Every finding on record at Care Plus Homehealth Care Inc

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR §484.102 Survey Dates: 01/05, 01/06, 01/07/2026 Active Census: 38 At this Emergency Preparedness survey, Care Plus Homehealth Care, INC, was found to be in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR §484.102. QR completed by Area 3 on 1/9/2026.

This visit was for a Federal Recertification and State Re-Licensure survey of a Home Health Provider. Survey Dates: 01/05, 01/06, and 01/07/2026 12-Month Unduplicated Skilled Admissions: 100 Partially Extended on 01/07/2026 at 2:32 PM This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Refer to State Form for additional State Findings. Abbreviations: HHA- Home Health Aide POC-Plan of Care SOC- Start of Care RN-Registered Nurse SN- Skilled Nursing LPN- Licensed Practical Nurse PT- Physical Therapy OASIS- Outcome and Assessment Information Set ADL- Activities of Daily Living DME- Durable Medical Equipment CM-Clinical Manager QR completed by Area 3 on 1/9/2026.

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 the patients received the frequency of services as ordered by physician for 1 of 2 active clinical records reviewed with only HHA services. (Patient #7) Findings Include: 1. An undated policy titled "Physician/Allowed Non-Physician Practitioner (NPP) Orders" indicated but was not limited to, " … All medications and treatments, that are part of the client's plan of care, must be ordered by the physician … NPP …" 2. A review of Patient #7's active clinical record evidenced a POC with a SOC of 07/23/2025 and a recertification period from 11/20/2025 to 01/18/2026. The POC evidenced the patient received HHA services 3 to 7 hours a day, 7 days a week for personal care and assistance with ADLs. A review of the HHA visit notes failed to evidence visit notes on the following weekend dates: 11/15, 11/16, 11/22, 11/23, 11/29, 11/30, 12/06, 12/07, 12/13, and 12/14/2025. During an interview with the Administrator on 01/07/2026 at 12:30 PM, they indicated Patient #7 was receiving attendant care services and they had not received an order for the patient. The HHAs go to the patient when they need them. They explained on the POCs, they needed to better differentiate attendant care services and HHA services. During an interview with the Administrator, Alternate Administrator, and the DON on 01/07/2026 at 3:50 PM, they indicated there was no updated order to evidence the patient requested to hold services on the weekends. 410 IAC 17-13-1(a)

