Every finding on record at Choice 4u Home Health LLC

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR §484.102. Survey Dates: 12/04/2025 and 12/05/2025 Active Census: 7 At this Emergency Preparedness survey, Choice 4U Home Health, LLC was found to be in compliance with Emergency Preparedness Requirements for Medicaid Participating Providers and Suppliers, 42 CFR §484.102. QR completed by Area 3 on 12/09/2025.

This visit was for an Initial Federal Medicaid survey for a Home Health provider. Survey Dates: 12/04/2025 and 12/05/2025 12 Month Unduplicated Admissions: 12 This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Refer to State Form for additional State Findings. Abbreviations: HHA Home Health Aide SN Skilled Nursing CM Clinical Manager POC Plan of Care SOC Start of care

Written notice of patient's rights CFR(s): 484.50(a)(1)(i) (i) Written notice of the patient's rights and responsibilities under this rule, and the HHA's transfer and discharge policies as set forth in paragraph (d) of this section. Written notice must be understandable to persons who have limited English proficiency and accessible to individuals with disabilities; This ELEMENT is not met as evidenced by: Based on record review and interview, the Agency failed to ensure they provided the HHA’s transfer and discharge policies to 1 of 7 active patients. (Patient #4) Findings include: 1. A review of the clinical record for Patient #4 with a SOC of 10/02/2025, failed to evidence written notice of the Agency's transfer and discharge policy to Patient #4. 2. On 12/05/2025 at 11:50 AM, the CM indicated it was an oversight on their part there was not a signed receipt of the transfer and discharge policy. 410 IAC 17-12-3(a)1(A) AND (B)

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 ensure an OASIS privacy notice was provided to 1 of 7 active patients for whom the OASIS data was collected. (Patient #4) Findings include: 1. A review of a policy titled ‘OASIS Privacy Policy’ stated, “… Patients are informed that: Their information is protected under HIPAA. OASIS data is required by Medicare for quality reporting. They may request how their information is used and disclosed …” 2. A review of the clinical record of Patient #4 failed to evidence notification of the OASIS Privacy Policy. 3. On 12/05/2025 at 11:50 AM, the CM indicated it was an oversight on their part there was not a signed receipt of the OASIS Privacy Policy.

Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This ELEMENT is not met as evidenced by: Based on record review and interview, the Agency failed to ensure the comprehensive assessment was completed within the last 5 days of the certification period with 1 of 7 active patients. (Patient # 5) Findings include: 1. A review of a policy titled, 'CLIENT REASSESSMENT/UPDATE OF COMPREHENSIVE ASSESSMENT' stated, "... 1. Every second calendar month begins with start of care {within last five (5) days of the episode, including day sixty (60) ... PURPOSE To identify decline or improvement in health status, modify the plan of care and document changes ..." 2. A review of the clinical record of Patient #5 evidenced a POC dated 10/08/2025 and signed by the CM for the certification period of 10/08/2025 through 12/06/2025 and a POC dated 12/03/2025 and signed by the CM for the certification period of 12/07/2025 through 01/05/2025. Further review of the clinical record failed to evidence a reassessment for the recertification period of 12/07/2025 through 01/05/2025. 3. On 12/05/2025 at 12:05 PM, the CM indicated they were not aware a POC could not be created without an assessment being conducted. The CM indicated they updated the POC and faxed to the physician on 12/03/2025, and had initiated the assessment but had not completed it. 410 IAC 17-14-1(a)(1)(B)

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 assessments were completed prior to a POC developed for 1 of 7 active clinical records reviewed. (Patient #5) Findings include: 1. A review of a policy titled, 'CLIENT REASSESSMENT/UPDATE OF COMPREHENSIVE ASSESSMENT' stated, "... 1. Every second calendar month begins with start of care {within last five (5) days of the episode, including day sixty (60) ... PURPOSE To identify decline or improvement in health status, modify the plan of care and document changes ..." 2. A review of the clinical record of Patient #5 evidenced a POC dated 12/03/2025 and signed by the CM for the recertification period of 12/07/2025 through 01/05/2025. Further review of the clinical record evidenced a nurses note dated 12/03/2025, signed by the CM indicated they had faxed the "recertification and case conference to the MD" but failed to evidence a reassessment for the recertification period of 12/07/2025 through 01/05/2025. 3. On 12/05/2025 at 12:05 PM, the CM indicated they were not aware a POC could not be created without an assessment being conducted. The CM indicated they updated the POC and faxed to the physician on 12/03/2025 and had initiated the assessment but had not completed it. 410 IAC 17-13-1(a)

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 LPN supervisory visits were conducted with 1 of 7 active patients receiving skilled nursing services. (LPN 1) (Patient #1) Findings include: 1. A review of a policy titled, 'Supervisory Visit Policy' stated, "... b. Licensed Practical Nurse (LPN) Supervision Supervised by a Registered Nurse at least 1 time per month ..." 2. A review of the clinical record of Patient #1 with a SOC 06/12/2025 evidenced LPN supervisory visits were conducted 10/20/2025 and 12/05/2025. The record failed to evidence a supervisory visit was conducted in November of 2025. 3. On 12/05/2025 at 11 AM, the CM indicated they were not sure why there was not a supervisory visit conducted in November but indicated the one dated for 12/05/2025 should have been dated 11/05/2025. 410 IAC 17-14-1(a)(1)(J)-RN

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 CM failed to ensure the HHA followed the HHA POC with 1 of 1 patient receiving HHA services. (Patient # 7) (HHA 1) Findings include: 1. A review of a policy titled, 'HOME HEALTH AIDE CARE PLAN POLICY' stated, "A complete and appropriate Care Plan, identifying duties to be performed by the Home Health Aide ... All home health aide staff will follow the identified plan ... " A review of a policy titled, 'HOME HEALTH AIDE: DOCUMENTATION POLICY' stated, "... Home Health Aides will document care/services provided on the home health aide charting form. Care/services provided should be in accordance with direction provided in the Home Health Aide Care Plan. PURPOSE To provide documentation of the care performed by the Home Health Aide on each visit ..." 2. A review of the clinical record of Patient #7 evidenced a POC with a SOC 11/12/2025 with orders but not limited to HHA 1 time a week for 8 weeks. The clinical record of Patient #7 contained an HHA POC dated 11/12/2025 which indicated the following services to be completed each visit: tub bath, assist Bath-Chair, personal care, assist with dressing, hair care, shampoo, and check pressure areas. Further review of the clinical record contained HHA visit notes which evidenced the following: on 11/19/2025, the service provided was a partial bed bath; on 11/26/2025, the service provided was a partial bed bath, on 12/03/2025, services provided were assisted with tub bath and washed hair. 3. On 12/05/2025 at 10 AM, HHA 1 indicated they had not been taught what to document, they document only what they do. On 12/05/2025 at 1:52 PM, the CM indicated they had not realized the HHA should follow the POC in detail. 410 IAC 17-13-2(a)