake monitoring, and weight records and educate the patient on improving nutritional intake, reading food labels, meal planning, eating out, and obesity management. Review of agency documents titled “Skilled Nurse Visit” completed by the Alternate Clinical Manager/registered nurse (RN) and dated 6/20/2023, 7/4/2023, and 7/18/2023, failed to evidence the RN reviewed the patient’s caloric intake monitoring and weight records and failed to educate the patient on improving nutritional intake, reading food labels, meal planning, eating out, and obesity management as directed in the plan of care. Review indicated the skilled nurse was to instruct the patient on the benefits of advanced care planning, assisting the patient with obtaining advanced care planning forms, and refer to medical social worker or with primary care physician for covered services for advanced care planning. Review failed to evidence the RN educated the patient to and provided the forms for advanced care planning as directed in the plan of care. During an interview on 8/2/2023, at 3:51PM, the Clinical Manager indicated clinicians should perform the tasks at every visit as ordered in the plan of care. During an interview on 8/3/2023, at 4:46 PM, the Alternate Clinical Manager indicated there was no caloric intake or weight records for the patient and indicated the patient was obese and ate fast food often. The Alternate Clinical Manager indicated the patient needed education on better nutrition. At 4:49 PM, the Alternate Clinical Manager indicated the patient did not have a do not resuscitate order (type of advanced care plan) and did not have an emergency plan in place. 3. Clinical record review on 8/3/2023, for Patient #2, evidenced an agency document titled “Start of Care” completed by the Clinical Manager/registered nurse (RN) and dated 5/23/2023, which indicated the RN assessed the patient to have two stasis wounds (wounds to the lower extremities caused by damaged veins), one to the right lower leg and a wound to the left lower leg. Review of an agency document titled “Home Health Certification and Plan of Care” for certification period 5/23/2023-7/21/2023, indicated the skilled nurse was to provide skilled services 2 times a week for 1 week and then 1 time every other week for 8 weeks and was to assess the integumentary system (body system to include the skin) and for wound progression or decline. Review of agency documents titled “Skilled Nurse Visit” completed by the Clinical Manager and dated 5/25/2023, 6/9/2023, and 7/5/2023, indicated the blisters to both legs were healing and cream was applied daily and as needed. Review of document completed by the Clinical Manager and dated 7/15/2023, indicated the patient had a new wound to the left thigh, a pressure ulcer (wounds to the skin and underlying tissue resulting from prolonged pressure to the skin) stage II (some skin loss or damage involving the top-most skin layers), that was not present at the last skilled nursing visit. Review failed to evidence the RN assessed the wound to include the measurements of the wound. During an interview on 8/3/2023, at 3:17 PM, the Clinical Manager indicated she did not assess the wounds to both legs during her skilled nurse visits but just cleansed the wound and applied cream. At 3:30 PM, the Clinical Manager indicated the assessment of the wound should include wound measurements. 4. Clinical record review on 8/2/2023, for Patient #3, evidenced an agency document titled “Home Health Certification and Plan of Care” for certification period 6/9/2023-8/7/2023, which indicated the agency was to notify the physician of a temperature less than 96 degrees Fahrenheit. Review indicated the patient’s diagnoses included, but were not limited to, heart disease and diabetes (a chronic condition which affects the way the body processes blood sugar) and indicated the patient’s medications included Lantus (a type of insulin; a medication used to lower blood sugar). Review indicated the skilled nurse was to educate the patient on diabetes management to include diabetic foot care and the cardiovascular (system that supplies blood throughout the body) disease management. Review indicated the patient’s mental status included depression and indicated the skilled nurse was to educate on depression management. Review of an agency document titled “Start of Care” completed by RN 1 and dated 