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure the POC was individualized, included all DME and supplies, medication route and indication, hospitalization and emergency room risk, and instructions for a timely discharge for 4 of 7 active clinical records reviewed. (Patients #1, #2, #3, and #7) Findings Include: 1. A review of an undated policy titled "Plan of Care" indicated but was not limited to, " … 2. The Plan of Care shall be completed in full to include: … m. Medications … n. Medical supplies and equipment required … r. Instructions for timely discharge or referral. s. Discharge plans … u. Other appropriate items. v. All of the above items must always be addressed on the Plan of Care. …" 2. A review of Patient #1's active clinical record evidenced a POC with a SOC of 12/19/2025 and an initial certification from 12/19/2025 to 02/16/2026. The POC evidenced the following diagnoses: Sepsis (a medical emergency caused by an infection and causes damage to the body's tissues and organs), Pneumonia (a lung infection with the air sacs filled with fluid or pus), Atrial Fibrillation (a rapid, irregular heart rate), Hyperglycemia (high blood sugar), and Hypertension (high blood pressure). The POC evidenced the patient's DME included a walker and grab bars. The POC evidenced the patient took 5 milligrams (mg) of Eliquis (a blood thinner which prevents blood clots) 2 times a day orally. The section titled "Safety Measures" indicated but were not limited to, " … Fall precautions/Transfer Safety, Universal/Infection Precautions, Keep pathways clear, Proper use of assistive device …" During a home visit at Patient #1's residence on 01/06/2026 at 9:34 AM, it was evidenced the patient had a blood pressure cuff, an automatic blood pressure monitor, pulse oximeter, 2-wheel walker, spirometer, and a stretchy exercise band. The POC failed to evidence all of Patient #1's DME and bleeding precautions. 3. A review of Patient #2's active clinical record evidenced a POC with a SOC of 11/07/2023 and a recertification period from 12/26/2025 to 02/23/2026. The POC revealed the following diagnoses: Lumbar Radiculopathy (pain or weakness caused by the compression of a nerve in the lower spine), Spinal Stenosis (narrowing of spaces causing pain and numbness), Parkinsonism (a condition causing tremors, stiffness, and balance issues), chronic pain, and Nerve Root and Plexus Disorder (damage or compression to the nerves as they exit the spine). The POC evidenced the patient's DME included a bath bench, walker, wheelchair, grab bars, and non-sterile gloves. During a home visit at Patient #2's residence on 01/06/2026 at 1:58 PM, it evidenced the patient had an elevated toilet seat and a rollator they use with their PT. Patient #2's POC failed to evidence all of the patient's DME. 4. A review of Patient #3's active clinical record evidenced a POC with a SOC of 10/02/2025 and a recertification period from 12/01/2025 to 01/29/2026. The POC included the following diagnoses: Idiopathic Pulmonary Fibrosis (a chronic disease causing difficulty with breathing), Orthostatic Hypotension (the blood pressure lowers when standing after sitting or lying down), Open-angle Glaucoma (a disease where there is build-up of fluid in the eye, causing increased pressure, causing some vision loss), physical debility, and Monoplegia of lower limb affecting unspecified side (condition where one side of the body was weaker than the other). The patient's medications included Albuterol Sulfate (used to treat difficulty breathing, coughing, and wheezing) 2.5 milligrams (mg)/3 milliliters (ml) 4 times a day, 650 mg of Acetaminophen 3 times a day for pain relief, 81 mg of Aspirin (for pain and inflammation), 22.3mg and 6.8 mg/ml of Cosopt (used to treat high pressure in the eye) in each eye, 0.005 percent of Latanoprost (used to treat high pressure in the eye) in each eye, 2.5 mg of Midodrine (to treat Orthostatic Hypotension) 3 times a day, 17 grams (g) of Polyethylene glycol daily (used to help treat constipation), and 60 mg/ml of Prolia (used to help improve bone mass and strength)injected under the skin, in the fatty layer. The POC evidenced the patient's DME was non-sterile gloves. The section titled "Discharge Plan(s)" indicated but was not limited to, " … Discussed discharge plans with patient/caregiver? Yes. …" The patient's hospitalization and emergency room visit was marked as "n/a" (sic not applicable). During a home visit at Patient #3's residence on 01/06/2026 at 11:08 AM, it was evidenced the patient had a rollator, electric wheelchair, shower bench, elevated toilet seat, grab bars, wipes, and briefs. A review of Patient #3's medication list evidenced the following medications: Albuterol Sulfate 2.5 milligrams (mg)/3 milliliters (ml) 4 times a day as needed for shortness of breath through a nebulizer , 650 mg of Acetaminophen 3 times a day orally for pain relief, 81 mg of Aspirin daily, 22.3mg and 6.8 mg/ml of Cosopt in each eye daily, 0.005 percent of Latanoprost in each eye daily, 2.5 mg of Midodrine 3 times a day orally, 17 grams (g) of Polyethylene glycol daily orally as needed for constipation, and 80 mg of Atorvastatin Calium (to lower cholesterol) orally once a day. Patient #3's POC failed to include all of the patient's medications, their routes, and indications, DME, timely discharge instruction and plan, and hospitalization and emergency room risk. 5. A review of Patient #7's active clinical record evidenced a POC with a SOC of 07/23/2025 and a recertification period from 11/20/2025 to 01/18/2026. The POC evidenced the following diagnoses: Dislocation of internal right hip prothesis, pain in right hip, Hypertensive Chronic Kidney Disease (high blood pressure causes narrowing of the blood vessels to the kidney), and Nonrheumatic Aortic Stenosis (narrowing of the heart valve restricting blood flow). The Emergency and Hospitalization risk factors section included but was not limited to, " … Recent Hospitalizations stays or Emergency Room visits: N/a (sic not applicable) What occurs that makes you want to or need to go to the hospital: N/a. …". The section titled "Discharge Plan(s)" indicated but was not limited to, " … Per patient request, Discussed discharge plans with patient/caregiver? Yes. …" Patient #7's POC failed to include timely discharge instruction and plan and hospitalization and emergency room risk. 6. During an interview with RN 1 on 01/07/2026 at 10:56 AM and 12:59 PM, they indicated the POC should include all DME, anticoagulant precautions, discharge plan, hospitalization risk, and medications including their route and indication. 7. During an interview with the Administrator, Alternate Administrator/Alternate DON, and the DON on 01/07/2026 at 2:35 PM, they indicated all patient POCs were to include all of the patients' DME, hospitalization risk, discharge plan, and all medications including their route, dose, frequency, and indication. They indicated Corporate Staff 7, a CM, was completing and reviewing the POCs. 8. During an interview with a CM, Corporate Staff 7 on 01/07/2026 at 3:57 PM, they indicated they completed and reviewed POCs. They explained the POC should include all medications including their route, indication, and dose, all DME, and the discharge plan. They explained they were unaware the POC should include the patients' risk for hospitalization or emergency room visit. 410 IAC 17-13-1(a)(i-xiii)

