Every finding on record at Caregivers, Inc

Indianapolis, Indiana · CCN 157230

26 findings across 2 surveys, in the inspector's own words.

The inspector’s own words from form CMS-2567, unedited, including CMS’s own spacing. Names and some dates are redacted by CMS.

Survey of January 8, 2026

18 findings

E0000

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, 01/7, 01/08/2026. Active Census: 191 At this Emergency Preparedness survey, Caregivers Incorporated, 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 1/15/2026.

G0000

This visit was for a Federal Recertification and State Re-Licensure survey of a Home Health provider. Survey Dates: 01/05, 01/06, 01/7, 01/08/2026. 12-Month Unduplicated Skilled Admissions: 92 This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Fully Extended Survey was announced on 01/08/2026 at 9:10 AM. During this Federal Certification Survey, was found to be out of compliance with Conditions of Participation 42 CFR §484.60 Care Planning, Coordination of Services, and Quality of Care, and 42 CFR §484.70 Infection prevention and control. Based on the Condition-level deficiencies during the 12/18/2025 survey, your HHA was subject to a partial or extended survey pursuant to section 1891(c)(2)(D) of the Social Security Act on 01/08/2026. 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 01/08/2026 and continuing through 01/07/2028. Abbreviations: HHA Home Health Aide QAPI Quality Assurance Performance Improvement POC Plan of Care OASIS Outcome and Assessment Information Set SOC Start of Care DME Durable Medical Equipment RN Registered Nurse CM Clinical Manager SN Skilled Nursing PT Physical Therapist LPN Licensed Practical Nurse EMR Electronic Medical Record ADL Activities of Daily Living EP Emergency Preparedness IV Intravenous CVC Central Venous Catheter ICHD In Center Hemodialysis HHD Home Hemodialysis MD Medical Doctor PSA Personal Services Agency This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Refer to State Form for additional State Findings. QR completed by Area 3 on 1/15/2026.

G0372

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to submit OASIS within 30 days of assessment completion for 3 of 7 active clinical records reviewed (Patients: #6, 7, and 11) and 5 of 5 inactive clinical records reviewed. (Patients: #8, 9, 10, 12, and 13) Findings Include: 1. A review of an undated agency policy titled “Encoding and Reporting OASIS Data” indicated, but was not limited to, “ … Caregivers, Inc. will electronically report all OASIS data collected in accordance with federal regulations … Caregivers, Inc. will encode individual patient assessment data within thirty (30) days of completing the comprehensive assessment … ” 2. During the entrance conference on 01/05/2026 at 9:30 AM, when queried regarding the submissions of OASIS, the Administrator/Clinical Manager reported Admin 8, the Quality Assurance (QA) Manager, submitted OASIS after review within 30 days of completion. 3. A review of an IQIES report titled “HHA Error Summary By Agency” dated 12/29/2025, report period 12/29/2024 to 12/29/2025, indicated but was not limited to, Caregivers, Inc. had the error number -3330, error description: Record submitted late: The submission date is more than 30 days after M00090 on this new record. # of assessments with error: 275 out of 915 records processed, a percentage of 30.5% with error. 4. A review of an agency document titled “OASIS (a comprehensive assessment designed to collect information related to a home care recipient’s demographic, clinical, functional, and service needs) Agency Final Validation.” The documents were for the reporting period of 12/29/2024 to 12/29/2025 the year to date, which indicated but was not limited to untimely submission errors reported to Caregivers, Inc, as the following: the active records for Patient #6 had a section titled “RFA” (Reason For Assessment) listed as 01, indicating SOC OASIS assessment had been submitted on 12/05/2025 and the M0090 date (date of completion) of 10/15/2025 with message -3330 indicating record submitted late; more than 30 days after the M0090 date of the record; Patient #7 had a section titled RFA listed as 01, indicating SOC OASIS assessment had been submitted on 12/23/2025 and the M0090 date of 11/17/2025 with message -3330 indicating record submitted late; more than 30 days after the M0090 date of the record; and Patient #11 had a section titled RFA listed as 01, indicating SOC OASIS assessment had been submitted on 11/14/2025 and the M0090 of 10/10/2025 with message -3330 indicating record submitted late; more than 30 days after the M0090 date of the record. The inactive records for Patient #8 had a section titled RFA listed as 09, indicating Discharge from Agency OASIS assessment had been submitted on 12/10/2025 and the M0090 date of 03/27/2025 with message -3330 indicating record submitted late; more than 30 days after the M0090 date of the record; Patient #9 had a section titled RFA listed as 09, indicating Discharge from Agency OASIS assessment had been submitted on 12/23/2025 and the M0090 date of 10/15/2025 with message -3330 indicating record submitted late; more than 30 days after the M0090 date of the record; Patient #10 had a section titled RFA listed as 09, indicating Discharge from Agency OASIS assessment had been submitted on 12/10/2025 and the M0090 date of 09/23/2025 with message -3330 indicating record submitted late; more than 30 days after the M0090 date of the record; Patient #12 had a section titled RFA listed as 09, indicating Discharge from Agency OASIS assessment had been submitted on 12/10/2025 and the M0090 date of 04/04/2025 with message -3330 indicating record submitted late; more than 30 days after the M0090 date of the record; and Patient #13 had a section titled RFA listed as 09, indicating Discharge from Agency OASIS assessment had been submitted on 12/10/2025 and the M0090 date of 06/20/2025 with message -3330 indicating record submitted late; more than 30 days after the M0090 date of the record. 5. A review of the active clinical record for Patient #6, SOC date 10/15/2025, contained a comprehensive assessment dated 10/15/2025, completed by PT 2. The OASIS Assessment reason was for SOC for the certification period 10/15/2025 to 12/13/2025. The agency failed to evidence the SOC OASIS Assessment had been submitted timely. 6. A review of the active clinical record for Patient #7, SOC date 11/17/2025, contained a comprehensive assessment dated 11/17/2025, completed by PT 1. The OASIS Assessment reason was for SOC for the certification period 11/17/2025 to 01/15/2026. The agency failed to evidence the SOC OASIS Assessment had been submitted timely. 7. A review of the inactive clinical record for Patient #8, discharge date 03/27/2025, contained a comprehensive assessment dated 03/27/2025, completed by PT 1. The OASIS Assessment reason was for discharge from the certification period 02/26/2025 to 04/26/2025. The agency failed to evidence the discharge OASIS Assessment had been submitted timely. 8. A review of the inactive clinical record for Patient #9, discharge date 03/27/2025, contained a comprehensive assessment dated 10/15/2025, completed by RN 1. The OASIS Assessment reason was for discharge from the certification period 08/19/2025 to 10/17/2025. The agency failed to evidence the discharge OASIS Assessment had been submitted timely. 9. A review of the inactive clinical record for Patient #10, discharge date 03/27/2025, contained a comprehensive assessment dated 03/27/2025, completed by RN 3. The OASIS Assessment reason was for discharge from the certification period 08/15/2025 to 10/13/2025. The agency failed to evidence the discharge OASIS Assessment had been submitted timely. 10. A focused review of the active clinical record for Patient #11, SOC date 10/10/2025, contained a comprehensive assessment dated 10/10/2025, completed by PT 1. The OASIS Assessment reason was for SOC for the certification period 10/10/2025 to 12/08/2025. The agency failed to evidence the SOC OASIS Assessment had been submitted timely. 11. A review of the inactive clinical record for Patient #12, discharge date 03/27/2025, contained a comprehensive assessment dated 04/04/2025, completed by PT 1. The OASIS Assessment reason was for discharge from the certification period 02/25/2025 to 04/25/2025. The agency failed to evidence the discharge OASIS Assessment had been submitted timely. 12. A review of the inactive clinical record for Patient #13, discharge date 03/27/2025, contained a comprehensive assessment dated 06/20/2025, completed by PT 2. The OASIS Assessment reason was for discharge from the certification period 04/29/2025 to 06/27/2025. The agency failed to evidence the discharge OASIS Assessment had been submitted timely. During an interview on 01/05/2026 at 11:55 AM, when asked about the OASIS submissions and timeline, the Administrator and Admin 8 confirmed that the OASIS should be submitted within 30 days of the comprehensive assessment M0090 date of completion. Admin 8 communicated they had issues with untimely submissions due to late clinician documentation and their move to their new office. Admin 8 further indicated they had untimely submissions in 2024 as well and had reported the issue to the Administrator. When asked for the 2024 process improvement plan for OASIS untimely submissions, the Administrator failed to provide evidence from the previous application the agency used to document QAPI and meetings.

G0570

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on record review and interview, the agency failed to ensure: the services were provided per the POC (See G0572); the services were provided only as ordered by physician (See G0580); notify the physician of not meeting the POC (See G0590); and coordination of care for all services provided to the patient (See G0606); and failed to provide patients/caregivers with a visit schedule (See G0614). The cumulative effects of these systemic problems resulted in the home health agency's inability to ensure the provision of quality health care in a safe environment for the Condition of Participation of 42 CFR 484.60, Care Planning, Coordination of Care, and Quality of Care, with the potential to affect all 191 current patients receiving Home Health services from this provider. Findings Include: 410 IAC 17-13-1(a) *