6/9/2023, indicated the patient’s temperature was 95.4 degrees Fahrenheit and failed to evidence RN 1 notified the physician as directed in the plan of care. Review indicated the patient had swelling to both lower extremities. Review indicated the patient was assessed to have signs and symptoms of depression. Review of an agency document titled “Skilled Nurse Visit” completed by RN 1 and dated 6/22/2023, indicated the patient had swelling to the lower extremities. Review failed to evidence the RN educated the patient per the plan of care to cardiovascular disease process causing the swelling. Review failed to evidence the skilled nurse educated the patient per the plan of care on the management of depression and diabetes to include diabetic foot care. During an interview on 8/3/2023, at 12:35 PM, RN 1 indicated she did not think she notified the physician of the temperature outside of parameters and indicated she should have. At 12:52 PM, RN 1 indicated the patient seemed happy so she did not educate on depression management. At 12:54 PM, RN 1 indicated she must not have educated the patient on diabetic management and diabetic foot care. During an interview on 8/3/2023, at 1:08 PM, the Clinical Manager indicated the RN should have educated the patient per the plan of care on the swelling due to the cardiovascular disease to include elevating the legs and monitoring fluid intake and diet. 410 IAC 17-14-1(a)(1)(H)

Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This ELEMENT is not met as evidenced by: Based on record review and interview, the skilled nurse failed to provide patient education in 2 of 5 clinical records reviewed with high risk medications. (Patients #1, 2) The findings include: 1. Clinical record review on 8/1/2023, for Patient #1, evidenced an agency document titled “Home Health Certification and Plan of Care” for certification period 4/21/2023-6/19/202, evidenced the patient’s medications included Xarelto (an anticoagulant medication used to thin the blood) and included bleeding precautions in the patient’s safety measures. Review of an agency document titled “Start of Care” completed by the Alternate Clinical Manager/registered nurse (RN) and dated 4/21/2023, indicated the patient did not receive instruction on special precautions for high risk medication to include anticoagulants. During an interview on 8/3/2023 at 4:42 PM, the Alternate Clinical Manager indicated it was an oversight that the patient was not educated on the risks of Xarelto and should have been. 2. Clinical record review on 8/3/2023, for Patient #2, evidenced an agency document titled “Home Health Certification and Plan of Care” for certification period 5/23/2023-7/21/2023, which indicated the patient’s medications included Amaryl (a hypoglycemic medication used to treat high blood sugar). Review of an agency document titled “Start of Care” completed by the Clinical Manager/RN and dated 5/23/2023, indicated the patient did not receive instruction on special precautions for high risk medication to include hypoglycemics. During an interview on 8/3/2023, at 3:36 PM, the Clinical Manager indicated the patient should have been educated on the special precautions for the use of Amaryl.

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 skilled nurse failed to accurately prepare clinical notes in 4 of 6 clinical records reviewed. (Patients #1, 2, 4, 5) The findings include: 5. Clinical record review on 8/3/2023, for patient #4, start of care 6/13/2023, evidenced an agency document titled “PT Re-Evaluation” signed by PT 1 on 7/19/2023, that indicated the physician was notified and agreed with an updated PT frequency of once a week for 4 weeks. Record review failed to evidence subsequent PT visits documented since the re-evaluation (23 days later). Review failed to evidence the PT prepared timely clinical notes. During an interview on 8/3/2023, at 2:58 PM, the Clinical Manager indicated PT 1 has seen the patient since the re-evaluation and will call to find out where the documentation was. 6. Clinical record review on 8/3/2023, for Patient #5, evidenced an agency document of a start of care comprehensive assessment performed on 6/7/2023, by RN 2, which failed to evidence psychosocial, sensory, and respiratory assessments completed, discharge planning, or a visit narrative to describe any missing pieces of the comprehensive assessment. During an interview on 8/3/2023, at 2:08 PM, the Clinical Manager indicated the comprehensive assessment included respiratory, sensory and psychosocial status. The Clinical Manager indicated the discharge planning began at the start of care and should assess the patient's preferences to create goals and determine where to discharge the patient. During an interview on 8/3/2023, at 2:44 PM, the Clinical Manager indicated all assessments should have been completed on the start of care comprehensive assessment. 