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure they received orders from the physician to provide services before the physician signed the POC for 1 of 2 active clinical records reviewed with patients receiving HHA services. (Patient #3) Findings Include: 1. An undated policy titled "Physician/Allowed Non-Physician Practitioner (NPP) Orders" indicated but was not limited to, " … All medications, treatments and services provided to clients must be ordered by a physician/allowed non-physician practitioner (NPP). The orders may be initiated via telephone or in writing and must be countersigned by the provider in a timely manner. …" 2. A review of Patient #3's active clinical record evidenced a POC with a SOC of 10/02/2025 and a recertification period from 12/01/2025 to 01/29/2026. The POC evidenced the patient received HHA services 3 hours a day, 4 days a week for personal care and assistance with ADLs. Patient #3's active clinical record failed to evidence an order for the patient's recertification period. During an interview with HHA 1 on 01/06/2026 at 12:00 PM, they indicated they provided services to the patient 4 days a week and they were increasing the frequency this week for Patient #3. During an interview with RN 1 on 01/07/2026 at 10:56 AM, they indicated when they perform a recertification assessment, they fax the updated POC to the physician to obtain their signature. When queried regarding whether they received verbal orders for the recertification from the physician before receiving the signed POC, they indicated they had not called the physician to obtain a verbal order for the recertification. During an interview with the Administrator, Alternate Administrator/Alternate DON, and the DON on 01/07/2026 at 2:35 PM, they indicated there were no orders from the physician for Patient #3. The Alternate DON indicated they were unaware they needed orders from the physician with the patient asking the agency to receive services. 410 IAC 17-13-1(a)

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the physician was notified of the patient going to the hospital for 1 of 1 active clinical records reviewed with a patient going to the hospital. (Patient #2) Findings Include: 1. A review of an agency policy dated 11/10/2025 and titled "Home Health Physician Notification Process" indicated but was not limited to, " … Care Plus Home Health requires prompt and accurate physician notification when a patient experiences a fall, incident, or any significant change in condition, status, or plan of care. Notifications must be documented and completed in accordance with clinical judgement … Physician notification is required for … Change in patient status (Improvement, decline, hospitalization, ER (sic Emergency room) visit) …" 2. A review of Patient #2's active clinical record evidenced a document titled "Patient Communication Log". The note dated 12/10/2025 by the DON evidenced the DON had called Patient #2 to determine if they had gone to the hospital. The note dated 12/11/2025 by the Administrator evidenced the patient had gone to the hospital, but was not hospitalized. The agency failed to ensure the physician was notified of the patient going to the hospital. During an interview with the DON on 01/07/2026 at 1:25 PM, they indicated there was no communication note evidencing they notified Patient #2's physician of the patient's emergency room visit. 410 IAC 17-13-1(a)(2)

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 and interview, the agency failed to ensure infection control practices were upheld for hand hygiene practices for 1 of 1 home visit with a HHA (HHA 1) providing care. Findings Include: 1. A review of an undated policy titled "Handwashing/Hand Hygiene" indicated but was not limited to, " … 3. Indications for handwashing and hand antisepsis: … f. after removing gloves … Hand Hygiene Technique … 3. Multiple use cloth towels are not recommended for use in health care settings. …" 2. During a home visit at Patient #3's residence on 01/06/2026 at 11:08 AM, HHA 1 was observed providing care for Patient #3. HHA 1 wiped the patient's rollator with a disinfectant wipe, placed a towel on the rollator, doffed gloves, and donned new gloves without performing hand hygiene. After the HHA applied lotion to the patient's arms and legs, they doffed their gloves and donned new gloves, and failed to perform hand hygiene after doffing gloves. The HHA was observed taking the patient's food out of the microwave, doffed their gloves, and proceeded to adjust the patient's hearing aid. The HHA failed to perform hand hygiene after doffing their gloves. During an interview with HHA 1 on 01/06/2026 at 12:00 PM, they indicated hand hygiene was to be performed every time they doffed their gloves. 410 IAC 17-12-1(m)