G0572

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure patients were provided services as ordered in the POC for 3 of 6 active records reviewed. (Patients: #3, 4, and 5) and 2 of 2 inactive records reviewed. (Patient: #6, and 7) Findings Include: 1. A review of an undated agency policy titled “Medical Supervision” indicated, but was not limited to, “ … A Physician Plan of Care is developed for each Client … The physician’s orders shall outline the disciplines providing care and the type, frequency, and duration of services to be provided … ” 2. A review of the clinical record for Patient #3, SOC 04/29/2024, contained a POC for the certification period from 12/20/2025 to 02/17/2026. The POC indicated Patient #3 had a primary diagnosis of Quadriplegia (a condition caused by an injury to the spinal cord, causing paralysis affecting all four limbs). Patient #3 had orders for SN 3 times a week for cardiopulmonary assessments, wound care to wound #1, pubis area above suprapubic catheter (pressure ulcer), wound care to wound #2, coccyx wound care to wound #3 midline coccyx, and wound care to wound #4 right distal coccyx, bowel program, and catheter changes. A review of the SN visit notes for the week of 12/27/2025 to 01/02/2026 failed to evidence a SN visit had been made. During an interview on 01/08/2026 at 11:10 AM, with the Administrator/Alternate Clinical Manager, RN 2, the case manager for Patient #3, and LPN 2, when asked about the missed SN visits for the week of 12/29/2025 to 01/02/206 cancelled by the agency, LPN 2 communicated they had car issues and had notified the Administrator/Alternate Clinical Manager. 3. A review of the clinical record for Patient #4, SOC 12/08/2025, contained a POC for the certification period from 12/08/2025 to 02/05/2026. The POC indicated Patient #4 had a primary diagnosis of Alcoholic Polyneuropathy (a condition caused by prolonged and heavy consumption of alcohol, causing nerve damage to the peripheral nerves throughout the body to malfunction simultaneously). Patient #4 had orders for PT one time a week for one week, two times a week for two weeks, and one time a week for 5 weeks, for therapeutic exercise, endurance training, transfer training, balance training, gait training, and pain management. A review of the PT visit notes evidenced the following: the week of 12/8/2025 to 12/12/2025, PT 1 completed the SOC on 12/08/2025; the week of 12/13/2025 to 12/19/2025, no PT visits were made; the week of 12/20/2025 to 12/26/2025, no PT visits were made; the week of 01/03/2026 to 01/08/2026, PT completed a visit on 01/05/2026. During an interview on 01/08/2026 at 1:35 PM, when asked about the missing PT visits for Patient #4, PT 1 communicated they were waiting for the office to make them aware they had authorization from the insurance company. 4. A review of the clinical record for Patient #5, SOC 11/20/2025, contained a POC for the certification period from 11/20/2025 to 01/10/2026. The POC indicated Patient #5 had a primary diagnosis of Type 2 Diabetes Mellitus (a chronic condition affecting the body's inability to regulate and process sugar in the bloodstream, causing high blood sugars). Patient #5 had orders for PT: one time per week for one week, then two times per week for 8 weeks, for therapeutic exercise, endurance training, transfer training, balance training, gait training, and pain management. Patient #5 had orders for a HHA 3 times a week for 7 weeks, starting 11/26/2025, for ADL and personal care assistance. A review of an agency document titled “Paraprofessional Assignment Sheet” signed and dated 11/26/2025 by PT 2, contained a care plan start date of 11/26/2025 for Patient #5 to receive HHA services with a frequency of 3 times a week for 8 weeks, two hours per service for assistance in ADLs of bathing, dressing, every Monday, Wednesday, and Friday. A review of the HHA visit notes evidenced the following: the week of 11/22/2025 to 11/28/2025, no HHA visits were completed, and the week of 11/29/2025 to 12/05/2025, no HHA visits were completed. During an interview on 01/08/2026 at 1:35 PM, when asked about the missing HHA visits for Patient #5, PT 2 communicated they were waiting for the office to make them aware they had authorization from the insurance company. 5. A review of the inactive clinical record for Patient #6, SOC 10/15/2025, and date of discharge 12/28/2025, contained a POC for the certification period from 10/15/2025 to 12/13/2025. The POC indicated Patient #6 had a primary diagnosis of Spastic Quadriplegic Cerebral Palsy (a condition causing increased muscle tone, causing muscle stiffness, and involuntary muscle movements). Patient #6 had orders for PT: one time a day for one day, one time a week for one week, and two times a week for 7 weeks, for balance training, transfer training, bed mobility training, and establishing a home exercise program. A review of the PT visit notes evidenced the following: the week of 10/15/2025 to 10/17/2025, PT 1 completed the SOC on 10/15/2025 and a visit on 10/17/2025; the week of 10/18/2025 to 10/24/2025, PT visits were completed 10/21/2025 and 10/23/2025; the week 10/25/2025 to 10/31/2025, no PT visits were completed; the week 11/01/2025 to 11/07/2025 no PT visits were completed; the week 11/08/2025 to 11/14/2025 no PT visits were completed; the week 11/22/2025 to 11/28/2025 a PT visit had been completed on 11/24/2025, and discharge visit completed 11/28/2025. During an interview on 01/08/2026 at 1:35 PM, when asked about the missing PT visits for Patient #7, PT 2 stated they were waiting for the office to notify them of authorization from the insurance company. When asked about notification to the MD regarding the POC PT frequency not being followed, PT 2 stated, “No, they did not notify the patient’s MD or obtain a hold services order regarding PT visits not being completed per the POC. 6. A review of the clinical record for Patient #7, SOC 11/17/2025, contained a POC for the certification period from 11/17/2025 to 01/15/2026. The POC indicated Patient #7 had a primary diagnosis of Type 2 Diabetes Mellitus with Diabetic Polyneuropathy (a chronic condition that occurs when the body fails to produce insulin to control blood sugar levels in the bloodstream, causing nerve damage due to prolonged high blood sugar levels). Patient #7 had orders for PT one time a week for 5 weeks for therapeutic exercise, endurance training, transfer training, balance training, gait training, and pain management. A review of the PT visit notes evidenced the following: for the week of 11/17/2025 to 11/21/2025, PT 1 completed the SOC on 11/17/2025; the clinical record failed to evidence any further visits had been completed. During an interview on 01/08/2026 at 3:00 PM, when asked about the missing PT visits for Patient #6, and the location of the hold order or notification to the patient’s MD regarding PT 1, it was communicated they were waiting for the office to make them aware they had authorization from the insurance company. 410 IAC 17-13-1(a)

G0580

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 wound care treatments were provided only as ordered by a physician in 1 of 2 active clinical records reviewed, with patients receiving wound care treatments. (Patient: #2) Findings Include: 1. A review of an undated agency policy titled “Wound Care Protocol for Home Healthcare Agency” indicated, but was not limited to, “ ... Wound care dressing should be changed according to the wound care plan physician’s instructions, ensuring aseptic techniques are used during the process … 2. During a home visit observation at the residence for Patient #2, on 01/06/2026 at 2:00 PM, observed LPN 1, performing wound care. LPN 1 sprayed wound cleanser on the wound dressing of Patient #2’s scalp wounds to remove the old non-adherent dressings. After removing the dressings, cleansed the 3 wounds with wound cleaner and 4x4 gauze, and measured the wounds. LPN 1 removed their gloves, performed hand hygiene, donned new gloves, LPN 1 obtained the non-adherent dressings, cut the dressings to size, and applied gentamicin ointment (an antibiotic ointment) to the dressings, then placed the dressings on the patient’s wounds, adhering the wounds to the scalp with steri-strip tape. A review of the clinical record for Patient #2, SOC 07/28/2025, certification period 11/25/2025 to 01/23/2026, indicated but was not limited to primary diagnosis Encounter for Change or Removal of Surgical Wound Dressing, and other diagnosis included; Aftercare Following Surgery for Neoplasm (a new and abnormal growth of tissue in some part of the body that can be benign or cancerous), Squamous Cell Carcinoma (a type of skin cancer)of Skin of Scalp and Neck, and Type 2 Diabetes Mellitus(a chronic condition when the body cannot use insulin to regulate the amounts of sugar in the blood). Patient #2 had orders for SN 1 time a week to change and instruct caregiver/family, wound dressing as ordered: wound care #1 right frontal scalp as follows; cleanse/irrigate with (solution) soap and water apply duoderm or non stick dressing secure with duoderm/tape; wound care to wound #2 left parietal scalp as follows; cleanse/irrigate with (solution) soap and water apply duoderm or non stick dressing secure with duoderm/tape. During an interview on 01/07/2026 at 1:10 PM, when asked about where the documentation would be located for communication notifying the physician of Patient #2’s new wound, increased drainage, and changes in the wounds, RN 1 stated, “One or 2 weeks ago, the third wound showed up. The patient had a home visit from the patient’s nurse practitioner, who ordered gentamicin ointment for the wounds. No, there is not orders changing the wound care, and there needed to be updated orders. That is my fault.” 410 IAC 17-13-1(a)

G0590

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 observation, record review, and interview, the agency failed to ensure the RN notified the physician of changes in the patient’s wounds for 1 of 2 (Patient: #2) active clinical records reviewed receiving wound care, and failed to ensure the physician had been notified of the agency’s inability to provide services in 2 of 3 (Patients: #4, and 7), active clinical records reviewed of patients receiving PT services, and 1 of 2 (Patient: #3) active clinical records reviewed receiving LPN services, and 1 of 2 inactive clinical records received PT services. (Patient: #6) Findings Include: 1. A review of an undated agency policy titled “Medical Supervision” indicated, but was not limited to, “ … A Physician Plan of Care is developed for each Client … The physician’s orders shall outline the disciplines providing care and the type, frequency, and duration of services to be provided … 4. Physician will be contacted when any of the following occurs: 1. Condition changes … e. Any change in Client condition or Caregivers, Inc., services …” 2. A review of an undated agency policy titled “Provision for 24-Hour RN Availability” indicated, but was not limited to, “ … The Registered Nurse will be available to make a home visit, if necessary … ” 3. A review of an undated agency policy titled “Wound Care Protocol for Home Healthcare Agency” indicated but was not limited to, “ ... Wound care dressing should be changed according to the wound care plan physician’s instructions, ensuring aseptic techniques are used during the process … Signs of infection, such as increased redness, warmth, or discharge, must be reported to the physician immediately. All supplies used in wound care must be disposed of properly to minimize contamination risks. 4. During a home visit observation for Patient #2, on 01/06/2026 at 2:00 PM, observed LPN 1 performing wound care. LPN 1 sprayed wound cleanser on the wound dressing of Patient #2’s scalp wounds to remove the old non-adherent dressings. After removing the dressings, LPN 1 informed Patient #2 that they had 3 scalp wounds, and Patient #2 requested a mirror to examine them. Patient #2 reported they did not like the way the wounds looked and needed to call the MD for follow-up. LPN 1 cleansed the 3 wounds with wound cleaner and 4x4 gauze, measured the wounds, removed their gloves, performed hand hygiene, and donned new gloves. The LPN obtained the non-adherent dressings, used scissors to cut the dressings to size, applied gentamicin (an antibiotic ointment) to the non-adherent dressings, and then placed the dressings on Patient #2's three scalp wounds, adhering the dressings to the scalp with steri-strip tape. A review of the clinical record for Patient #2, SOC 07/28/2025, certification period 11/25/2025 to 01/23/2026, indicated but was not limited to primary diagnosis Encounter for Change or Removal of Surgical Wound Dressing, and other diagnosis included; Aftercare Following Surgery for Neoplasm (a new and abnormal growth of tissue in some part of the body that can be benign or cancerous), Squamous Cell Carcinoma (a type of skin cancer)of Skin of Scalp and Neck, and Type 2 Diabetes Mellitus(a chronic condition when the body cannot use insulin to regulate the amounts of sugar in the blood). Patient #2 had orders for SN 1 time a week to change and instruct caregiver/family, wound dressing as ordered: wound care #1 right frontal scalp as follows; cleanse/irrigate with (solution) soap and water apply duoderm or non stick dressing secure with duoderm/tape; wound care to wound #2 left parietal scalp as follows; cleanse/irrigate with (solution) soap and water apply duoderm or non stick dressing secure with duoderm/tape. During an interview on 01/07/2026 at 1:10 PM, when asked about where the documentation would be located for communication notifying the physician of Patient #2’s new wound, increased drainage, and changes in the wounds, RN 1 stated, “One or 2 weeks ago, the third wound showed up. The patient had a home visit from the patient’s nurse practitioner, who ordered gentamicin ointment for the wounds. No, no documentation of the physician being notified of changes in Patient #2’s wounds and the new wound. I didn’t do it.” 5. A review of the clinical record for Patient #3, SOC 04/29/2024, contained a POC for the certification period from 12/20/2025 to 02/17/2026. The POC indicated Patient #3 had a primary diagnosis of Quadriplegia (a condition caused by an injury to the spinal cord causing paralysis affecting all four limbs), and other diagnoses included but not limited to, Autonomic Dysreflexia (a potentially life threatening condition involving abnormal, overreaction of the autonomic nervous system (the network of nerves through your body that control unconscious processes such as breathing, heart beating, blood pressure, and digestion) to certain types of stimulation) leading to severe high blood pressure and other symptoms), Neurogenic bowel (loss of bowel function due to nerve damage), Encounter for Fitting Adjustment of Urinary Device, and Pressure Ulcer of Right Ankle, Stage 3 (full thickness skin loss that involves damage to the subcutaneous tissue). Patient #3 had orders for SN 3 times a week for cardiopulmonary assessments, wound care to wound #1, pubis area above suprapubic catheter (pressure ulcer), wound care to wound #2, coccyx wound care to wound #3 midline coccyx, and wound care to wound #4 right distal coccyx, bowel program, and catheter changes. A review of the SN notes for the week of 12/27/2025 to 01/02/2026 failed to evidence SN visits. A review of agency documents titled “Missed Visit Notes” evidenced the following: on 01/04/2026, LPN 2 documented missed visit notes for 12/29/2025, 12/31/2025, and 01/02/2026, noting missed visit reason cancelled by the agency, no agency staff available. During an interview on 01/08/2026 at 11:10 AM, with the Administrator/Alternate Clinical Manager, RN 2, the case manager for Patient #3, and LPN 2, when asked about the missed SN visits for the week of 12/29/2025 to 01/02/206 cancelled by the agency, LPN 2 communicated they had car issues and had notified the Administrator/Alternate Clinical Manager. The Administrator/Alternate Clinical Manager confirmed LPN 2 reported missed visits, and they had been the nurse on call. The Administrator/Alternate Clinical Manager further reported there were no other nurses available to see Patient #3, and the caregiver had provided care for Patient #3. When asked about the on-call nurse seeing patients, the Administrator/Alternate Clinical Manager indicated the on-call nurse should have seen Patient #3. RN 2 communicated they had not been notified of Patient #3 not being seen by the SN for a week and had not reported to the MD the inability to provide care per the POC. 6. A review of the clinical record for Patient #4, SOC 12/08/2025, contained a POC for the certification period from 12/08/2025 to 02/05/2026. The POC indicated Patient #4 had a primary diagnosis of Alcoholic Polyneuropathy (a condition caused by prolonged and heavy consumption of alcohol, causing nerve damage to the peripheral nerves throughout the body to malfunction simultaneously) and other diagnoses of Difficulty Walking. Patient #4 had orders for PT one time a week for one week, two times a week for two weeks, and one time a week for 5 weeks, for therapeutic exercise, endurance training, transfer training, balance training, gait training, and pain management. A review of the PT visit notes evidenced the following: the week of 12/8/2025 to 12/12/2025, PT 1 completed the SOC on 12/08/2025; the week of 12/13/2025 to 12/19/2025, no PT visits were made; the week of 12/20/2025 to 12/26/2025, no PT visits were made; the week of 01/03/2026 to 01/08/2026, PT 1 completed a visit on 01/05/2026. During an interview on 01/08/2026 at 1:35 PM, when asked about the missing PT visits for Patient #4, PT 1 stated they were waiting for the office to notify them of authorization from the insurance company. When asked about notification to the MD regarding the POC PT frequency not being followed, PT 1 stated, “No, they did not notify the patient’s MD and did not document the patient had been notified. I know if it isn’t documented, it isn’t done.” 7. A review of the inactive clinical record for Patient #6, SOC 10/15/2025, and date of discharge 12/28/2025, contained a POC for the certification period from 10/15/2025 to 12/13/2025. The POC indicated Patient #6 had a primary diagnosis of Spastic Quadriplegic Cerebral Palsy (a condition causing increased muscle tone, causing muscle stiffness and involuntary muscle movements), and other diagnoses Repeated Falls, Essential Hypertension (high blood pressure), Visual Disturbances, Idiopathic Epilepsy and Epileptic Syndrome ( a condition due to abnormal electrical activity I the brain causing unprovoked seizures). Patient #7 had orders for PT one time a day, one time a week for one week, and two times a week for 7 weeks, for balance training, transfer training, bed mobility training, and establishing a home exercise program. A review of the PT visit notes evidenced the following: the week of 10/15/2025 to 10/17/2025, PT 1 completed the SOC on 10/15/2025 and a visit on 10/17/2025; the week of 10/18/2025 to 10/24/2025, PT visits were completed 10/21/2025 and 10/23/2025; the week 10/25/2025 to 10/31/2025, no PT visits were completed; the week 11/01/2025 to 11/07/2025 no PT visits were completed; the week 11/08/2025 to 11/14/2025 no PT visits were completed; the week 11/22/2025 to 11/28/2025 a PT visit had been completed on 11/24/2025, and discharge visit completed 11/28/2025. During an interview on 01/08/2026 at 1:35 PM, when asked about the missing PT visits for Patient #7, PT 2 stated they were waiting for the office to notify them of authorization from the insurance company. When asked about notification to the MD regarding the POC PT frequency not being followed, PT 2 stated, “No, they did not notify the patient’s MD to obtain a hold services order or regarding PT visits not being completed per the POC.” PT 2 further communicated, if it isn’t documented, it isn’t done.” 8. A review of the clinical record for Patient #7, SOC 11/17/2025, contained a POC for the certification period from 11/17/2025 to 01/15/2026. The POC indicated Patient #7 had a primary diagnosis of Type 2 Diabetes Mellitus with Diabetic Polyneuropathy (a chronic condition that occurs when the body fails to produce insulin to control blood sugar levels in the bloodstream, causing nerve damage due to prolonged high blood sugar levels), and other diagnoses Low Back Pain, and Unsteadiness on Feet. Patient #7 had orders for PT one time a week for 5 weeks for therapeutic exercise, endurance training, transfer training, balance training, gait training, and pain management. A review of the PT visit notes evidenced the following: the week of 11/17/2025 to 11/21/2025, PT 1 completed the SOC on 11/17/2025; the clinical record failed to evidence any further visits had been completed. During an interview on 01/08/2026 at 3:00 PM, when asked about the missing PT visits for Patient #6, and the location of the hold order or notification to the patient’s MD regarding the missed visits, PT 1 communicated they were waiting for the office to make them aware they had authorization from the insurance company. When asked about notification to the MD regarding the POC PT frequency not being followed, PT 1 stated, “No, they did not notify the patient’s MD and did not document the patient had been notified. I know if it isn’t documented, it isn’t done.” 410 IAC 17-13-1(a)(2)

