Every finding on record at Community Health at Home

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR §484.102 Survey Dates: 04/20, 04/21, 04/22, 04/23, 04/24/2026 Active Census: 578 At this Emergency Preparedness survey, Community Health at Home, LLC 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 A3, 5/5/2026.

This visit was for a Federal Recertification and State Re-Licensure survey of a Home Health Provider. Survey Dates: 04/20, 04/21, 04/22, 04/23, and 04/24/2026 12-Month Unduplicated Skilled Admissions: 3027 Partially Extended on 04/23/2026 at 1:15 PM. This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Refer to State Form for additional State Findings. Abbreviations: HHA Home Health Aide POC Plan of Care DON Director of Nursing PT Physical Therapy SOC Start of Care RN Registered Nurse SN Skilled Nursing OASIS Outcome and Assessment Information Set ADL Activities of Daily Living PTA Physical Therapy Assistant OT Occupational Therapist COTA Certified Occupational Therapist Assistant ADON Alternate Director of Nursing ROC Resumption of Care DC Discharge QR completed by A3 on 5/5/2026.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the following information: (1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessments were completed and accurately reflected the patients' health status for 3 of 5 active clinical records reviewed in which the patients had a line, drain, and/or tube (Patient #1, 8, and 9). Findings Include: 4. A review of Patient #9's active clinical record evidenced a recertification comprehensive assessment dated 03/19/2026. The patient had the following diagnoses: Hypertensive Chronic Kidney Disease (when high uncontrolled blood pressure damaged the kidneys causing disfunction) with Stage 5 End Stage Renal Disease (the kidneys no longer function causing the need for Dialysis (a treatment used to filter waste and excess fluids from the body when the kidneys no longer function appropriately)) and Type 2 Diabetes Mellitus (the body was unable to produce or use insulin appropriately causing high blood sugar levels) with Diabetic Neuropathy (nerve damage in the kidneys caused by high blood sugar). During an interview with Patient #9 on 04/23/2026 at 2:27 PM, they indicated they received Dialysis from Entity 2, a dialysis center, on Mondays, Wednesdays, and Fridays and had a Central Venous Catheter (CVC). The comprehensive assessment failed to ensure the CVC was assessed and showed no signs of infection and the dressing was clean, dry, and intact. 6. During an interview with PT 4 on 04/24/2026 at 12:51 PM, they explained if a patient had a CVC, tracheostomy, and gastrostomy tube they would assess them to ensure there were no signs of redness or something unusual. 9. During an interview with RN 5 on 04/24/2026 at 2:05 PM, they assessed the insertion site and document the look and the type of site care if performed. RN 5 explained they only assessed the dressing of the CVC in the comprehensive assessment. 410 IAC 17-14-1(a)(1)(A)(B) #1. Review of an agency policy dated 09/15/2025 and titled "33.34, Comprehensive Patient Assessment," indicated but is not limited to, " … 4. Content of Comprehensive Assessment … The comprehensive assessment will accurately reflect the patient's status … will include … Physiological (Physical Health Component) … Assessment Content: … special nutritional needs/dietary requirements … head-to-toe assessment (Respiratory … Integumentary) …" #2. Review of Patient #1's active clinical record revealed a SOC comprehensive assessment dated 04/06/2026. The comprehensive assessment indicated Patient #1 had but is not limited to, End Stage Renal Disease (ESRD, the final, permanent stage of chronic kidney disease requiring regular dialysis or a transplant of survival) and dependence on renal dialysis (life- saving medical treatment that mimics kidney function by filtering waste products, toxins, and excess fluid from blood when kidneys have failed). The comprehensive assessment indicated Patient #1 had a IV (intravenous) access. The comprehensive assessment indicated Patient #1 had a central line (long, flexible, and thin tube inserted into a large vein, typically in the neck, chest, or groin with the tip resting near the heart). The comprehensive assessment failed to evidence the status of the central line, including an assessment of the insertion site and the dressing status. #3. Review of Patient #8's active clinical record revealed a SOC comprehensive assessment dated 03/12/2026. The comprehensive assessment indicated Patient #8 had but is