Duties of a HH aide CFR(s): 484.80(g)(3) The duties of a home health aide include: (i) The provision of hands-on personal care; (ii) The performance of simple procedures as an extension of therapy or nursing services; (iii) Assistance in ambulation or exercises; and (iv) Assistance in administering medications ordinarily self-administered. This ELEMENT is not met as evidenced by: Based on observation and interview, the agency failed to ensure the HHA performed tasks within their scope for 1 of 1 home visit with a HHA. (HHA 1) Findings Include: 1. A review of a document titled "Job Description Home Health Aide" indicated but was not limited to, " … The Home Health Aide provides personal care services under the direction of the Registered Nurse … performs services for clients as necessary to maintain their personal comfort. …" 2. During a home visit at Patient #3's residence on 01/06/2026 at 11:08 AM, HHA 1 was observed providing care for Patient #3. HHA 1 was observed administering a drop of Latanoprost Ophthalmic Emulsion 0.005 percent (used to treat high pressure in the eye) into both of the patient's eyes. During an interview with HHA 1 on 01/07/2026 at 10:31 AM, they indicated they administered Patient #3's eye drops because the task was listed in the white binder provided by the patient's caregiver, Person 1. When queried regarding who trained the HHA to administer the eye drops, they explained Person 1 showed them how to give the patient the medication. During an interview with the Administrator, Alternate Administrator/Alternate DON, and the DON on 01/07/2026 at 1:53 PM, they indicated HHAs were not allowed to administer medications to patients. 410 IAC 17-14-1 (h)(12)

An Emergency Preparedness Survey was conducted by the Indiana State Department of Health in accordance with 42 CFR 484.102.Survey Date: December 13, 14, 2022 Facility Number: 013291Provider Number: 157665Census 20 At this Emergency Preparedness survey, Care Plus Home HealthCare was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 484.102 QR: 12/18/22 Area 2

This visit was for a Federal Recertification and State Re-Licensure Survey of a Home Health Provider. Survey Date: 12-13-2022 and 12-14-2022 Census: 20 Unduplicated Skilled Census: 12 QR: 12/18/22 Area 2

Have a confidential clinical record CFR(s): 484.50(c)(6) Have a confidential clinical record. Access to or release of patient information and clinical records is permitted in accordance with 45 CFR parts 160 and 164. This ELEMENT is not met as evidenced by: Based on observation and interview, the agency failed to ensure the privacy of patient and employee records as noted over 2 of 2 survey days. Findings include: 1. On 12-14-22 at 9:35 AM, Administrator #1 confirmed the January 2022 reviewed and approved policy titled, "Information Management Plan." The policy indicated but was not limited to, "... Systems will be in place to ensure safe and effective management of information...11. Data confidentiality: a. All client information and personnel information is strictly confidential...." 2. On 12-13-22 at 3:00 PM, observed an agency room labeled, "Supply Room" was open. A sign on the open door stated, "Stop, authorized personnel only beyond this point." The room held an open, unlocked file cabinet. The second drawer held 14 patient records. On the floor of the supply room, 5 white/red cardboard boxes held patient clinical records. 3. On 12-14-22 at 8:00 AM, the agency was opened by Administrative Staff #4. Upon entrance, the supply room was surveyed. The room was open with the file cabinet open and cardboard boxes on the floor. 4. On 12-14-22 at 10:00 AM, a contractor working on agency structural repairs was noted in the adjacent hallway of the supply room with the door open. 5. On 12-13-22 at 10:12 AM, during the entrance conference, Administrator #1 indicated medical records and supplies were accessed only by the administrator or office manager. The records and supplies were kept in a locked supply office. 6. On 12-14-22 at 12:58 PM, Administrators #1 and #4 were queried about the supply room access. The Administrators indicated accessibility to the supply room was available to employees when requesting supplies. The process was described as, "employees request supplies, we let them into the room and the employee signs for supplies." 410 IAC 17-12-3(B)(3)