G0606

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 the LPNs coordinated care, communicating patient concerns to the RN in 2 of 2 active patient records reviewed who received LPN services. (Patient #2 and 3) Findings Include: 1. A review of undated agency policy titled “Coordination of Client Services” indicated, but was not limited to, “ … To ensure services are coordinated between members of the interdisciplinary team. To ensure appropriate, quality care is being provided to Clients … 3. Interdisciplinary care conferences shall be conducted as often as necessary to respond to changes in the Client’s care needs, services, care, or goals … ” 2. During a home visit observation at the residence for Patient #2, on 01/06/2026 at 2:00 PM, observed LPN 1 performing wound care. LPN 1 sprayed wound cleanser on the wound dressing of Patient 2's scalp wounds to remove the old non-adherent dressings. After removing the dressings, LPN 1 informed Patient #3 that there were now 3 scalp wounds, and Patient #3 requested the LPN to obtain their mirror to examine the wounds. Patient #2 reported they did not like the way the wounds looked and needed to call the MD for follow-up. LPN 1 cleansed the 3 wounds with wound cleaner and 4x4 gauze, and measured the wounds. LPN 1 removed their gloves, completed hand hygiene, donned new gloves, and obtained the non-adherent dressings. The LPN cut the dressings to size and applied gentamicin ointment (an antibiotic ointment) to the non-adherent dressings, then placed the dressings on the patient’s wounds, adhering the wounds to the scalp with steri-strip tape. A review of the clinical record for Patient #2, SOC date 07/28/2025, contained agency documents titled “Case Communication Notes.” A review of the communication notes dated 11/08/2025to 01/07/2026 failed to evidence LPN 1 had documented or reported to RN 1 changes in Patient #2’s wound drainage, appearance, number of wounds, and Patient #2’s concerns in the way the wounds appeared, to RN 1. During an interview on 01/07/2026 at 1:10 PM, RN 1 confirmed communication regarding the patient’s care needs between the care team should be documented in the communication notes. When asked if LPN 1 had called them and reported an increase in wounds and changes in Patient #2’s wounds, RN 1 stated, “No, the LPN did not contact me with changes in the wounds.” RN 1 further reviewed the notes in the EMR system for Patient #2 and reported there had been no documentation in LPN 1’s visit note dated 01/07/2026, and the communication notes of reporting Patient #2’s wound changes. 3. A review of the clinical record for Patient #3, SOC 04/29/2024, contained a POC for the certification period from 12/20/2025 to 02/17/2026. The POC indicated Patient #3 had a primary diagnosis of Quadriplegia (a condition caused by an injury to the spinal cord causing paralysis affecting all four limbs), and other diagnoses included but are not limited to, Autonomic Dysreflexia (a potentially life threatening condition involving abnormal, overreaction of the autonomic nervous system (the network of nerves through your body that control unconscious processes such as breathing, heart beating, blood pressure, and digestion) to certain types of stimulation) leading to severe high blood pressure and other symptoms), Neurogenic bowel (loss of bowel function due to nerve damage), Encounter for Fitting Adjustment of Urinary Device, and Pressure Ulcer of Right Ankle, Stage 3 (full thickness skin loss that involves damage to the subcutaneous tissue). Patient #3 had orders for SN 3 times a week for cardiopulmonary assessments, wound care to wound #1, pubis area above suprapubic catheter (pressure ulcer), wound care to wound #2, coccyx wound care to wound #3 midline coccyx, and wound care to wound #4 right distal coccyx, bowel program, and catheter changes. During a home visit at the residence of Patient #3, on 01/06/2026, at 9:45 AM, Patient #3 and the patient caregiver, provided a list of medications for review and communicated Patient #3 had an MD appoint two weeks ago and had the MD increased Labetalol (a medication used to treat to high blood pressure) from 100 milligrams (mg) to 150 mg twice daily. During an interview on 01/08/2026 at 11:00 AM, with LPN 2 and RN 2, when asked about the LPN reporting increased dosage of Labetalol, and missing visits for a week from 12/27/2025 through 01/02/2026 for wound care, and bowel program, RN 2 communicated they were not aware of Patient #3 not being seen for a week or the increase in Patient #3’s Labetalol. When asked LPN 2 about reporting to RN 2, LPN 2 indicated they had made the Administrator aware of their car issues that week, not being able to see Patient #3, and had not reported the medication changes to RN 2.

G0614

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to provide patients and caregivers with a visit schedule for the frequency of visits by agency staff during 2 of 4 home visits conducted. (Patients: #2 and 4) Findings include: 1. During a home visit at Patient #2’s residence on 01/07/2026 at 4:35 PM, the admission booklet for Patient #2 was reviewed. No agency calendar was found in the patient's booklet or at home. The agency failed to provide the patient and/or caregiver with an agency service calendar. When Patient #2 asked LPN 1 about a return visit, LPN 1 stated, “They did not know when the patient would have another visit.” 2. During a home visit at Patient #4’s residence on 01/06/2026 at 2:00 PM, the admission booklet for Patient #4 was reviewed. No agency calendar was found in the patient's booklet or at home. The agency failed to provide the patient and/or caregiver with an agency service calendar. When Patient #4 asked PT 1 about when they would see them again, PT 1 stated, “They did not know when the patient would have another visit. They would give them a call.”

G0654

Track adverse patient events CFR(s): 484.65(c)(2) Performance improvement activities must track adverse patient events, analyze their causes, and implement preventive actions. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the agency tracked and analyzed adverse patient events and implemented actions to prevent adverse events for 1 of 1 agency. Findings Include: 1. A review of an undated agency policy titled “Quality Assessment and Performance Improvement (QAPI)” indicated but was not limited to, “Agency shall establish a performance improvement plan to continuously measure, assess, and improve the performance of clinical and other processes … To monitor the effectiveness and safety of services and the quality of care; To identify opportunities for improvement in ... care, treatment, and services; … To reduce factors that contribute to unanticipated adverse events and/or outcomes … ” 2. A review of the of the agency’s IQIES report titled “Potentially Avoidable Event Report” dated for current period for10/2024 to 09/2025, indicated the agency had a potentially avoidable events with one patient having to seek emergent care for hypo/hyperglycemia (low/high blood sugar) and one patient had an increase in number of pressure ulcers. 3. A review of the agency’s IQIES report titled “Potentially Avoidable Event: Patient Listing Report” dated for the current period for10/2024 to 09/2025, indicated inactive Patient #14, SOC 11/11/2024, and transfer/discharge date 12/24/2024 had been treated for emergent care for Hypo/Hyperglycemia. The report further evidenced Patient #15 SOC 11/28/2023, and transfer/discharge date of 05/20/2025, with an increase in the number of pressure ulcers. During an interview on 01/08/2026 at 9:10 AM, when asked about tracking patient avoidable events or adverse events for the agency, the Administrator communicated they had not tracked adverse events and were unaware of the IQIES reports for monitoring agency information. When shown the IQIES report of the patient listing, it confirmed they were aware of Patient #14 with the blood sugar issues and Patient #15's wounds. The Administrator further confirmed they had not reviewed the adverse events in the QAPI meeting and could not provide QAPI data for 2024. 410 IAC 17-12-2(a)