1. Review of an agency policy revised November 2021, titled “Wound Care” stated, “… A qualified agency Registered Nurse or Registered Physical Therapist will assess wound(s) as part of the comprehensive initial assessment and will document all findings as per agency policy. … The admitting clinician will document each wound status including location and etiology, measurement of length, width and depth, undermining and tunneling, if present, description of the wound bed, signs and symptoms of infection, healing and peri wound skin condition … At each dressing change the wound will be assessed and documentation will include a description of the wound bed, drainage, signs and symptoms of infection, healing and peri wound skin condition. … At least every week, the wound assessment and documentation will include measurement of length, width, depth and undermining and tunneling if present….” 2. Clinical record review on 8/1/2023, for Patient #1, evidenced an agency document titled “Start of Care” completed by the Alternate Clinical Manager/registered nurse (RN) and dated 4/21/2023, evidenced a section for potential risk for infection assessment and caregiver status, to include the caregiver availability, which was not completed by the RN. Review of the patient’s risk for pressure ulcer development indicated the RN assessed the patient ambulate with assistance and assessed the patient to be chairbound for the functional status for ambulation. Review failed to evidence the RN completed the section for the assessment of the patient’s strengths. Review evidenced the patient’s current plan of care indicated the patient’s medications included Xarelto (a medication used to thin the blood) and failed to evidence the RN included bleeding precautions in the assessment of the patient’s safety measures. During an interview on 8/3/2023, at 4:42 PM, the Alternate Clinical Manager indicated the assessment of the patient’s ambulation status should be clear. 3. Clinical record review on 8/3/2023, for Patient #2, evidenced an agency document titled “Start of Care” completed by the Clinical Manager/RN and dated 5/23/2023, which indicated the RN assessed the patient to have two stasis wounds (wounds to the lower extremities caused by damaged veins), one to the right lower leg and a wound to the left lower leg. Review failed to evidence the RN prepared the clinical note to include an assessment of the wounds to include size, description of the wound to include color, drainage, and odor, and appearance of the surrounding tissue. During an interview on 8/3/2023, at 3:10 PM, the Clinical Manager indicated the wounds to both legs were blisters and indicated a blister was not a wound. The Clinical Manager indicated the wound assessment should include the measurement of the wound, the assessment of the surrounding skin, drainage, and signs and symptoms of infection. 4. During an interview on 8/2/2023, at 3:28 PM, the Clinical Manager indicated the clinician should complete the comprehensive assessment in its entirety. 17-14-1(a)(1)(E) 410 IAC 17-14-1(c)(5)

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the home health aides (HHA) had complete, patient-specific written patient care instructions to be performed by the home health aides in 2 of 4 clinical records reviewed with HHA services. (Patients #1, 2) The findings include: 1. Review of an agency policy revised November 2018, titled “Home Health Aide Plan of Care” stated, “… The home health aide plan of care will be individualized to the specific patient and will include at least: … Frequency of visits …. Safety measures ….” 