not limited to, Malfunction of tracheostomy stoma (complication to the surgical opening (stoma) in the neck and windpipe (trachea) to create a direct airway, often with an inserted tube), Malignant Neoplasm of the Larynx (cancer of the voice box), Malignant Neoplasm of overlapping sites of Hypopharynx (cancerous tumor located in the lower part of the throat that has spread across multiple sub-regions) and encounter for attention to gastrostomy (also known as a g-tube, a surgical opening into the stomach from the abdominal wall for the introduction of food). The comprehensive assessment evidenced Patient #8 had a tracheostomy. The comprehensive assessment evidenced Patient #8 had a feeding tube or g-tube. The comprehensive assessment failed to evidence the status of the tracheostomy and g-tube, including an assessment of the insertion site, dressing status, patency, size of the tubes, condition of the tubes, or any issues. #5. During an interview on 04/23/2026 at 10:26 AM, RN 1 indicated they assess the dialysis catheter to ensure the dressing is clean, dry, and intact. RN 1 indicated they do not touch or do anything else with the dialysis catheter. When queried about documentation of the central line assessment, RN 1 indicated there is place to document a line assessment, but unsure if there is a place in the SOC comprehensive assessment. #7. During an interview on 04/24/2026 at 1:07 PM, PT 5 indicated they perform SOC comprehensive assessments. When queried what is included on the comprehensive assessment, PT 5 indicated skin, pain, vitals, mood, cognition, transferring, and patient specific items. PT 5 indicated the comprehensive assessment is tailored to the patient. When queried about the assessment of a patient with a tracheostomy or g-tube, PT 5 indicated they would assess the tracheostomy or g-tube and document the findings. PT 5 indicated if they found issues with the tracheostomy or g-tube during the assessment they would notify the physician for skilled nursing if appropriate. PT 5 indicated the comprehensive assessment and POC should match, and include rehabilitation potential and discharge plan. #8. During an interview on 04/24/2026 at 1:27 PM, PT 6 indicated the comprehensive assessment is specific to the patient. When queried about the assessment of g-tubes, tracheostomy, or central lines, PT 6 indicated they would assess the line or tube and document the assessment in the narrative or section titled "Special Procedure".

Patient's needs CFR(s): 484.55(c)(4) The patient's medical, nursing, rehabilitative, social, and discharge planning needs; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessments included the patient's rehabilitation potential and/or discharge plans for 11 of 12 active clinical records reviewed. (Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, and #11) Findings Include: #7. Review of Patient #1's active clinical record revealed a SOC comprehensive assessment dated 04/06/2026 and signed by RN 1. Review of Patient #1's active clinical record revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 04/06/2026 for the certification period of 04/06/2026 through 06/04/2026. The POC evidenced the patient's discharge plan was to "discharge to the care of caregiver under supervision of physician when goals are met". The comprehensive assessment failed to evidence the discharge plan and rehabilitation potential. #8. Review of Patient #2's active clinical record revealed a recertification comprehensive assessment dated 03/24/2026 and signed by PT 7. Review of Patient #2's active clinical record revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 11/29/2025 for the certification period of 03/29/2026 through 05/27/2026. The POC evidenced Patient #2's discharge plan was "discharge to care of caregiver under supervision of physician when goals are met". The comprehensive assessment failed to evidence the discharge plan. #9. Review of Patient #6's active clinical record revealed a SOC comprehensive assessment dated 03/03/2026 and signed by RN 6. Review of Patient #6's active clinical record revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 03/03/2026 for the certification period of 03/03/2026 through 05/01/2026. The POC evidenced Patient #6's rehabilitation potential was "fair/improvement in status is uncertain". The POC evidenced Patient #6's discharge plan was "discharge to care of caregiver under supervision of physician when goals are met". The comprehensive assessment failed to evidence the discharge plan and rehabilitation potential. #10. Review of Patient #7's active clinical record revealed a SOC assessment dated 03/27/2026 and signed by RN 3. Review of Patient #7's active clinical record revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 03/27/2026 for the certification period of 03/27/2026 through 05/25/2026. The POC evidenced Patient #7's rehabilitation potential was "fair/improvement in status is uncertain". The POC evidenced Patient #7's discharge plan was "discharge to care of caregiver under supervision of physician when goals are met". The comprehensive assessment failed to evidence the discharge plan and rehabilitation potential. #11. Review of Patient #8's active clinical record revealed a SOC comprehensive assessment dated 03/12/2026. Review of Patient #8's active clinical record revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 03/12/2026 for the certification period of 03/12/2026 through 05/10/2026. The POC evidenced Patient #8's rehabilitation potential was "Guarded/minimal improvement in status is expected; decline is possible". The POC evidenced Patient #8's discharge plan was "discharge to self-care under supervision of physician when goals are met". The comprehensive assessment failed to evidence the discharge plan and rehabilitation potential. #12. Review of Patient #11's active clinical record revealed a recertification comprehensive assessment dated 03/11/2026. Review of Patient #11's active clinical record revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 01/22/2024 for the certification period of 03/12/2026 through 05/10/2026. The POC evidenced Patient #11's rehabilitation potential was "Fair/Improvement in status is uncertain". The POC evidenced Patient #11's discharge plan was "discharge to care of caregiver under supervision of physician when goals are met". The comprehensive assessment failed to evidence the discharge plan and rehabilitation potential. #16. During an interview on 04/24/2026 at 1:07 PM, PT 5 indicated they performed SOC comprehensive assessments. When queried what was included on the comprehensive assessment, PT 5 indicated skin, pain, vitals, mood, cognition, transferring, and patient specific items. PT 5 indicated the comprehensive assessment was tailored to the patient. PT 5 indicated the comprehensive assessment and POC matched and included rehabilitation potential and discharge plan. #17. During an interview on 04/24/2026 at 1:27 PM, PT 6 indicated the comprehensive assessment included a PT eval and the OASIS questions. When queried about rehabilitation potential and discharge planning, Pt 6 indicated the rehabilitation potential and discharge plan were included on the comprehensive assessment. 1. A review of an agency policy dated 09/15/2025 and titled "Comprehensive Patient Assessment" indicated but was not limited to, " … 4. Content of Comprehensive Assessment … Rehabilitative needs … Discharge planning needs. …" 2. A review of Patient #3's active clinical record evidenced a SOC OASIS assessment dated 04/02/2026. The comprehensive assessment failed to evidence the patient's rehabilitation potential and discharge plan. Patient #3's active clinical record evidenced a POC with a SOC of 04/02/2026 and an initial certification from 04/02/2026 to 05/31/2026. The patient's rehabilitation potential was listed as "Good" and the plan was to discharge the patient when goals were met. 3. A review of Patient #4's active clinical record evidenced an SOC OASIS assessment dated 03/30/2026. The comprehensive assessment failed to evidence the patient's rehabilitation potential and discharge plan. Patient #4's active clinical record included a POC with a SOC of 03/30/2026 and an initial certification period from 03/30/2026 to 05/28/2026. The patient's rehabilitation potential was listed as "Good" and the plan was to discharge the patient when goals were met. 4. A review of Patient #5's active clinical record evidenced a ROC assessment was performed on 03/26/2026. The section titled "Goals Not Met" indicated but was not limited to, " … 2. Patient/Caregiver verbalizes agreement with discharge plans. … Additional time required to meet intervention/goal …". The comprehensive assessment failed to evidence the patient's rehabilitation potential and discharge plan. 5. A review of Patient #9's active clinical record evidenced a recertification comprehensive assessment dated 03/19/2026. The section titled "Goals Not Met" indicated but was not limited to, " … 2. Patient/Caregiver verbalizes agreement with discharge plans. … Additional time required to meet intervention/goal …" Patient #9's POC with a SOC of 