G0656

Improvements are sustained CFR(s): 484.65(c)(3) The HHA must take actions aimed at performance improvement, and, after implementing those actions, the HHA must measure its success and track performance to ensure that improvements are sustained. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to measure and track performance improvement projects to determine if improvement occurred and was sustained from data derived from untimely OASIS assessments, and failed to implement a process improvement plan for the frequency and detail of data collection for 1 of 1 agency. Findings Include: 1. A review of an undated agency policy titled “Quality Assessment and Performance Improvement (QAPI)” indicated but was not limited to, “Agency shall establish a performance improvement plan to continuously measure, assess, and improve the performance of clinical and other processes … To monitor the effectiveness and safety of services and the quality of care; To identify opportunities for improvement in ... care, treatment, and services; To improve ... outcomes through a coordinated collaborative approach ... improving ... performance; To evaluate all areas of concern and implement plans to resolve the issues ... To support the organization’s process improvement through data collection and outcome measurement in compliance initiative and OASIS data Collection required by CMS … OASIS review and evaluation of accuracy and content. Staff performance assessment activities. Staff recruitment orientation and continuing education programs. Case Conferences. Clinical record and utilization review findings. Clinical staff competency evaluation programs. Satisfaction surveys of clients, referral sources, physicians, and staff. Risk management program. Sentinel events/ Adverse events. Incident reports, accidents, and worker compensation claims. Infection control activities and systems that support them. Annual program evaluation. ... Scope of Program: 1. The program will be capable of showing measurable improvement in indicators that will improve the health outcomes, client safety, and quality of care. 2. The agency will identify, measure, analyze, and track quality indicators that include client adverse events, and other relevant data to assess processes of care, services, and operations … 4. Data will be systematically collected to measure process and outcome … ” 2. A review of the 2024 and 2025 QAPI programs failed to evidence that a performance improvement project (PIP) was developed, ongoing, or completed for those years for an identified agency opportunity for improvement. 3. A review of an IQIES report titled “HHA Error Summary By Agency” dated 12/29/2025, report period 12/29/2024 to 12/29/2025, indicated but was not limited to, Caregivers, Inc. had the error number -3330, error description: Record submitted late: The submission date is more than 30 days after M00090 on this new record. # of assessments with error: 275 out of 915 records processed, a percentage of 30.5% with error. 4. A review of an agency document titled “OASIS (a comprehensive assessment designed to collect information related to a home care recipient’s demographic, clinical, functional, and service needs) Agency Final Validation.” The documents were for the reporting period of 12/29/2024 to 12/29/2025 the year to date, which indicated but was not limited to untimely submission errors reported to Caregivers, Inc, as the following: the active records for Patient #6 had a section titled “RFA” (Reason For Assessment) listed as 01, indicating SOC OASIS assessment had been submitted on 12/05/2025 and the M0090 date (date of completion) of 10/15/2025 with message -3330 indicating record submitted late; more than 30 days after the M0090 date of the record; Patient #7 had a section titled RFA listed as 01, indicating SOC OASIS assessment had been submitted on 12/23/2025 and the M0090 date of 11/17/2025 with message -3330 indicating record submitted late; more than 30 days after the M0090 date of the record; and Patient #11 had a section titled RFA listed as 01, indicating SOC OASIS assessment had been submitted on 11/14/2025 and the M0090 of 10/10/2025 with message -3330 indicating record submitted late; more than 30 days after the M0090 date of the record. The inactive records for Patient #8 had a section titled RFA listed as 09, indicating Discharge from Agency OASIS assessment had been submitted on 12/10/2025 and the M0090 date of 03/27/2025 with message -3330 indicating record submitted late; more than 30 days after the M0090 date of the record; Patient #9 had a section titled RFA listed as 09, indicating Discharge from Agency OASIS assessment had been submitted on 12/23/2025 and the M0090 date of 10/15/2025 with message -3330 indicating record submitted late; more than 30 days after the M0090 date of the record; Patient #10 had a section titled RFA listed as 09, indicating Discharge from Agency OASIS assessment had been submitted on 12/10/2025 and the M0090 date of 09/23/2025 with message -3330 indicating record submitted late; more than 30 days after the M0090 date of the record; Patient #12 had a section titled RFA listed as 09, indicating Discharge from Agency OASIS assessment had been submitted on 12/10/2025 and the M0090 date of 04/04/2025 with message -3330 indicating record submitted late; more than 30 days after the M0090 date of the record; and Patient #13 had a section titled RFA listed as 09, indicating Discharge from Agency OASIS assessment had been submitted on 12/10/2025 and the M0090 date of 06/20/2025 with message -3330 indicating record submitted late; more than 30 days after the M0090 date of the record. 5. A review of the active clinical record for Patient #6, SOC date 10/15/2025, contained a comprehensive assessment dated 10/15/2025, completed by PT 2. The OASIS Assessment reason was for SOC for the certification period 10/15/2025 to 12/13/2025. The agency failed to evidence the SOC OASIS Assessment had been submitted timely. 6. A review of the active clinical record for Patient #7, SOC date 11/17/2025, contained a comprehensive assessment dated 11/17/2025, completed by PT 1. The OASIS Assessment reason was for SOC for the certification period 11/17/2025 to 01/15/2026. The agency failed to evidence the SOC OASIS Assessment had been submitted timely. 7. A review of the inactive clinical record for Patient #8, discharge date 03/27/2025, contained a comprehensive assessment dated 03/27/2025, completed by PT 1. The OASIS Assessment reason was for discharge from the certification period 02/26/2025 to 04/26/2025. The agency failed to evidence the discharge OASIS Assessment had been submitted timely. 8. A review of the inactive clinical record for Patient #9, discharge date 03/27/2025, contained a comprehensive assessment dated 10/15/2025, completed by RN 1. The OASIS Assessment reason was for discharge from the certification period 08/19/2025 to 10/17/2025. The agency failed to evidence the discharge OASIS Assessment had been submitted timely. 9. A review of the inactive clinical record for Patient #10, discharge date 03/27/2025, contained a comprehensive assessment dated 03/27/2025, completed by RN 3. The OASIS Assessment reason was for discharge from the certification period 08/15/2025 to 10/13/2025. The agency failed to evidence the discharge OASIS Assessment had been submitted timely. 10. A focused review of the active clinical record for Patient #11, SOC date 10/10/2025, contained a comprehensive assessment dated 10/10/2025, completed by PT 1. The OASIS Assessment reason was for SOC for the certification period 10/10/2025 to 12/08/2025. The agency failed to evidence the SOC OASIS Assessment had been submitted timely. 11. A review of the inactive clinical record for Patient #12, discharge date 03/27/2025, contained a comprehensive assessment dated 04/04/2025, completed by PT 1. The OASIS Assessment reason was for discharge from the certification period 02/25/2025 to 04/25/2025. The agency failed to evidence the discharge OASIS Assessment had been submitted timely. 12. A review of the inactive clinical record for Patient #13, discharge date 03/27/2025, contained a comprehensive assessment dated 06/20/2025, completed by PT 2. The OASIS Assessment reason was for discharge from the certification period 04/29/2025 to 06/27/2025. The agency failed to evidence the discharge OASIS Assessment had been submitted timely. During an interview on 01/07/2026 at 4:20 PM, when asked about the agency's untimely OASIS submissions for 2024 and 2025 and a Process Improvement Plan (PIP) being implemented, Admin 8, the OASIS submissions Coordinator, and the Administrator stated they had been aware of the untimely submissions of OASIS and reviewed the OASIS submissions reports. When asked about the Process Improvement Plan (PIP) being implemented, the Administrator stated they had not implemented a PIP for OASIS this year and were starting from a blank slate. When asked about the 2024 PIP for untimely submissions, Admin 8 indicated they had reported the untimely OASIS submissions for 2024, provided the reports to the former Administrator, and there should had been a plan in place. The Administrator could not provide any 2024 PIPs. 410 IAC 17-12-2(a)

G0680

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 observation, record review, and interview, the agency failed to ensure the clinical staff followed infection control guidelines in 4 of 4 home visits (See G0682); and failed to ensure they developed and maintained an agency-wide infection control program outlining surveillance, identification, prevention, control, and investigation of all infectious and communicable diseases. (See G 0684) The cumulative effects of these systemic problems resulted in the agency's inability to ensure patients are protected from infectious diseases or improper infection control practices for the Condition of Participation of 42 CFR §484.70, Infection prevention and control, with the potential to affect all 191 current patients receiving Home Health services from this provider. Findings Include: *

G0682

G0684

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 have an agency wide infection control program for surveillance, identification, prevention, control, and investigation of infectious and communicable diseases, ongoing systematic collection, analysis, interpretation and evaluation for 1 of 1 agency. Findings Include: 1. A review of an undated agency policy titled “Infection Control Surveillance” indicated "Policy: Caregivers, Inc. will establish a continuous data monitoring and collecting system to detect infections or identify changes in infection trends ... Total Surveillance ... Targeted surveillance ... Outbreak surveillance ... The Agency will implement a process of identifying all infections in the client and/ or employee population and evaluate the effectiveness of current control measures, or identify an action plan to improve the incidence of infections. 2. A review of a binder titled “QAPI” contained an agency document dated 05/31/2025, titled “Meeting Minutes Quality Assessment/Quality Assurance” indicating the Administrator/Alternate Clinical Manger facilitated a staff meeting, and established agency specific Quality Assurance tools for chart reviews, incident reporting, falls, medication errors, tracking systems for hospitalization and infection control reporting by June 25, 2025. 3. A review of an agency document dated 12/22/2025, titled “ QAPI Annual Report” prepared by the Administrator/Alternate Clinical Manager with the Governing Body present for oversight, contained in the section titled “ V. Clinical Quality Indicators” subsection “B. Infection Control” that indicated “Infection tracing not formally implemented during 2025 and identified tracking identified as required to develop and implement formal tracking beginning 2026.” During an interview on 01/08/2026 at 9:10 AM, when asked for the infection control logs and QAPI reviews of infections, the Administrator/Alternate Clinical Manager stated the agency did not complete or monitor its infections for 2025 and could not provide the agency’s QAPI or infection control surveillance for 2024. The Administrator communicated they had found the 2018 QAPI review of infections. The Administrator further confirmed they had not been tracking patient or staff infections. 4. A review of an agency document dated 01/18/2018, titled “Performance Improvement Management Team,” noted a regular meeting of the Clinical Management Team reviewed Infectious Reports to include: 0 IV infections, 0 wound infections, 2 Urinary Tract Infections with patients on antibiotics, and one long-term Foley catheter and one with incontinence issues. 5. A review of the clinical record for Patient #1, SOC 01/04/2022, contained a Medication Profile that indicated, but was not limited to, Doxycycline Hyclate (an antibiotic) 100 milligrams (mg), twice a day, with a start date of 02/28/2023, and stop date 03/06/2023; Levaquin ( an antibiotic) 500 mg, 1 time every 48 hours, with a start date of 06/23/2023, and stop date 06/30/2023; Cirpfloxacin (an antibiotic) 500 mg once a day, with a start date of 09/23/2024, and a stop date of 09/25/2024. 6. A review of the clinical record for Patient #2, SOC 07/28/2025, contained a Medication Profile that indicated, but was not limited to, Gentamicin (an antibiotic cream) Sulfate External Cream 0.1%, apply one time a week for wound care scalp, with a start date of 11/24/2025, and Minoazole Nitrate ( an anitfungul powder) external powder 2%, use twice a day for fungal infection, with a start date of 07/28/2025. 7. A review of the clinical record for Patient #3, SOC 04/29/2024, contained a Medication Profile that indicated, but was not limited to, Cephalexin ( an antibiotic) 500 mg twice a day for 7 days, with a start date of 06/19/2024, and a stop date of 08/05/2024. The findings were reviewed with the Administrator/Alternate Clinical Manager and the Director of Clinical Services/Alternate Administrator on 01/08/26 from 3:10 PM to 3:55 PM, during which they had no further information or documentation to provide.