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure all medications were listed on the plan of care for 1 of 1 active patients receiving an intravenous infusion. (Patient #4) Findings inlcude: 1. On 12-14-2022 at 9:35 AM, Administrator #1 (Admin #1) confirmed a January, 2022 reviewed policy titled, "Care Plans". The policy indicated but was not limited to, "Each client will have a care plan on file that addresses their identified needs...". 2. During a clinical record review of Patient #4 on 12-13-2022 at 12:15 PM, the clinical record failed to evidence a medication review and there were no medications on the plan of care (POC). Patient #4 was admitted on 11-17-2022 with a diagnosis of Osteomyelitis (an infection within the bones) and Type 2 Diabetes. A review of the POC for the initial certification period 11-17-2022 to 01-15-2023 indicated no medications were listed on the POC. The clinical record included a faxed hospital record for the patient to start Daptomycin (an antibiotic) 850 milligrams (mg) intravenously (IV) daily and Entrapenem (an antibiotic) 1 gram IV daily. The hospital discharge records listed the following outpatient medications: blood glucose test strips, Clopidogrel (Plavix) 75mg tablet , take 1 by mouth every day, Cyclobenzaprine (Flexeril) 5 mg tablet by mouth three times a day as needed for muscle soreness, Dapagliflozin (Faxiga) 10mg by mouth daily, Duloxetine (Cymbalta) 30 mg by mouth daily, Exenatide Microspheres extended release injection (ER), 2mg/0.85 milliliter into the skin every 7 days, Insulin Glargine (Basalgar)100 unit/ml (3ml) inject 40 units into the skin nightly, Insulin Lispro (Humalog)100 unit/ml inject 15 units into the skin 3 times daily before meals, Lisinopril (Zestril) 20 mg, take 1 tablet by mouth every day, Odansetron (Zofran-ODT), 4 mg, take one tablet by mouth every 8 hours as needed for nausea and vomiting, Melatonin 5 mg, take 10 mg by mouth as needed for insomnia, Pregabalin (Lyrica) 150 mg, take on capsule by mouth daily as needed for erectile dysfunction, Atorvastatin (Lipitor) 20 mg, take one tablet by mouth daily, Hydrocodone- Acetaminophen 7.5-325 tablet, take on tablet by mouth every 6 hours as needed for pain. 3. On 12-14-2022 at 2:51 PM, Admin #1 confirmed the medications were not on the POC. Admin #1 indicated, "They just were not there.". 410 IAC 17-14-1(a)(1)(B)

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on observation, record review and interview the agency failed to ensure the plan of care included all medications and treatments for 1 of 1 patients receiving intravenous therapy. (Patient #4) Findings include: 1. On 12-14-2022 at 9:35 AM, Administrator #1 (Admin #1) confirmed a January 2022 reviewed policy titled, "Care Plans." The policy indicated but was not limited to, "Each client will have a care plan on file that addresses their identified needs...." 2. During a clinical record review of Patient #4 on 12-13-2022 at 12:15 PM, evidenced Patient #4 was admitted on 11-17-2022 with a diagnosis of Osteomyelitis (an infection within the bones) and Type 2 Diabetes. A review of the plan of care (POC) for the certification period 11-17-2022 to 01-15-2023 failed to evidence medications as ordered. Clinical record review included a faxed hospital record for the patient to start Daptomycin (an antibiotic) 850 milligrams (mg) intravenously (IV) daily and Entrapenem (an antibiotic) 1 gram IV daily. The hospital discharge records listed the following outpatient medications: blood glucose test strips, Clopidogrel (Plavix) 75mg tablet , take 1 by mouth every day, Cyclobenzaprine (Flexeril) 5 mg tablet by mouth three times a day as needed for muscle soreness, Dapagliflozin (Faxiga) 10mg by mouth daily, Duloxetine (Cymbalta) 30 mg by mouth daily, Exenatide Microspheres extended release injection (ER), 2mg/0.85 milliliter into the skin every 7 days, Insulin Glargine (Basalgar)100 unit/ml (3ml) inject 40 units into the skin nightly, Insulin Lispro (Humalog)100 unit/ml inject 15 units into the skin 3 times daily before meals, Lisinopril (Zestril) 20 mg, take 1 tablet by mouth every day, Odansetron (Zofran-ODT), 4 mg, take one tablet by mouth every 8 hours as needed for nausea and vomiting, Melatonin 5 mg, take 10 mg by mouth as needed for insomnia, Pregabalin (Lyrica) 150 mg, take on capsule by mouth daily as needed for erectile dysfunction, Atorvastatin (Lipitor) 20 mg, take one tablet by mouth daily, Hydrocodone- Acetaminophen 7.5-325 tablet, take on tablet by mouth every 6 hours as needed for pain. 3. On 12-14-2022 at 2:51PM, Admin #1 confirmed the medications were not on the POC. Admin #1 indicated, "They just were not there.". 410 IAC 17-13-1 (a)(D)(x)