11/20/2025 and a recertification period from 03/20/2026 to 05/18/2026. The discharge plan listed evidenced the patient would be discharged once were met. The comprehensive assessment failed to include the patient's discharge plan included in the POC. 6. A review of Patient #12's active clinical record evidenced a recertification comprehensive assessment dated 04/09/2026. The section titled "Goals Not Met" indicated but was not limited to, " … 2. Patient/Caregiver verbalizes agreement with discharge plans. … Additional time required to meet intervention/goal …" Patient #12's POC with a SOC of 10/27/2023 and a recertification from 04/14/2026 to 06/12/2026. The rehab potential was listed as "Fair/Improvement in status is uncertain". The discharge plan was to discharge the patient to the care of the caregiver with the supervision of physician when goals were met. The comprehensive assessment failed to include the patient's rehabilitation potential and discharge included in the POC. 13. During an interview with RN 1 on 04/23/2026 at 10:26 AM, they indicated the comprehensive assessment should contain the patient's rehabilitation potential, discharge plans, and match the POC. 14. During an interview with the Administrator/Director of Clinical Services on 04/23/2026 at 12:57 PM, they explained the comprehensive assessment should match the POC and include the rehabilitation potential and discharge plan. 15. During an interview with PT 4 on 04/24/2026 at 12:51 PM, they indicated the comprehensive assessment was individualized to the patient and included the rehabilitation potential and discharge plan. 18. During an interview with RN 5 on 04/24/2026 at 2:05 PM, they indicated the comprehensive assessment and POC information should be the same and be individualized to the patient. 410 IAC 17-14-1(a)(1)(B)

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure the POC included all DME and seizure plan for 6 of 12 active clinical records reviewed. (Patients #1, #3, #5, #6, #8, and #10) Findings include: 4. Review of Patient #1's active clinical record revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 04/06/2026, for the certification period of 04/06/2026 through 06/04/2026, and signed by RN 1. The POC indicated Patient #1 had but is not limited to, Type II Diabetes Mellitus (chronic metabolic condition where the body resists the effects of insulin and fails to produce enough to maintain normal glucose levels causing high blood sugar), End Stage Renal Disease (ESRD, the final, permanent stage of chronic kidney disease requiring regular dialysis or a transplant of survival), and dependence on renal dialysis (life- saving medical treatment that mimics kidney function by filtering waste products, toxins, and excess fluid from blood when kidneys have failed). The POC stated, " … Last HA1C [hemoglobin A1C, a blood test measures the average blood sugar over the past two to three months] 8 does not have a glucometer at this time MD notified per order …" The POC subsection titled "DME and Supplies" indicated DME-glucometer and test supplies. The POC subsection titled "Rehab Potential" stated, "Guarded/Minimal improvement in status is expected; Decline is possible, good/marked improvement in status is expected." The POC subsection titled "Functional Limitations" indicated bowel/bladder incontinence (involuntary loss of control of bowel/bladder). The POC failed to evidence the specific rehabilitation potential, and accurate DME. 5. During a home visit on 04/23/2026 at 2:30 PM, Patient #6 was observed to have a bedside commode, briefs, power wheelchair, and a glucometer. Review of Patient #6's active clinical record revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 03/03/2026 for the certification period of 03/03/2026 through 05/01/2026. The POC indicated Patient #6 had but is not limited to, Type II Diabetes Mellitus (chronic metabolic condition where the body resists the effects of insulin and fails to produce enough to maintain normal glucose levels causing high blood sugar) and acquired absence of left leg above the knee (above the knee amputation). The POC subsection titled "DME and Supplies" indicated eyeglasses, hospital bed, continuous glucose monitor, shower/tub equipment, air cushion seat, and wheelchair. The POC failed to evidence DME: bedside commode, briefs, power wheelchair, and glucometer. 