G0714

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 the patient/caregiver/family were instructed and demonstrated wound care dressing changes for 1 of 2 active clinical records review (Patient #2) with wound care orders. Findings Include: A review of the clinical record for Patient #2, SOC 07/28/2025, certification period 11/25/2025 to 01/23/2026, indicated but was not limited to primary diagnosis Encounter for Change or Removal of Surgical Wound Dressing, and other diagnosis included; Aftercare Following Surgery for Neoplasm (a new and abnormal growth of tissue in some part of the body that can be benign or cancerous), Squamous Cell Carcinoma (a type of skin cancer)of Skin of Scalp and Neck, and Type 2 Diabetes Mellitus(a chronic condition when the body cannot use insulin to regulate the amounts of sugar in the blood). Patient #3 had orders for SN 1 time a week to change and instruct caregiver/family, wound dressing as ordered: wound care #1 right frontal scalp as follows; cleanse/irrigate with (solution) soap and water apply duoderm or non stick dressing secure with duoderm/tape; wound care to wound #2 left parietal scalp as follows; cleanse/irrigate with (solution) soap and water apply duoderm or non stick dressing secure with duoderm/tape. During an interview on 01/07/2026 at 1:00 PM, when questioned regarding Patient #3’s wound care only being completed 1 time a week, RN 1 stated, “The caregiver/family member is to complete the dressing change the other time a week.” When asked if they had instructed or observed the caregiver/family member perform dressing changes, RN 1 stated, “No, I have not seen the daughter. No, I did not educate on the dressing changes. We honestly didn’t do that. I know it is my fault.” 410 IAC 17-14-1(a)(1)(G)

G0798

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 HHA care plan was individualized and patient-specific for 1 of 1active records reviewed receiving SN and HHA services. (Patient: #3) Findings Include: 1. Review of an undated agency policy titled “Home Health Aide: Assignment” indicated but was not limited to “ ... To meet the Client’s needs for assistance with activities of daily living and personal care. To orient the aide to the Client and to the care plan. To provide direction … 1. The initial assessment for the need for health aide services shall be determined by the authorized nurse/therapist. The assignment of tasks will be identified in the home aide care plan/Assignment Sheet. 2. Factors to be considered shall include, but are not limited to: a. Specific medical and psychological needs of the Client … ” 2. A review of the clinical record for Patient #3, SOC 04/29/2024, contained a POC for the certification period from 12/20/2025 to 02/17/2026. The POC indicated Patient #3 had a primary diagnosis of Quadriplegia (a condition caused by an injury to the spinal cord causing paralysis affecting all four limbs), and other diagnoses included but are not limited to, Autonomic Dysreflexia (a potentially life threatening condition involving abnormal, overreaction of the autonomic nervous system (the network of nerves through your body that control unconscious processes such as breathing, heart beating, blood pressure, and digestion) to certain types of stimulation) leading to severe high blood pressure and other symptoms). Patient #3 had orders for HHA 6 hours daily 7 times weekly, for personal care services of bathing, grooming, dressing and safe transfers. A review of the agency document titled “Paraprofessional Assignment Sheet” electronically signed by RN 2 and dated 12/16/2025, indicated Patient #3 had a diagnosis of Quadriplegia, and HHA frequency of 7 times weekly, two times a day for 3 hours. Clinical findings indicated Patient #3 had paralysis and tired easily, safety precautions, catheter tubing/bag, electric cords, telephone within reach, adequate lighting, frequently used items in reach, clutter in pathways, and followed infection precautions and infection control, but failed to address safety precautions with Patient #4’s autonomic dysreflexia and precautions with preventative causes. During an interview on 01/08/2026 at 11:06 AM, during a conference with RN 2, LPN 2, and the Administrator, when asked about Patient #3’s HHA care plan having interventions for safety precautions HHAs should had provided Patient #3 for safety related to their diagnosis Autonomic Dysreflexia, communicated there were no safety plans or precautions documented for the HHAs to follow or orientation for HHAs who had provided care to Patient #3. When asked what about Patient #3’s episodes and increase in medication due to controlling high blood pressures, verbalized they were unaware, and were aware wrinkles in sheets or in clothes could manifest an episode.

G0948

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on the record review and interview, the Administrator/Alternate Clinical Manager failed to ensure responsibility for the day-to-day operations, including 24-hour RN availability. Findings Include: 1. A review of an agency policy revision date November 2021, titled “Home Health Administrator” indicated but was not limited to, “ … The Executive Director/Administrator position will be responsible for the direction, coordination, and general supervision of all home health services … Responsibilities of the position will include, but not be limited to: A. Planning, organizing, directing, and evaluating operations to ensure the provision of adequate and appropriate care and services. B. Ensuring organizational compliance … D. Recruiting, employing, and retaining qualified personnel … G. Directing and monitoring performance improvement activities… Assuring that all clinical services are furnished under the supervision of a physician or registered nurse … L. Assuring that the Clinical Manager and other appropriate staff supervision are available … ” 2. A review of an undated agency policy titled “Provision for 24-Hour RN Availability” indicated, but was not limited to, “ … The Registered Nurse will be available to make a home visit, if necessary … ” 3. During an interview on 01/07/2025 at 6:30 AM, a call was placed to the agency’s phone number (317) 252-5958 to verify on-call. Received a voicemail indicating, had reached the agency outside business hours and reached the nurse on call by pressing option #1. Admin 7, the on-call agency nurse, communicated that they were the RN on call and answered the agency's after-hours calls, directed calls to the appropriate staff. Admin 7 further indicated they lived in Florida and had not completed on-call visits for the agency. Admin 7 reported if a visit had been needed, they reported to the on-call nurse or case manager, who completed the needed visits. 4. A review of the clinical record for Patient #3, SOC 04/29/2024, contained a POC for the certification period from 12/20/2025 to 02/17/2026. The POC indicated Patient #3 had a primary diagnosis of Quadriplegia (a condition caused by an injury to the spinal cord causing paralysis affecting all four limbs), and other diagnoses included but are not limited to, Autonomic Dysreflexia (a potentially life threatening condition involving abnormal, overreaction of the autonomic nervous system (the network of nerves through your body that control unconscious processes such as breathing, heart beating, blood pressure, and digestion) to certain types of stimulation) leading to severe high blood pressure and other symptoms), Neurogenic bowel (loss of bowel function due to nerve damage), Encounter for Fitting Adjustment of Urinary Device, and Pressure Ulcer of Right Ankle, Stage 3 (full thickness skin loss that involves damage to the subcutaneous tissue). Patient #3 had orders for SN 3 times a week for cardiopulmonary assessments, wound care to wound #1, pubis area above suprapubic catheter (pressure ulcer), wound care to wound #2, coccyx wound care to wound #3 midline coccyx, and wound care to wound #4 right distal coccyx, bowel program, and catheter changes. A review of the SN notes for the week of 12/27/2025 to 01/02/2026 failed to evidence SN visits. A review of agency documents titled “Missed Visit Notes” evidenced the following: on 01/04/2026, LPN 2 documented missed visit notes for 12/29/2025, 12/31/2025, and 01/02/2026, noting the missed visit reason was cancelled by the agency, and no agency staff were available. During an interview on 01/08/2026 at 11:10 AM, with the Administrator/Alternate Clinical Manager, RN 2, the case manager for Patient #3, and LPN 2, when asked about the missed SN visits for the week of 12/29/2025 to 01/02/206 cancelled by the agency, LPN 2 communicated they had car issues and had notified the Administrator/Alternate Clinical Manager. The Administrator/Alternate Clinical Manager confirmed LPN 1 reported missed visits to the nurse on call, and no other nurses were available to see Patient #3. When asked about the on-call nurse seeing patients, the Administrator/Alternate Clinical Manager indicated they were the on-call nurse and should have seen the patient. 410 IAC 17-12-1(c)(1)

G0966

Assure patient needs are continually assessed CFR(s): 484.105(c)(4) Assuring that patient needs are continually assessed, and This ELEMENT is not met as evidenced by: Based on record review and interview, the Administrator failed to ensure the patients’ needs were continuously assessed and received services to meet their needs for 3 of 6 active records reviewed. (Patients: #3, 4, and 5) and 2 of 2 inactive records reviewed. (Patient: #6, and 7) Findings Include: 1. A review of an undated agency policy titled “Medical Supervision” indicated, but was not limited to, “ … A Physician Plan of Care is developed for each Client … The physician’s orders shall outline the disciplines providing care and the type, frequency, and duration of services to be provided … ” 2. A review of an agency policy revision date November 2021, titled “Home Health Administrator” indicated but was not limited to, “ … The Executive Director/Administrator position will be responsible for the direction, coordination, and general supervision of all home health services … Responsibilities of the position will include, but not be limited to: A. Planning, organizing, directing, and evaluating operations to ensure the provision of adequate and appropriate care and services. B. Ensuring organizational compliance … D. Recruiting, employing, and retaining qualified personnel … G. Directing and monitoring performance improvement activities… Assuring that all clinical services are furnished under the supervision of a physician or registered nurse … L. Assuring that the Clinical Manager and other appropriate staff supervision are available … ” 3. A review of an undated agency policy titled “Provision for 24-Hour RN Availability” indicated, but was not limited to, “ … The Registered Nurse will be available to make a home visit, if necessary … ” 4. A review of the clinical record for Patient #3, SOC 04/29/2024, contained a POC for the certification period from 12/20/2025 to 02/17/2026. The POC indicated Patient #3 had orders for SN 3 times a week for cardiopulmonary assessments, wound care to wound #1, pubis area above suprapubic catheter (pressure ulcer), wound care to wound #2, coccyx wound care to wound #3 midline coccyx, and wound care to wound #4 right distal coccyx, bowel program, and catheter changes. A review of the SN visit notes for the week of 12/27/2025 to 01/02/2026 failed to evidence a SN visit had been made. 5. A review of the clinical record for Patient #4, SOC 12/08/2025, contained a POC for the certification period from 12/08/2025 to 02/05/2026. The POC indicated Patient #4 had orders for PT one time a week for one week, two times a week for two weeks, and one time a week for 5 weeks, for therapeutic exercise, endurance training, transfer training, balance training, gait training, and pain management. A review of the PT visit notes evidenced the following: the week of 12/8/2025 to 12/12/2025, PT 1 completed the SOC on 12/08/2025; the week of 12/13/2025 to 12/19/2025, no PT visits were made; the week of 12/20/2025 to 12/26/2025, no PT visits were made; the week of 01/03/2026 to 01/08/2026, PT completed a visit on 01/05/2026. 6. A review of the clinical record for Patient #5, SOC 11/20/2025, contained a POC for the certification period from 11/20/2025 to 01/10/2026. The POC indicated Patient #5 had orders for PT: one time per week for one week, then two times per week for 8 weeks, for therapeutic exercise, endurance training, transfer training, balance training, gait training, and pain management. Patient #5 had orders for a HHA 3 times a week for 7 weeks, starting 11/26/2025, for ADL and personal care assistance. A review of an agency document titled “Paraprofessional Assignment Sheet” signed and dated 11/26/2025 by PT 2, contained a care plan start date of 11/26/2025 for Patient #5 to receive HHA frequency 3 times a week for 8 weeks, two hours per service for assistance in ADLs of bathing, dressing, every Monday, Wednesday, and Friday. A review of the HHA visit notes evidenced the following: the week of 11/22/2025 to 11/28/2025, no HHA visits were completed, and the week of 11/29/2025 to 12/05/2025, no HHA visits were completed. 7. A review of the inactive clinical record for Patient #6, SOC 10/15/2025, and date of discharge 12/28/2025, contained a POC for the certification period from 10/15/2025 to 12/13/2025. The POC indicated Patient #6 had orders for PT: one time a day for one day, one time a week for one week, and two times a week for 7 weeks, for balance training, transfer training, bed mobility training, and establishing a home exercise program. A review of the PT visit notes evidenced the following: the week of 10/15/2025 to 10/17/2025, PT 1 completed the SOC on 10/15/2025 and a visit on 10/17/2025; the week of 10/18/2025 to 10/24/2025, PT visits were completed 10/21/2025 and 10/23/2025; the week 10/25/2025 to 10/31/2025, no PT visits were completed; the week 11/01/2025 to 11/07/2025 no PT visits were completed; the week 11/08/2025 to 11/14/2025 no PT visits were completed; the week 11/22/2025 to 11/28/2025 a PT visit had been completed on 11/24/2025, and discharge visit completed 11/28/2025. 8. A review of the clinical record for Patient #7, SOC 11/17/2025, contained a POC for the certification period from 11/17/2025 to 01/15/2026. The POC indicated Patient #7 had orders for PT one time a week for 5 weeks for therapeutic exercise, endurance training, transfer training, balance training, gait training, and pain management. A review of the PT visit notes evidenced the following: for the week of 11/17/2025 to 11/21/2025, PT 1 completed the SOC on 11/17/2025; the clinical record failed to evidence any further visits had been completed. During an interview on 01/08/2026 at 11:10 AM, with the Administrator/Alternate Clinical Manager, RN 2, the case manager for Patient #3, and LPN 2, when asked about the missed SN visits for the week of 12/29/2025 to 01/02/206 cancelled by the agency, LPN 2 communicated they had car issues and had notified the Administrator/Alternate Clinical Manager. The Administrator/Alternate Clinical Manager confirmed the reported missed visits and had been the nurse on call, and there were no other nurses available to see Patient #3 and the caregiver had provided care for Patient #3. When asked about the on-call nurse seeing patients, the Administrator/Alternate Clinical Manager indicated they were the on-call nurse and should had seen the patient. When reviewing the clinical records for Patients #4, 5, 6, and 7, and asked about the clinical services not being provided as ordered per the POC, the Administrator indicated the agency had been waiting on insurance authorization.