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 agency failed to provide the agency’s Clinical Manager’s name and contact information to the patients in 3 of 3 patients with home visits (Patients: #1, 2, and 3) with the potential to affect all patients receiving services from this agency. Findings Include: 1. A review of an agency Admission packet was provided by the Administrator, Administrative Staff #1, on 12-13-2022, at 10:50 AM. The agency’s admission packet failed to provide evidence of the agency’s Clinical Manager’s name and contact information. 2. During a home visit at Patient #1’s residence on 12-13-2022, at 9:00 AM, a review of the patient’s agency admission packet failed to evidence the agency’s Clinical Manager’s name and contact information. 3. During a home visit at Patient #3’s residence on 12-13-2022, at 9:50 AM, a review of the patient’s agency admission packet failed to evidence the agency’s Clinical Manager’s name and contact information. 4. During a home visit at Patient #2’s residence on 12-13-2022, at 12:15 PM, a review of the patient’s agency admission packet failed to evidence the agency’s Clinical Manager’s name and contact information. 5. During an interview on 12-14-2022, at 3:10 PM, Administrative Staff #1, confirmed that the Clinical Manager’s name and contact information was not provided to the patients.

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 and interview, the agency failed to ensure infection control practices were upheld according to the agency's policy, as observed by Registered Nurse (RN) #1 during 1 of 3 home visits for hand hygiene and the Agency for the proper disposal of biohazardous waste. (Patient #1) (Agency 1). Findings include: 7. During a home visit at Patient #1’s residence on 12-14-2022, at 9:00 AM, observed the Home Health Aide (HHA), HHA #1, open the door of the patient’s residence without wearing a face mask. The HHA did not wear a face mask during the visit while they provided oral care and meal preparation for Patient #1. During an interview on 12-14-2022, at 1:25 PM, the Administrator, Administrative Staff #1, when queried regarding the agency policy regarding mask requirement for staff providing patient care, stated, "No, our staff do not wear masks while providing patient care if they are vaccinated." 5. During a review of the agency supply room on 12-14-2022 at 12:58 PM, the Supply Room top shelf stored three biohazardous needle boxes two (2) small filled with utilized insulin syringes, one (1) large needle box filled 1/4 full of utilized insulin syringes and a broken lid. 6. During an interview on 12-14-2022 at 1:10 PM, Admin #1 was queried about the proper disposal of infectious waste. Admin #1 indicated they did not know how the needle boxes were placed on the shelf. Admin #1 indicated the waste should be disposed in the biohazardous room container. On 12-14-2022 at 11:38 AM, a policy titled “Hand Hygiene Policy” was provided by Administrator #1. The policy indicated but was not limited to, “…Policy Statements: B. Hand Hygiene is required with Any direct patient contact or with contact with the patient’s immediate environment… Procedures: 1. Perform hand hygiene upon entry and exit of patient room/home. 2. Perform hand hygiene prior to direct contact with the patient or their equipment… 4. Perform hand hygiene after contact with intact skin… 8. Perform hand hygiene after the removal of gloves. 9. Perform hand hygiene before accessing clean supplies…”. On 12-14-2022 at 11:38 AM, a policy titled “Bag Technique Guidelines” was provided by Admin #1. The policy indicated but was not limited to, “… 8. Hand hygiene must be performed prior to entering the bag at any time…” During a home visit at Patient #3's residence on 12-14-2022 at 9:55 AM, observed Registered Nurse (RN) RN #1 provide skilled nursing care for Patient #3. RN #1 failed to perform hand hygiene prior to reaching into the disposable bag to obtain alcohol swabs. RN #1 failed to perform hand hygiene before reapplying gloves. RN #1 administered insulin into Patient #3's abdomen and after administration, failed to remove their gloves and perform hand hygiene prior to reaching into RN #1’s bag. RN #1 removed clean stethoscope, manual blood pressure cuff, thermometer, and pulse oximeter without performing hand hygiene and applying a clean pair of gloves. During a home visit at Patient On 12-14-2022 at 12:20 PM, a home visit was completed with RN #2 with Patient #2. RN #2 failed to wear a mask for the entirety of the visit. During an interview on 12-14-2022 at 3:25 PM, Admin #1 was queried regarding the policy for hand hygiene during a home visit. Admin #1 indicated hand hygiene must be performed upon entering the home and anytime the employee moves from clean to dirty areas of the bag or after touching the patient.