2. Clinical record review on 8/1/2023, for Patient #1, evidenced an agency document titled “Home Health Certification and Plan of Care” for certification period 4/21/2023-6/19/2023, which evidenced the patient’s medications included Xarelto (an anticoagulant medication used to thin the blood) and included bleeding precautions in the patient’s safety measures. Review of an agency document titled “HHAide [home health aide] Care Plan” signed by the Alternate Clinical Manager/registered nurse (RN) and dated 6/15/2023, failed to evidence the RN instructed the HHA of the bleeding precautions. Review failed to evidence the RN directed the HHA of the HHA frequency. Review indicated the RN instructed the HHA to assist with ambulation and indicated the patient was chairbound. During an interview on 8/2/2023 at 3:41 PM, the Clinical Manager indicated the bleeding precautions and HHA frequency should have been included in the HHA care plan. The Clinical Manager indicated the patient’s ambulatory status was contradicting and unclear. During an interview on 8/3/2023, at 4:42 PM, the Alternate Clinical Manager indicated the patient informed her she used to walk but did not anymore and indicated the patient’s ambulatory status should be more clear. 3. Clinical record review on 8/3/2023, for Patient #2, evidenced an agency document titled “Home Health Certification and Plan of Care” for certification period 5/23/2023-7/21/2023, which indicated the patient’s medications included, but were not limited to, Plavix (a medication used to prevent clots and increasing the risk of bleeding). Review of an agency document titled “HHAide Care Plan” signed by the Clinical Manager/RN and dated 5/23/2023, failed to evidence the RN instructed the HHA of the bleeding precautions. During an interview on 8/3/2023, at 3:38 PM, the Clinical Manager indicated the HHA care plan should include bleeding precautions. 410 IAC 17-13-2(a)

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure the home health aide (HHA) provided services as directed in the aide care plan in 4 of 4 clinical records reviewed with HHA services. (Patients #1, 2, 3, 6) The findings include: 6. Clinical record review on 8/1/2023, for patient #6, evidenced a HHA care plan for episode 7/19/2023 – 9/16/2023, electronically signed by RN 1, which indicated the HHA should record the patient’s last bowel movement at every visit. Record review of agency HHA visit documents from 7/21/2023, 7/25/2023 and 7/28/2023, indicated the task of recording the patient’s last bowel movement was completed, but failed to evidence when the last bowel movement occurred. During an interview on 8/3/2023, at 2:31 PM, the clinical manager indicated the bowel movement should have been documented. 1. Clinical record review on 8/1/2023, for Patient #1, evidenced an agency document titled “HHAide [home health aide] Care Plan” signed by the Alternate Clinical Manager/registered nurse (RN) and dated 6/15/2023, which indicated the HHA was to record the last bowel movement at every visit. During an observation of care at the home of Patient #1 with HHA 1 on 8/2/2023, from 9:59 AM to 10:49 AM, HHA 1 was not observed recording the patient’s last bowel movement as directed per the HHA care plan. Review of agency documents titled “HHA Visit” completed by HHA 1 and dated 7/3/2023, 7/7/2023, 7/11/2023, 7/14/2023, 7/21/2023, 7/25/2023, 7/28/2023, and 8/2/023, failed to evidence the HHA recorded the patient’s last bowel movement per the HHA care plan. 2. Clinical record review on 8/3/2023, for Patient #2, evidenced an agency document titled “HHAide Care Plan” signed by the Clinical Manager/RN and dated 5/23/2023, which indicated the HHA was to record the last bowel movement at every visit. Review of agency documents titled “HHA Visit” completed by HHA 1 and dated 5/26/2023, 6/2/2023, 6/9/2023, 6/16/2023, and 6/23/2023, failed to evidence the HHA recorded the patient’s last bowel movement per the HHA care plan. 3. Clinical record review on 8/2/2023, for Patient #3, evidenced an agency document titled “HHAide Care Plan” signed by the Clinical Manager/RN and dated 6/9/2023, which indicated the HHA was to record the last bowel movement at every visit. Review of agency documents titled “HHA Visit” completed by HHA 1 and dated 6/10/2023, 6/14/2023, 6/21/2023, and 6/28/2023, failed to evidence the HHA recorded the patient’s last bowel movement per the HHA care plan. 4. During an interview on 8/2/2023, at 3:45 PM, the Administrator indicated the HHA should perform the tasks on the HHA care plan. 5. During an interview on 8/2/2023, at 3:45 PM, Administrative Staff 2 indicated the HHA should record the last bowel movement on the HHA visit note.