Survey of November 7, 2022

8 findings

G0000

This visit was for a Federal Recertification and State Re-Licensure survey of a Home Health agency. Survey Dates: 10/31/22, 11/1/22, 11/2/22, 11/3/22, 11/4/22, and 11/7/22. Census: 827 This deficiency report reflects State Findings cited in accordance with 410 IAC 17 et seq. QR by Area 3 on 11/14/2022 and Area 4 on 11/30-12/1/2022

G0414

HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator's name, business address, and business phone number in order to receive complaints. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to provide patients/families with contact information for the current administrator, including the administrator's name, title, business address, and business phone number in order to receive agency complaints in 2 (Patients 5 and 17) of 7 home visits observed of a total sample of 18 patients. Findings include: 1. Review of an undated agency policy titled 'CODE OF ETHICS C-510,' stated, " ... SPECIAL INSTRUCTIONS ... Patients are informed of how/who to contact at the agency if concerns arise and are also given the phone number of the Office of Health Facility Complaints and a brief explanation of how to file a complaint." 2. A review of the agency's preprinted and bound admission packet, page 8 contained a section titled, 'PROBLEM-SOLVING PROCEDURE' evidenced, "We are committed to ensuring that your rights are protected. If you feel that our staff had failed to follow our policies or has in any way denied your rights, please follow these steps without fear of discrimination or reprisal: 1. notify Employee 3, Clinical Operations Manager, by phone at [phone number], Monday through Friday from 8:00 a.m. to 5:00 p.m. Most problems can be solved at this level..." A review of the agency's preprinted and bound admission packet, page 18 contained a section titled, 'COMPLAINTS' that stated, "If you believe that your privacy rights have been violated, you may complain to the agency or the Secretary of the U.S. Department of Health and Human Services. There will be no retaliation against you for filing a complaint. The complaint should be filed in writing, should contain the specific incident(s) in terms of subject, date, and other relevant matters. A complaint to the Secretary must be filed within 180 days of when the act or omission complained of occurred and must describe the act or omissions believed to be in violation of applicable requirements. [45 CFR subsection 160.306] for Further information regarding filing a complaint, contact: Employee 1, Vice President of Clinical Services, Caregivers, Inc. [agency's address and phone number]." 3. On 11/2/22 at 11:30 AM, during a home visit for Patient 17, a review of the admission packet in the home revealed a space on the back cover for "Administrator" and a space for a corresponding phone number. In that space was handwritten, "[Employee 1] and the agency's phone number". When queried as to who the patient could call at the agency if there were ever any issues or concerns, the patient indicated they would call Employee 1. After the visit was completed, Nurse A was asked if they knew who the Administrator was and the nurse stated, "[Employee 2] and indicated that he/she had even met [the Administrator]. 4. On 11/2/22 at 2:00 PM during a visit with Patient 5 and Physical Therapist (P.T.) 2, a review of the admission packet in the home revealed a space on the back cover for the Administrator's name and the corresponding phone number. Only the name of an Occupational Therapist as handwritten adjacent to this area, with a corresponding phone number. Admission packets reviewed in the home failed to evidence an Administrator's name, title, and contact number. 5. In an interview on 10/31/22 at 10:30 AM, when queried as to which agency staff member handles incoming complaints, the Vice president of Clinical Operations indicated that both the Clinical Operations Manager and he/she handled the complaints. 6. During a telephone interview on 11/4/22 at 4:17 PM with the current administrator, who was unavailable in person during the survey, indicated being aware of the fact that the current preprinted admission packets were void of the administrator's name and title for patients/families, as required for reporting complaints. 7. During an interview on 11/7/22 at 11:03 AM, the Vice President of Clinical Services indicated awareness that the current preprinted and bound admission folders were void of the Administrator's name, title, and contact information and indicated he was presently strategizing to rectify this.

G0526

Content of the comprehensive assessment CFR(s): 484.55(c) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the following information: This STANDARD is not met as evidenced by: Based on record review and interview, the Agency failed to ensure the content of the comprehensive assessment accurately reflected the patient's health status and compliance with medication administration in 1 clinical record review of 18. (Patient 3) Findings include: A review of an agency’s undated policy titled, ‘SKILLED NURSING SERVICES,’ revealed, “POLICY Skilled nursing services will be provided by a Registered Nurse or a Licensed Practical/Vocational Nurse under the supervision of a Registered Nurse and in accordance with a medically approved Plan of Care (physician’s orders). SPECIAL INSTRUCTIONS … 1. The registered nurse: a. performs the initial assessment visit. b. Regularly reevaluates the patient needs…c. Informs the physician and other personnel of changes …" A review of an agency’s undated policy titled, ‘CLINICAL DOCUMENTATION C-680,’ revealed, “POLICY Agency will document each direct contact with the patient … and monitored by the skilled professional responsible for managing the patient’s care. PURPOSE To ensure that there is an accurate record … To document conformance with the Plan of Care …" A review of the clinical record for Patient #3, with a SOC of 6/10/21, and a recertification period of 10/3/22 to 12/1/22, with diagnoses that included, but were not limited to: Mild Cognitive Impairment, and Chronic Pulmonary Disease, evidenced an agency document titled “Home Health Certification and Plan of Care” for skilled nursing monthly for medication set-up. A review of a skilled visit note for Patient #3 evidenced an LPN 2 visit on 7/21/22, which revealed the patient’s blood pressure was 98/69. The document indicated the patient missed week Sunday-Tuesday PM dose. [The note did not specify which medication dose was missed.] In the communication section of the visit note, there were the following questions: Communicated with physician: LPN 2 answered “no”; Change in order: LPN 2 answered “no”; Communicated with Other: LPN 2 answered “yes”, Describe: LPN 2 answered “VA Pharmacy for Medication refills.” A review of the clinical record of Patient #3 revealed a “Recertification Skilled Adult Assessment (non-Oasis)” document signed and dated by RN 2 on 8/3/22. RN 2 indicated Patient #3 was able to take medications at the correct times if prepared in advance by another person or given reminders, and that they are compliant with their medication regime. A review of a skilled visit note for Patient #3 evidenced an LPN 2 visit on 8/30/22, that indicated the Patient stated they felt tired, energy down, drained, starting yesterday. Patient #3 blood pressure was 90/56. LPN 2 indicated the Patient missed 11 evening medications, 1 morning dose, and 8 bedtime doses. In the communication section of the visit note, there were questions: Communicated with physician: LPN 2 answered “no”; Change in order: LPN 2 answered “no”; Communicated with Other: LPN 2 answered “yes”, Describe: LPN 2 answered “VA Pharmacy for refills”. A review of a skilled visit note for Patient #3 evidenced an LPN (licensed practical nurse) 2 visit on 9/27/22, indicated the patient missed 3 weeks of evening medications, 3 morning doses, and 4 bedtime doses. In the communication section of the visit note, there were questions: Communicated with a physician: LPN 2 answered “no”; Change in order: LPN 2 answered “no”; Communicated with Other: LPN 2 answered “yes”, Describe: LPN 2 answered, “VA Pharmacy for Medication refills.” A review of the clinical record of Patient #3 revealed a “Recertification Skilled Adult Assessment (non-Oasis)” document signed and dated by RN (registered nurse) 2 on 10/3/22. RN 2 indicated Patient #3 was able to take medications at the correct times if prepared in advance by another person or given reminders, and that they are compliant with their medication regime. During an interview with Patient #3 on 11/4/22 at 3:45 PM, Patient #3 stated they do miss some medications at times. During an interview with RN 2 on 11/4/22 at 8:34 AM, RN 2 indicated LPNs will call the RN with patient changes or concerns, and if they do not, the RN will see the LPN’s notes. When RN 2 was queried about the LPN’s documentation of Patient #3's missed medication doses/noncompliance with plan of care medication orders, RN 2 indicated they were not aware. During an interview with the Vice President of Clinical Services on 11/7/22 at 9:43 AM, indicated it was disappointing to learn this. 410 IAC 17-15-1(a)

G0536

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 that clinicians performed a review of all medications the patients were taking in 1 (Patient 5) of 7 home visits observed, of a total sample of 18 patients. Findings include: 1. Review of an undated agency policy titled, 'MEDICATION PROFILE C-700,' stated, "POLICY The Registered Nurse or Therapist will complete a medication profile for each patient at the time of admission. The medication profile shall include all prescriptions and nonprescription including regularly scheduled medication and those taken intermittently or as needed. The profile will be reviewed and updated as needed to reflect current medications the patient is taking. PURPOSE ...To provide documentation of changes in the medication regime as they happen, and to support changes as needed in the plan of care...SPECIAL INSTRUCTIONS ...10. The Medication Profile shall be reviewed by a Registered Nurse every sixty (60) days and updated whenever there is change or discontinuation in medication ..." Review of an undated agency policy titled, 'MEDICATION RECONCILIATION C-709,' stated, "POLICY Agency will reconcile all medications taken by the client prior to admission to home care with those ordered at the time of admission, before and after inpatient stays and at the time of discharge. PURPOSE To prevent potential medication errors and to assure clients are receiving all prescribed and necessary medications DEFINITIONS Reconciliation: to establish a close relationship between ordered medications and intended medications when a client is admitted to a different care setting. Medications: includes all over the counter, prescription, regularly taken PRN medications, herbals, and nutraceuticals that the client takes in all places of residence. SPECIAL INSTRUCTIONS 1. At the time of admission to the home care agency, the admitting professional will document a complete list of medications taken by the client prior to admission. This will include all over the counter, prescribed, and PRN medications. Documentation of these medications will be listed on the Medication Profile and include name, dose, route of administration, frequency and when last dose was taken. 2. The information will be obtained from the client if possible. If the client was unable to communicate this information, it may be obtained from family members, medication bottle labels, client pharmacy or from an inpatient facility if recently discharged. 3. The admission professional will review this medication list with the physician and confirm those medications that are to be continued or discontinued. The doses will be confirmed with the physician and changes will be noted in the record and on the Physician Plan of Care. 4. If the client is admitted to an inpatient setting while receiving home care services. a list of current medications will be sent to the admitting facility. 5. When the client is discharged from the inpatient setting, the medications will be reviewed and the orders updates to reflect changes and/or continuation of previous orders. 6. When the client is discharged from home care services, a current list of medications will be reviewed with the client and physician and given to the client. 7. If the discharge is to an inpatient setting, the list of currently prescribed medications and other medications the client currently takes, will be sent to the admitting facility." The policy failed to require medication reconciliation was performed whenever medication was introduced, changed, or discontinued throughout the certification period. 2. Review of the clinical record for Patient 5 contained a document dated 10/12/22, titled 'Home Health Certification and Plan of Care' with a Start of Care date of 10/12/22 and a certification period of 10/12/22 through 12/10/22. Page 1 contained diagnoses that included but were not limited to: pulmonary embolism (or PE, which occurs when a blood clot gets stuck in an artery in the lung, blocking blood flow to part of the lung. Blood clots most often start in the legs and travel up through the right side of the heart and into the lungs. This is called deep vein thrombosis (DVT)), acute embolism and thrombosis of the right peroneal vein (a condition in which a blood clot forms in a vein, most commonly in the deep veins of the legs or pelvis. This is known as deep vein thrombosis or DVT, blood clots can dislodge and travel in the blood, particularly to the pulmonary arteries. This is known as pulmonary embolism or PE), Crohn's Disease (a type of inflammatory bowel disease (IBD) that causes swelling of the tissues (inflammation) in your digestive tract, which can lead to abdominal pain, severe diarrhea, fatigue, weight loss, and malnutrition). Page 1 also contained a list of the patient's current medications, "Apixaban Starter Pack Oral Tablet Therapy Pack 5 MG / As directed / ORAL / Twice a Day 2 Tablets by mouth twice a day for 7 days then 1 tablet by mouth twice per day /...Pantoprazole Sodium Oral Tablet Delayed Release 40 MG / 1 tablet / ORAL / Once a Day / (N[ew])...Sertraline HCl Oral Tablet 50 MG / 1 tablet / ORAL / Once a Day / (N[ew])...Cefpodoxime Proxetil Oral Tablet 200 MG / 1 tablet / ORAL / Twice a Day Take for four days / (N[ew])...Pepcid Oral Tablet 40 MG / 1 tablet / ORAL / PRN Twice a Day Upset Stomach / (N[ew])". Page 3 contained a narrative that stated, "73-year-old female admitted to hospital with acute respiratory failure and pulmonary embolism due to severe reaction to medication given I.V. (intravenous) for Crohn's Disease..." 3. On 11/2/22 at 2:00 PM during a home visit with Patient 5, Physical Therapist (P.T.) 2 inquired if there were "any new meds" and the patient replied, "no". The patient's medication list was not reviewed with the patient. Later the patient discussed having had adverse reactions to "biologic" medications (Biologic therapies can help achieve remission by reducing symptoms, as well as provide healing for damage to intestines caused by inflammation, these therapies are usually prescribed for those with more severe Crohn's symptoms who haven't found relief with other methods) that had been prescribed to him/her previous to recent hospitalization and expressed a desire to "never take [that class of medication] again". The patient then stated, "I'll just stay on 15 milligrams of Prednisone (a corticosteroid, often known as steroids, are an anti-inflammatory medicine prescribed for a wide range of conditions,) indicating this would be a long-term medication for him/her and further stated, "I'd rather be fat than take that [biologic medication] again." 4. In an interview on 11/3/22 at 3:39 PM, with the Vice President of Clinical Services (VPCS), when discussing that the clinical record 5 failed to evidence Prednisone on the medication list and that Patient 5 had stated they were currently taking Prednisone during the home visit, the VPCS indicated he expected that P.T. 2 would have any documented any medications the patient was currently taking and he that would investigate the matter further. In a follow-up interview on 11/4/22 at 10:23 AM, the VPCS indicated he also saw no evidence of Prednisone being documented on the medication list, but noted that the medication discharge list from the hospital had Prednisone listed as a 'discontinued' medication. He further stated he would involve the clinician and would determine what changes needed to be made, if any, and that the Physician would be notified as well. He added, "there's no excuse for it." 410 IAC 17-14-1(a)(1)(B)