6. Review of Patient #8's active clinical record revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 03/12/2026 for the certification period of 03/12/2026 through 05/10/2026. The POC indicated Patient #8 had but is not limited to, Type II Diabetes Mellitus (chronic metabolic condition where the body resists the effects of insulin and fails to produce enough to maintain normal glucose levels causing high blood sugar), Malfunction of tracheostomy stoma (complication to the surgical opening (stoma) in the neck and windpipe (trachea) to create a direct airway, often with an inserted tube), Malignant Neoplasm of the Larynx (cancer of the voice box), Malignant Neoplasm of overlapping sites of Hypopharynx (cancerous tumor located in the lower part of the throat that has spread across multiple sub-regions) and encounter for attention to gastrostomy (also known as a g-tube, a surgical opening into the stomach from the abdominal wall for the introduction of food). The POC subsection titled "Functional Limitation" evidenced Patient #8 experienced incontinence. The POC subsection titled "DME and Supplies" indicated eye glasses, grab bars shower/tub, cane, pump-feeding and supplies, pump-suction and supplies, respiratory supplies, shower/tub equipment, gastrostomy/feeding, gloves, and tracheostomy. The POC failed to evidence DME: diabetic supplies and incontinence supplies. 10. During an interview on 04/24/2026 at 1:27 PM, PT 6 indicated DME included everything the patient has in their home. PT 6 indicted DME is wheelchair, walker, cane, bathroom equipment, cooling agents, hospital bed, trapeze bar, vital equipment, nebulizer, CPAP (Continuous Positive Airway Pressure, provides a continuous stream of pressurized air to keep a person's airways open while sleeping), and briefs or chucks. 1. An agency policy titled "Plan of Care and Physician and Allowed Practitioner Orders" with a revised date of 03/05/2024 indicated but was not limited to, " … 2. The POC should be based upon a current assessment … The POC must include: … Types of supplies. Types of equipment … 2. Patient #3's active clinical record evidenced a POC with a SOC of 04/02/2026 and an initial certification from 04/02/2026 to 05/31/2026. The DME listed were: bath chair, grab bars for the toilet, cane, rolling walker, rails/grab bars, shower/tub equipment. The POC evidenced the patient had seizure precautions. During an interview with the patient at Patient #3's residence on 04/21/2026 at 1:30 PM, they indicated they used the seizure helmet when they were moving around. When queried regarding their seizure plan, they explained no one had discussed a seizure plan with them and had a seizure earlier this year during their surgery according to the surgeon. The POC failed to include all DME the patient used in their home and a seizure plan for the patient. 3. During a home visit at Patient #5's residence on 04/22/2026 at 1:14 PM, it was evidenced the patient had a powered wheelchair and had adult briefs for their incontinence. Patient #5's POC with a SOC of 03/02/2026 and an initial certification period from 03/02/2026 to 04/30/2026. The POC listed the following DME: Glucometer and test supplies, scooter, solution/skin prep, and wound care. A review of Patient #5's active clinical record evidenced a ROC assessment was performed on 03/26/2026. The ROC revealed the following DME: Power wheelchair, reacher, and grab bars. 4. A review of Patient #10's active clinical record evidenced a POC with a SOC of 03/13/2025 and a recertification from 03/08/2026 to 05/06/2026. The DME included was the patient's grab bars for shower/tub, grab bars for toilet, raised toilet seat, reacher, hospital bed, walker rolling, wheelchair, powered wheelchair, rails/grab bars, shower/tub equipment, gloves, personal care, solution/skin prep, and wound care. Patient #10's recertification comprehensive assessment dated 03/03/2026 evidenced the patient had a cane, bedside commode, chair lift, and gait belt. The POC failed to include all of the patient's DME needed for care included on the comprehensive assessment. 7. During an interview with RN 1 on 04/23/2026 at 10:26 AM, they explained all DME should be included on the POC and the POC should match the comprehensive assessment. 8. During an interview with the Administrator/Director of Clinical Services on 04/23/2026 at 12:57 PM, they indicated if a DME was not in the home, the item should not be included on the POC. All DME should be listed on the POC. 9. During an interview with PT 4 on 04/24/2026 at 12:51 PM, they indicated DME included the patient's shower chair, bench, bedside commode, and oxygen. PT 4 explained the clinicians had a list they went through on the comprehensive assessment and if the patient had the DME, it was included. 11. During an interview with RN 5 on 04/24/2026 at 2:05 PM, they explained all DME found in the home should be included on the POC. 410 IAC 17-13-1(a)(1)(D)(ii and xiii)