HH aide supervision elements CFR(s): 484.80(h)(4)(i-vi) Home health aide supervision must ensure that aides furnish care in a safe and effective manner, including, but not limited to, the following elements: (i) Following the patient's plan of care for completion of tasks assigned to a home health aide by the registered nurse or other appropriate skilled professional; (ii) Maintaining an open communication process with the patient, representative (if any), caregivers, and family; (iii) Demonstrating competency with assigned tasks; (iv) Complying with infection prevention and control policies and procedures; (v) Reporting changes in the patient's condition; and (vi) Honoring patient rights. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the home health aide (HHA) was supervised to ensure the aide furnished care that followed the patient’s plan of care in 3 of 4 clinical records reviewed with home health aide services. (Patients #1, 2, 3) The findings include: 1. Clinical record review on 8/1/2023, for Patient #1, evidenced an agency document titled “HHAide [home health aide] Care Plan” signed by the Alternate Clinical Manager/registered nurse (RN) and dated 6/15/2023, which indicated the HHA was to record the last bowel movement at every visit. Review of agency documents titled “HHA Visit” completed by the HHA and dated 7/3/2023, 7/7/2023, 7/11/2023, 7/14/2023, 7/21/2023, and 7/25/2023, failed to evidence the HHA recorded the patient’s last bowel movement per the HHA care plan. Review of agency documents titled “HHA Supervisory Visit” signed by the Alternate Clinical Manager and dated 7/11/2023 and 7/25/2023, indicated the HHA followed the plan of care for completion of tasks as assigned. Review failed to evidence the RN provided home health aide supervision to ensure the home health aide followed the aide care plan as directed. During an interview on 8/3/2023, at 4:54 PM, the Alternate Clinical Manager indicated she did not look at the HHA visit notes because she did not have access to review the HHA visit notes in the electronic health record. 2. Clinical record review on 8/3/2023, for Patient #2, evidenced an agency document titled “HHAide Care Plan” signed by the Clinical Manager/RN and dated 5/23/2023, which indicated the HHA was to record the last bowel movement at every visit. Review of agency documents titled “HHA Visit” completed by HHA 1 and dated 5/26/2023, 6/2/2023, 6/9/2023, 6/16/2023, and 6/23/2023, failed to evidence the HHA recorded the patient’s last bowel movement per the HHA care plan. Review of agency documents titled “HHA Supervisory Visit” signed by the Clinical Manager and dated 6/6/2023, 6/20/2023, and 7/3/2023, indicated the HHA followed the plan of care for completion of tasks as assigned. Review failed to evidence the RN provided home health aide supervision to ensure the home health aide followed the aide care plan as directed. 3. Clinical record review on 8/2/2023, for Patient #3, evidenced an agency document titled “HHAide Care Plan” signed by the Clinical Manager/RN and dated 6/9/2023, which indicated the HHA was to record the last bowel movement at every visit. Review of agency documents titled “HHA Visit” completed by HHA 1 and dated 6/10/2023, 6/14/2023, 6/21/2023, and 6/28/2023, failed to evidence the HHA recorded the patient’s last bowel movement per the HHA care plan. Review of agency documents titled “HHA Supervisory Visit” signed by RN 1 and dated 6/23/2023 and 7/6/2023, indicated the HHA followed the plan of care for completion of tasks as assigned. Review failed to evidence the RN provided home health aide supervision to ensure the home health aide followed the aide care plan as directed. During an interview on 8/3/2023, at 12:56 PM, RN 1 indicated the HHA notes should be reviewed to ensure the HHA is providing care per the care plan. 4. During an interview on 8/2/2023, at 3:46 PM, the Clinical Manager indicated the RN should review the HHA visit notes as part of the HHA supervision and discuss any concerns with the HHA not following the plan of care with the HHA. The Clinical Manager indicated the RN should not have marked the HHA was following the care plan for completion of tasks as assigned. 410 IAC 17-14-1(n)

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the clinical record contained all required clinical notes in 1 of 1 clinical record reviewed with more than 1 certification period. (Patient #1) The findings include: Clinical record review on 8/1/2023, for Patient #1, evidenced an agency document titled “Home Health Certification and Plan of Care” for certification period 6/20/2023-8/18/2023, which indicated the agency was to provide home health aide (HHA) services 2 times a week for 9 weeks. Review failed to evidence home health aide visit notes for the week of 7/9/2023. During an interview on 8/2/2023, at 4:00 PM, the Clinical Manager indicated she thought the HHA did make visits during the week of 7/9/2023 and the notes were not in the record at time of review. The Clinical Manager indicated the reason they were not in the electronic health record was because there was a “glitch” with the electronic health record during that time. During an interview on 8/3/2023, at 3:03 PM, the Clinical Manager indicated the HHA made visits to the patient on 7/11/2023 and 7/14/2023 and were not documented in the electronic health record due to a “glitch” but were restored and in the record as of 8/3/2023. 17-15-1(a)(4)