G0572

G0602

Communication with all physicians CFR(s): 484.60(d)(1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the Agency failed to ensure communication with the attending physician occurred with a change of status and medication non-compliance in 1 of 18 clinical records reviewed. (Patient 3) Findings include: A review of an agency’s undated policy titled, ‘COORDINATION OF PATIENT SERVICES C-360’ revealed, “POLICY All personnel furnishing services shall maintain a liaison to assure that their efforts are coordinated effectively and support the objectives outlined in the Plan of Care. This may be done through formal care conference…PURPOSE To ensure services are coordinated between members of the interdisciplinary team. To ensure appropriate, quality care is being provided to patients. To establish effective interchange, reporting, and coordination of patient care does occur…To identify needs to modify the plan of care…” A review of an agency’s undated policy titled, ‘SKILLED NURSING SERVICES’ revealed, “POLICY Skilled nursing services will be provided by a Registered Nurse or a Licensed Practical/Vocational Nurse under the supervision of a Registered Nurse and in accordance with a medically approved Plan of Care…SPECIAL INSTRUCTIONS…2. The Licensed Practical Nurse:…d. Reports findings and observations to the registered nurse and other members of the team to assure coordination and timely response to patient changes or needs…” A review of the clinical record of Patient #3, with a SOC of 6/10/21, and a recertification period of 10/3/22 to 12/1/22, with diagnoses but not limited to, Mild Cognitive Impairment, and Chronic Pulmonary Disease, evidenced by an agency document titled “Home Health Certification and Plan of Care” for skilled nursing monthly for medication set-up. A review of the clinical record of Patient #3 revealed a “Recertification Skilled Adult Assessment (non Oasis)” document signed and dated by RN (registered nurse) 2 on 10/3/22. RN 2 indicated Patient #3 was able to take medications at the correct times if prepared in advance by another person or given reminders, and that they are compliant with their medication regime. A review of the clinical record of Patient #3 revealed a “Recertification Skilled Adult Assessment (non Oasis)” document signed and dated by RN 2 on 8/3/22. RN 2 indicated Patient #3 was able to take medications at the correct times if prepared in advance by another person or given reminders, and that they are compliant with their medication regime. A review of a skilled visit note for Patient #3 evidenced an LPN (licensed practical nurse) 2 visit on 9/27/22, indicated the patient missed 3 weeks of evening medications, 3 morning doses, and 4 bedtime doses. In the communication section of the visit note, there are questions: Communicated with physician: LPN 2 answered “no”; Change in order: LPN 2 answered “no”; Communicated with Other: LPN 2 answered “yes”, Describe: LPN 2 answered, “VA Pharmacy for Medication refills”. A review of a skilled visit note for Patient #3 evidenced an LPN 2 visit on 8/30/22, indicated that the Patient stated they felt tired, energy down, drained, starting yesterday. Patient #3's blood pressure was 90/56. LPN 2 indicated the Patient missed 11 evening medications, 1 morning dose, and 8 bedtime doses. In the communication section of the visit note, there are questions: Communicated with physician: LPN 2 answered “no”; Change in order: LPN 2 answered “no”; Communicated with Other: LPN 2 answered “yes”, Describe: LPN 2 answered “VA Pharmacy for refills”. A review of a skilled visit note for Patient #3 evidenced an LPN 2 visit on 7/21/22, which revealed the patient’s blood pressure was 98/69. The document indicated the patient missed week Sunday-Tuesday evening dose. In the communication section of the visit note, there are questions: Communicated with physician: LPN 2 answered “no”; Change in order: LPN 2 answered “no”; Communicated with Other: LPN 2 answered “yes”, Describe: LPN 2 answered “VA Pharmacy for Medication refills”. A review of a document titled, “Case Conference” dated 9/30/22 revealed the date of the Case Conference was 9/28/22 for Patient #3, members attending the conference were RN, LPN, PT, Care Coordinator, Clinical Operations Manager, VP of Clinical Operations. Questions on the case conference document that included but were not limited to were: “Has the client experienced an onset of new symptoms such as dizziness, confusion, or shortness of breath within the past 14 days? The answer was ‘no’; Has there been a significant change in the client’s condition during this episode? (good or bad), the answer was ’no’; Is the client and/or family compliant with the plan of care, the answer was ‘yes’. Issues and Resolutions: None, No care coordination needs have been identified at this time”. A review of a document titled, “Case Conference” dated 8/2/22 revealed the date of the Case Conference was 7/27/22 for Patient #3, members attending the conference were RN, LPN, PT, Care Coordinator, Clinical Operations Manager, VP of Clinical Operations. Questions on the case conference document that included but were not limited to were: “Has the client experienced an onset of new symptoms such as dizziness, confusion, or shortness of breath within the past 14 days? The answer was ‘no’; Has there been a significant change in the client’s condition during this episode? (good or bad), the answer was ’no’; Is the client and/or family compliant with the plan of care, the answer was ‘yes’. Issues and Resolutions: None, No care coordination needs have been identified at this time”. During an interview with RN 2 on 11/4/22 at 8:34 AM, RN 2 indicated LPNs will call the RN with patient changes or concerns, and if they do not, the RN will see the LPN’s notes. RN indicated that they had no knowledge of missed medications. 410 IAC 17-14-1(a)(1)(G)

G0682

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation, record review, and interview the agency failed to ensure staff implemented infection prevention measures, including hand hygiene while providing patient care in 5 (licensed practical nurse #1, registered nurse #1, registered nurse #2, and physical therapist #1, physical therapist #2) of 7 home visits observations. Findings include: 1. A review of an agency’s undated policy titled, ‘INFECTION PREVENTION/CONTROL B-403’ revealed POLICY Agency will observe the recommended precautions for home care as identified by the Centers for Disease Control and Prevention (CDC)…PURPOSE To ensure employee and patient safety….STANDARD PRECAUTIONS _ TIER ONE 1. Standard precautions apply to blood, all body fluids, secretions, excretions, non-intact skin, and mucous membranes. All are to be treated as a potential source of infection…2. Hands are washed if contaminated with blood or body fluid, immediately after gloves are removed, between patient contacts…3. Gloves are worn when touching…contaminated items…” A review of the Centers for Disease Control on 7/15/22, “When to Perform Hand Hygiene” (https://www.cdc.gov/handhygiene/providers/), revealed that, “Multiple opportunities for hand hygiene may occur during a single care episode. Following are the clinical indications for hand hygiene: Use an Alcohol-Based Hand Sanitizer or wash with soap and water immediately before touching a patient, when hands are visibly soiled, before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices, after caring for a person with known or suspected infectious diarrhea, before moving from work on a soiled body site to a clean body site on the same patient, after known or suspected exposure to spores (e.g. B. anthracis, C difficile outbreaks), after touching a patient or the patient’s immediate environment, after contact with blood, body fluids or contaminated surfaces, or immediately after glove removal.” “WHEN AND HOW TO WEAR GLOVES” revealed, “Wear gloves, according to Standard Precautions, when it can be reasonably anticipated that contact with blood or other potentially infectious materials, mucous membranes, non-intact skin, potentially contaminated skin or contaminated equipment could occur. Gloves are not a substitute for hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, before touching the patient or the patient’s environment. Perform hand hygiene immediately after removing gloves. Change gloves and perform hand hygiene during patient care, if…moving from work on a soiled body site to a clean body site on the same patient…” 2. During Patient #11’s home visit with LPN (licensed practical nurse) 1 for wound care on 11/2/22 at 12 PM, LPN 1 initiated the visit by creating a barrier and placing their bag on the barrier. LPN 1 reached into their bag for a paper towel and went into the patient’s bathroom to wash their hands. LPN 1 placed the paper towel on the side of the sink, and performed hand hygiene, then picked up the towel that was on the side of the sink to dry their hands. LPN 1 created barriers for Patient #11’s left lower extremity and dressing supplies, applied gloves, and opened all the dressing packages, stacking 3 ABD (abdominal) pads on top of each other. LPN 1 removed the old dressing, removed gloves, performed hand hygiene, donned clean pair of gloves, cleansed the wound, doffed gloves, performed hand hygiene, donned clean pair of gloves, and applied the Fibercol Plus dressing to the wound bed. LPN 1 reached for 1 ABD pad, in doing so, 1 ABD pad fell to the floor, ½ landed on the barrier where their nursing bag was placed, and the other ½ landed on the floor. LPN 1 reached for the ABD pad and placed it back on top of the other ABD pad that was on the barrier. The ABD that was in LPN 1 hand was placed on the backside of Patient #11’s left lower extremity, LPN1 then reached for the other 2 ABD pads placing them on the front side of Patient #11’s left lower extremity. LPN 1 proceeded to wrap the left lower extremity with kerlix, and ace wrap as ordered. LPN 1 bagged up trash and handed it to the patient’s family member to throw away. LPN 1 performed hand hygiene. LPN 1 reached into their nursing bag for a gallon baggie that contained equipment for vital signs and placed it on top of a box. LPN 1 proceeded to take the patient’s vital signs cleaning each item and placing back into the baggie. When completed, LPN 1 placed the baggie back into their nursing bag. LPN 1 took a paper towel out of their nursing bag and went into the bathroom to wash their hands and placed the paper towel on the side of the sink. When completed, LPN 1 turned the water off with their bare hands and dried their hands with the paper towel that was placed on the side of the sink. 3. During Patient #7’s home visit with RN (registered nurse) 2 for an assessment on 11/1/22 at 11 AM, RN 2 initiated the visit by washing their hands at the kitchen sink, then hung their bag on the back of a chair, placed their vital sign equipment, their phone, eyeglass case and tablet on the dining room table. RN 2 took Patient #7’s vital signs, cleaned their equipment, and placed them in their bag, then completed the patient assessment, performed hand hygiene, then documented the vital signs and the assessment on their tablet. RN 2 cleaned the tablet prior to handing the patient’s family member for signature. After signing the tablet, RN 2 took the tablet, along with their phone in hand, and placed their eyeglass case in the front pocket of their shirt. Once outside, when speaking about bag techniques and barriers, RN 2 stated, “I messed up then”. 4. During an interview with the Vice President of Services on 11/3/22 at 9:50 AM, they indicated they had already spoken to RN 2 and that additional training is needed for staff. 5. Review of an undated agency policy titled, 'HANDWASHING/HAND HYGIENE D-330', stated, "POLICY In an effort to reduce the risk for infection in patients and staff members, thorough hand washing/hand antisepsis is required for all employees. The agency will establish guidelines for all staff and will provide education and direction on accepted practices. PURPOSE To improve hand-hygiene practices of agency staff and to reduce transmission of pathogenic microorganisms to patients and personnel in the home care setting. SPECIAL INSTRUCTIONS 1. The hand hygiene procedure will be clearly outlined in the agency procedure manual. 2. Appropriate antiseptic cleanser may be used when appropriate and patient situation facilities are not available. 3. Indications for hand washing and hand antisepsis: … d. Between tasks on the same patient...F. After removing gloves. G. After touching objects that are potentially contaminated...n. If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands in all other clinical situations. Alternatively, wash hands with antimicrobial soap and water in all clinical situations...o. Decontaminate hands before having direct contact with patients...p. Decontaminate hands after contact with patient's intact skin...q. Decontaminate hands after contact with inanimate objects including equipment in the immediate vicinity of the patient... r. Decontaminate hands after removing gloves..." 6. During a home visit on 11/1/22 at 10:15 AM for Patient 15, PT 2 entered the apartment, greeted the patient, and set a large navy shoulder bag down on the floor of the apartment without a barrier. When taking the blood pressure for the patient, PT 2 set a small black zippered bag that contained a manual blood pressure cuff on an unsanitized surface, without a barrier, near the patient, sanitized the cuff after it's use, returned the now sanitized cuff to the small zippered bag, and placed it in the inside of the larger bag on the floor, without first having sanitized it. The therapist placed his/her electronic documentation device on a countertop in the kitchen without a barrier and without having first sanitized the area. The device was not sanitized during the visit. 7. During a home visit on 11/2/22 at 11:45 AM for Patient 17, RN 1, set a nursing tote bag on a barrier in a chair, and when sanitizing his/her hands, had to reach into the interior of the bag to access a container of hand sanitizer. The nurse reached into the interior of the bag to pump a portion of sanitizer into his/her hand, rubbed hands together with the sanitizer, and then reached back into the back for an electronic documentation device which was promptly sanitized with a wipe. Later, needing a manual blood pressure cuff, the nurse reached into the interior of the bag for sanitizer, rubbed hands together with the sanitizer, then reached back into the nursing bag for the blood pressure cuff itself. After contact with the patient, the nurse reached into the interior of the bag for sanitizer and rubbed hands together with the sanitizer. 8. During a home visit on 11/2/22 at 2:00 PM for Patient 5, PT 2 removed a large roll of garbage bags from a small tote bag and proceeded to tear off a new bag, attempted to unfold it and spread it out on the patient's couch, then placed the tote bag on this barrier. One of the straps of the bag hung over the barrier and laid on the seating surface of the couch. The therapist, now with an electronic documentation device in hand, took up the roll of garbage bags again to tear off a second barrier, and stuck the device under his left axilla, so both hands were freed to tear off and spread out the second barrier on the couch for the device to rest on, the therapist failed to sanitize the device. The therapist proceeded to wash his hands in the patient's bathroom, rubbed hands together with soap and water, rinsed hands under running water, left the bathroom with the faucet running, returned to the living room, reached into the interior of the bag, pulled out a folded-up paper towel, began to dry his/her hands with the towel and returned to the bathroom sink to shut off the water by turning the handles to the 'off' position using the paper towel. Later, a cotton gait belt was removed from the therapist's bag. The therapist unwound the gait belt as it had been rolled up and the loose end hit the carpeted floor. The therapist secured the gait belt around the patient in order that the patient may ambulate with assistance if needed. When the patient had completed this activity, the therapist removed the cotton gait belt, the loose end hitting the carpeted floor again, he/she continued to roll up the gait belt and placed it on the same barrier as the bag. Without first performing hand hygiene or sanitizing, the therapist picked up the device off the barrier, documented in the device, then placed the device back down onto the barrier. Later the therapist reached into the interior of the bag, into another clear bag that contained disposable gloves, and then donned gloves (without first sanitizing hands). Sanitizing wipes were located in the interior of the bag as well. With now gloved hands, the therapist took a wipe and picked up the cotton gait belt that had been rolled up, gently wiped the exterior of the 'roll' only, and then placed the gait belt back into the bag. Later, the therapist removed the left glove, gathered up the trash bag barriers, used disposable wipes, and the used left glove, with the right gloved hand, and disposed of it all in the bathroom. The therapist then returned without gloves. The therapist failed to sanitize hands after doffing gloves. 410 IAC 17-12-1(m)

