Every finding on record at Catherine Rose Home Health Agency, LLC

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102. Survey Dates: 02/16/2026 - 02/18/2026 Active Census: 10 At this Emergency Preparedness survey, Catherine Rose Home Health Agency LLC was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 484.102. QR by Area 3 on 2/27/2026.

This visit was for an Initial Medicaid and State Licensure survey for a Home Health provider. Survey Dates: 02/16/2026 - 02/18/2026 12 Month Unduplicated Admissions: 10 This deficiency report reflects State Findings cited in accordance with 410 IAC 17. ABBREVIATIONS: RN REGISTERED NURSE LPN LICENSED PRACTICE NURSE HHA HOME HEALTH AIDE POC PLAN OF CARE OASIS OUTCOME AND ASSESSMENT INFORMTION SET QR completed by Area 3 on 2/27/2026.

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 furnish the patient and/or patient’s legal representative with the contact information for the home health agency administrator, to include: the administrator's name, business address, and business phone number for the purpose of receiving complaints, prior to the patient receiving care for 3 of 3 home visits conducted (Patient #1, #3, #7). Findings include: 1.Review of a document titled “Admission Packet,” included a checklist of required information the agency provides patients upon admission. The document failed to include contact information for the home health agency administrator. 2. During a home visit with Patient #1 on 02/17/2026 at 10:00 AM, a review of the patient's folder provided by the agency, failed to evidence patient was informed of the name and contact information for the home health agency administrator. Interview with Patient #1 during the home visit indicated he/she was not able to identify who the Administrator of the home health agency was. 3. During a home visit with Patient #3 on 02/18/2026 at 10:00 AM, a review of the patient's folder provided by the agency, failed to evidence patient was informed of the name and contact information for the home health agency administrator. Interview with Patient #3 during the home visit indicated he/she was not able to identify who the Administrator of the home health agency was. 4. During a home visit with Patient #7 on 02/17/2026 at 10:00 AM, a review of the patient's folder provided by the agency, failed to evidence patient was informed of the name and contact information for the home health agency administrator. Interview with Patient #3 during the home visit indicated he/she was not able to identify who the Administrator of the home health agency was. 5. During an interview on 2/18/2026 at 12:53 PM, the administrative staff indicated the phone number for the agency was in the admission packets provided to patient but acknowledged the information wasn't in the admission packet and the patient didn't receive it.

OASIS privacy notice CFR(s): 484.50(a)(1)(iii) (iii) An OASIS privacy notice to all patients for whom the OASIS data is collected. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to supply the patient and/or the patient’s legal representative with an OASIS privacy notice to all patients for whom the OASIS data is collected, prior to providing care for 3 of 3 skilled home visits conducted (Patient #1, #3, #7). Findings include: Review of a document titled “Admission Packet,” included a checklist of required information the agency provides patients upon admission. The document failed to include the OASIS privacy notice. During a home visit on 02/17/2026 at 10:00 AM with Patient #1, SOC 01/05/2026, a review of the patient's folder provided by the agency, failed to evidence patient was provided with an OASIS privacy notice. During a home visit on 02/18/2026 at 10:00 AM with Patient #3, SOC 01/24/2026, a review of the patient's folder provided by the agency, failed to evidence patient was provided with an OASIS privacy notice. During a home visit on 02/18/2026 at 10:00 AM with Patient #7, SOC 01/10/2026, a review of the patient's folder provided by the agency, failed to evidence patient was provided with an OASIS privacy notice. During an interview on 2/18/2026 at 12:53 PM, the administrative staff was not aware that the specific OASIS privacy notices were required to be given to the patients.

Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to supply the patient and caregiver with written instructions communicating the name and contact information for the home health agency’s clinical manager for 3 of 3 home visits conducted (Patient #1, #3, #7). Findings include: 1.During a home visit with Patient #1 on 02/17/2026 at 10:00 AM, a review of the patient's folder provided by the agency, failed to evidence patient was informed of the name and contact information for the home health agency Clinical Manager. Interview with Patient #1 during the home visit indicated he/she was not able to identify who the Clinical Manager of the home health agency was. 2. During a home visit with Patient #3 on 02/18/2026 at 10:00 AM, a review of the patient's folder provided by the agency, failed to evidence patient was informed of the name and contact information for the home health agency Clinical Manager. Interview with Patient #3 during the home visit indicated he/she was not able to identify who the Clinical Manager of the home health agency was. 3. During a home visit with Patient #7 on 02/18/2026 at 10:00 AM, a review of the patient's folder provided by the agency, failed to evidence patient was informed of the name and contact information for the home health agency Clinical Manager. Interview with Patient #3 during the home visit indicated he/she was not able to identify who the Clinical Manager of the home health agency was. 4. During an interview on 2/18/2026 at 12:53 PM, the administrative staff indicated the phone number for the agency was in the admission packets provided to patient but acknowledged the information wasn't in the admission packet and the patient didn't receive it.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure HHA supervisory visits were completed every 14 days for patients receiving skilled professional services for 1 of 1 clinical record with HHA and skilled services reviewed (Patient #2). Findings include: Review of a document titled “Home Health Aide Supervision Policy,” specified the RN is to conduct supervisory visits for aides every 14 days when the patient is receiving skilled nursing services. The clinical record for Patient #2, certification period 12/30/2025 - 02/27/2026, evidenced HHA visits occurred on 01/06/2026, 01/08/2026, 01/13/2026, 01/15/2026, 01/20/2026, 01/22/2026, 01/27/2026, 01/29/2026, 02/03/2026, 02/10/2026, and 02/12/2026. The record evidenced the patient was also receiving skilled nursing services. The record failed to evidence HHA supervision occurred a minimum of every fourteen (14) days for patients receiving skilled services. During an interview on 02/17/2026, the Administrator indicated the agency was under the impression supervisory visits were to be completed every 14 days on skilled staff; they did not understand the regulations as HHAs of patients receiving skilled services must receive supervisory visits every 14 days. 410 IAC 17-14-1(n)

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure documentation was maintained of discharge summaries sent to patients' primary care provider after patients’ discharge from the agency for 2 of 3 closed records reviewed (Patient #8, #9). Findings include: 1 The clinical record for Patient #8, benefit period 12/25/2025 - 02/22/2026, evidenced a discharge date of 01/04/2026. The record evidenced a discharge summary and a nurses’ note indicating the physician was made aware. The record failed to evidence the discharge summary was sent to the patient’s primary care provider. 2. The clinical record for Patient #9, benefit period 12/26/2025 - 02/23/2026, evidenced a discharge date of 01/19/2026. The record evidenced a discharge summary and a nurses’ note indicating the physician was made aware. The record failed to evidence the discharge summary was sent to the patient’s primary care provider. 3. During an interview on 02/17/2026 at 12:45 PM, the Administrator indicated the agency’s expectation is for the discharge summary to be faxed to patients' primary care provider after discharge. She indicated documentation on nurses’ notes indicating the physician made aware of discharge did not include confirmation the discharge summary was sent or when it was sent, to the primary care provider. She acknowledged the documentation did not meet the requirement for Patient #8. 4. During an interview on 02/17/2026 at 3:50 PM, the Administrator indicated nurses’ notes contain documentation the patient’s primary care provider was made aware of Patient #9’s discharge from the home health agency. She acknowledged Patient #9’s clinical record does not contain documentation of the discharge summary was sent or when it was sent, to the patient’s primary care provider. 410 IAC 17-15-1(a)(6)