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 agency failed to ensure patient education was comprehensive for 1 of 1 active patients receiving an intravenous (IV) infusion. (Patient: #4) Findings include: 1. On 12-14-2022 at 9:35 AM, the Administrator (Admin #1) provided a January 2022 reviewed policy titled, "Client/Caregiver Education". The policy indicated but was not limited to, "The education and training for clients and families will target the clients ability to improve... 1. All clients and caregivers will receive verbal and written instructions as appropriate...2. Educational needs or knowledge deficits related to the disease process ... will be assessed...These would include but are not limited to: a. Physical limitations...". 2. On 12-13-2022 at 12:15 PM, the clinical record of Patient #4 was reviewed for the certification period 11-17-2022 to 01-15-23 with a diagnosis of Osteomyelitis and Type 2 Diabetes. Patient #4 was admitted on 11-17-2022 for a one time visit to teach the patient and family IV antibiotic therapy. The Care Plus Adult Assessment record indicated Patient #4 was visually impaired (legally blind) and has a partial amputation of the right foot. The patient was to receive teaching related to antibiotic intravenous therapy (Daptomycin and Erapetem) via a Peripherally Inserted Central Catheter (PICC) located in their right upper extremity. The record failed to demonstrate caregiver education and administration of the IV therapy was understood. 3. On 12-13-2022 at 2:45 PM, Admin #1 indicated the clinical record noted a collaboration with the family regarding the teaching of IV therapy. When queried about the education of the patient with a disability and where in the record demonstrated the caregiver verbalized knowledge of the IV therapy, Admin #1 and Administrator #2 indicated it did not. 410 IAC 17-14-1(a)(2)(E)

Protection of records CFR(s): 484.110(d) Standard: Protection of records. The clinical record, its contents, and the information contained therein must be safeguarded against loss or unauthorized use. The HHA must be in compliance with the rules regarding protected health information set out at 45 CFR parts 160 and 164. This STANDARD is not met as evidenced by: Based on observation and interview the agency failed to ensure all employee COVID vaccination records and all patient clinical records were stored safely as noted over 2 of 2 survey days. Findings include: 1. On 12-14-22 at 9:35 AM, Administrator #1 confirmed the January, 2022 reviewed and approved policy titled, "Information Management Plan". The policy indicated but was not limited to, "... Systems will be in place to ensure safe and effective management of information...11. Data confidentiality: a. All client information and personnel information is strictly confidential...." 2. On 12-13-22 at 3:00 PM, an agency room labeled, "Supply Room" was open. A sign on the open door indicated, "Stop, authorized personnel only beyond this point." The room held an open, unlocked file cabinet. The second drawer held 14 patient records. On the floor of the supply room, 5 white/red cardboard boxes held patient clinical records. 3. On 12-14-22 at 8:00 AM, the agency was opened by Administrative Staff #4. Upon entrance, the conference room door was left open. The conference room table held the patient complaint log and the employee COVID vaccination information. The supply room was surveyed; the room door was open with the file cabinet open and cardboard boxes on the floor as noted on 12-13-22 after entering the agency for survey. 4. On 12-14-22 at 10:00 AM, a contractor working on agency structural repairs was noted in the adjacent hallway of the supply room with the door open. 5. On 12-13-22 at 10:12 AM, during the entrance conference, Administrator #1 indicated medical records and supplies were accessed only by the administrator or office manager. The records and supplies were kept in a locked supply office. 6. On 12-14-22 at 12:58 PM, Administrators #1 and #4 were queried about the supply room access. The Administrators indicated accessibility to the supply room was available to employees when requesting supplies. The process was described as, "employees request supplies, we let them into the room and the employee signs for supplies." 410 IAC 17-15-1(c)