G0726

Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure that RNs (Registered Nurses) were monitoring and evaluating the LPN's (Licensed Practical Nurses) performance in the provision of services, provision of treatments, patient education, communication with the RN, and data collection regarding the patient's status and health needs in 3 of 18 clinical records review. (Patients 1, 3, and 11) Findings include: 1. A review of an agency's undated policy titled, 'LICENSED PRACTICAL NURSE SUPERVISION C-320' revealed "POLICY The Agency shall provide Licensed Practical Nurse services under the direction and supervision of a Registered Professional Nurse when services are indicated and ordered by the physician. At least once annually, all Licensed Practical Nurses will be supervised directly while providing care. PURPOSE To provide supervision of the Licensed Practical Nurse as required by state/federal guidelines....SPECIAL INSTRUCTIONS 1. The Nursing Supervisor or designated Registered Nurse will give the Licensed Practical Nurse direction for patient care by way of the Care Plan...A copy of this written plan is to be left in the patient's home and revised periodically, as necessary...2. Supervisory visits of Licensed Practical Nurses will be made in the following manner: a. A Registered Nurse must review the Nursing Care Plan with the Licensed Practical Nurse...b. The Registered Nurse supervisory visit may be completed directly while the Licensed Practical Nurse is providing service to the patient or indirectly by alternating visits with the LPN and RN...3. Supervisory visits are to be documented in the patient's chart..." A review of an agency's undated policy titled, 'CLINICAL SUPERVISION C-300' revealed, "POLICY Skilled nursing and other therapeutic services are provided under the supervision of a Registered Nurse...7. On-site supervision of patients receiving services will be performed by a Registered Nurse...to direct, demonstrate, and evaluate the implementation of the Plan of Care and the delivery of services..." A review of an agency's undated policy titled 'CODE OF ETHICS C-510' stated, "SPECIAL INSTRUCTION...7. Personnel: ...D. All personnel are supervised." 2. A review of the clinical record of Patient #1, with a SOC (start of care) date of 2/1/22, and a recertification period of 9/29/22 to 11/27/22, evidenced an agency document titled “Home Health Certification and Plan of Care” for skilled nursing weekly for medication set-up, weekly blood sugar check and INR (international normalised ratio, which measures for blood clotting). A review of the clinical record of Patient #1, evidenced a document dated 10/25/22 and signed by RN 2 titled, “RN/LPN Care Coordination” with RN 2 agreeing “with LPN visit note. There was no evidence of monitoring and evaluating the LPN's (Licensed Practical Nurses) performance in the provision of services, provision of treatments, patient education, communication with the RN, and data collection regarding the patient's status and health needs. 4. A review of the clinical record of Patient #3, with a SOC of 6/10/21, and a recertification period of 10/3/22 to 12/1/22, with diagnoses but not limited to, Mild Cognitive Impairment, and Chronic Pulmonary Disease, evidenced an agency document titled “Home Health Certification and Plan of Care” for skilled nursing monthly for medication set-up. A review of the clinical record of Patient #3 revealed a “Recertification Skilled Adult Assessment (non Oasis)” document signed and dated by RN 2 on 10/3/22. RN 2 indicated Patient #3 was able to take medications at the correct times if prepared in advance by another person or given reminders, and that they are compliant with their medication regime. A review of the clinical record of Patient #3 revealed a “Recertification Skilled Adult Assessment (non Oasis)” document signed and dated by RN 2 on 8/3/22. RN 2 indicated Patient #3 was able to take medications at the correct times if prepared in advance by another person or given reminders, and that they are compliant with their medication regime. A review of a skilled nursing visit for Patient #3 evidenced an LPN 2 visit on 9/27/22, indicated the Patient missed 3 weeks of evening medications, 3 morning doses, and 4 bedtime doses. In the communication section of the visit note, there are questions: Communicated with physician: LPN 2 answered “no”; Change in order: LPN 2 answered “no”; Communicated with Other: LPN 2 answered “yes”, Describe: LPN 2 answered, “VA Pharmacy for Medication refills”. A review of a skilled nursing visit for Patient #3 evidenced an LPN 2 visit on 8/30/22, indicated that the Patient states they feel tired, energy down, drained, starting yesterday. Patient #3's blood pressure was 90/56. LPN 2 indicated the Patient missed 11 evening medications, 1 AM dose, and 8 bedtime doses. In the communication section within the visit note, there are questions: Communicated with physician: LPN 2 answered “no”; Change in order: LPN 2 answered “no”; Communicated with Other: LPN 2 answered “yes”, Describe: LPN 2 answered “VA Pharmacy for refills”. A review of a skilled nursing visit for Patient #3 evidenced an LPN 2 visit on 7/21/22, which revealed the patient’s blood pressure was 98/69. The document indicated the “Patient missed week Sunday-Tuesday PM dose”. In the communication section within the visit note, there are questions: Communicated with physician: LPN 2 answered “no”; Change in order: LPN 2 answered “no”; Communicated with Other: LPN 2 answered “yes”, Describe: LPN 2 answered “VA Pharmacy for Medication refills”. A review of a document titled, “Case Conference” dated 9/30/22 revealed the date of the Case Conference was 9/28/22, members attending the conference were RN, LPN, PT, Care Coordinator, Clinical Operations Manager, VP of Clinical Operations. Questions on the form, but not limited to are: “Has the client experienced an onset of new symptoms such as dizziness, confusion, or shortness of breath within the past 14 days?" The answer was ‘no’; "Has there been a significant change in the client’s condition during this episode? (good or bad)", the answer was ’no’; "Is the client and/or family compliant with the plan of care", the answer was ‘yes’; "Issues and Resolutions: None, No care coordination needs have been identified at this time”. A review of a document titled, “Case Conference” dated 8/2/22 revealed the date of the Case Conference was 7/27/22, members attending the conference were RN, LPN, PT, Care Coordinator, Clinical Operations Manager, VP of Clinical Operations. Questions within the form, but not limited to are: “Has the client experienced an onset of new symptoms such as dizziness, confusion, or shortness of breath within the past 14 days?" The answer was ‘no’; "Has there been a significant change in the client’s condition during this episode? (good or bad)", the answer was ’no’; "Is the client and/or family compliant with the plan of care", the answer was ‘yes’; "Issues and Resolutions: None, No care coordination needs have been identified at this time”. There was no evidence of monitoring and evaluating the LPN's (Licensed Practical Nurses) performance in the provision of services, provision of treatments, patient education, communication with the RN, and data collection regarding the patient's status and health needs. 5. A review of Patient #11, with a SOC (start of care date) of 2/1/22, and a recertification period of 9/29/22 to 11/27/22, evidenced an agency document titled "Home Health Certification and Plan of Care" physician signed and dated 10/3/22. The plan of care evidenced SN (Skilled Nursing) visits 3 visits weekly for 1 certification period starting 9/29/22. The plan of care further evidenced wound care of LLE with instructions of the “cleansing wound, apply Fiberacol Plus, cover with ABD (abdominal pad) and secure with kerlix, and ace wrap”. A review of Patient #11, evidenced documents dated 2/28/22, 6/20/22, and 8/24/22 and signed by RN 2, titled RN/LPN Care Coordination with RN 2 agreeing “with LPN visit note”. There was no evidence of monitoring and evaluating the LPN's (Licensed Practical Nurses) performance in the provision of services, provision of treatments, patient education, communication with the RN, and data collection regarding the patient's status and health needs. 6. During an interview on 11/2/22 at 12:45 PM with LPN 1, when queried how often they were observed in the home environment providing care to patients, they replied, “every 2-3 weeks”. During an interview with RN 2 on 11/4/22 at 8:34 AM, RN 2 indicated supervisory visits occur monthly. 410 IAC 17-14-1(a)(1)(J)

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