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to provide services as ordered by the physician for 1 of 4 active clinical records reviewed with patients receiving wound care (Patient #8). Findings Include: 1. Review of an agency policy dated 09/15/2025 and titled "33.24, Plan of Care and Physician and Allowed Practitioner Orders," indicated but is not limited to, " … All care and services provided are according to current physician or allowed practitioners orders …" 2. Review of Patient #8's active clinical record evidenced SN visit notes. The note dated 03/26/2026, signed by Former Employee 6, stated, " … Skin assessment revealed two open areas to coccyx … consistent with incontinence-related skin breakdown … physician notified: new wound care orders received: cleanse with normal saline, apply calmoseptine [over the counter moisture barrier ointment designed to protect and heal skin irritations], and cover with foam pad … VO [verbal order] … 03/27/2026 0833 AM …" Review of Patient #8's active clinical record evidenced SN visit notes dated 04/01, 04/10, 04/15, and 04/22/2026. The SN visit notes failed to evidence Patient #8 received wound care. During an interview on 04/23/2026 at 1:42 PM, the Administrator/Director of Clinical Services explained Former Employee 6 obtained the verbal order for wound care, but never went back to officially put the verbal order in. During an interview on 04/24/2026 at 10:54 AM, Patient #8 explained the SN visited weekly to check vital signs, and ensure the patient did not have any needs. During an interview on 04/24/2026 at 12:51 PM, PT 4 indicated if a new wound was found they would check the stage, measure, refer to nursing, and notify the physician. During an interview on 04/24/2026 at 2:05 PM, RN 5 indicated if a new wound was found they would call the physician, describe the wound, obtain wound care order, and report the new wound to the manager and the rest of the team. 410 IAC 17-13-1(a)

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure they received hold orders for 1 of 1 active clinical records reviewed with a hospitalization during a certification period. (Patient #5) Findings include: 1. An agency policy dated 03/05/2024 and titled "Plan of Care and Physician and Allowed Practitioner Orders" indicated but was not limited to, " … 8. All care and services provided are according to current physician or allowed practitioners orders. Clinicians are responsible for alerting the physician … to any changes in patient care or condition that suggest a need to alter the POC. …" 2. A review of Patient #5's active clinical record evidenced an "Visit Note Report" dated 03/11/2026 by RN 7. The document evidenced the patient's transfer date was 03/06/2026. A review of Patient #5's active clinical record evidenced an "Episode Summary Report" with a transfer date of 03/06/2026 completed by RN 7 on 03/11/2026. The fax revealed the transfer summary was sent on 03/17/2026. Patient #5's active clinical record revealed a coordination note evidencing they placed the patient on hold. The clinical record failed to evidence a hold order from the physician for the services missed during the patient's hospitalization. During an interview with the Administrator/Director of Clinical Services on 04/23/2026 at 12:57 PM, they explained they placed a hold order communication note into the patient's record, after confirming the patient was hospitalized over 24 hours. The hold order was not an order from a physician, it was used to help the clinicians identify the patient's services were on hold. 410 IAC 17-13-1(a)(2)

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to coordinate care with other entities providing services for 5 of 5 active clinical records reviewed with patients currently receiving outside services. (Patient #1, 5, 6, 9, and 10) Findings Include: 4. Patient #5's POC with a SOC of 03/02/2026 and an initial certification period from 03/02/2026 to 04/30/2026. The POC revealed the patient lived in an Assisted Living Facility, Entity 3. During a home visit, Patient #5 was observed receiving care in Entity 3 on 04/22/2026 at 1:14 PM. An interview was conducted with Patient #5 and they indicated Entity 3 managed their medications and were there to assist when needed. A review of Patient #5's clinical record failed to evidence coordination notes with Entity 3. 5. A review of Patient #9's active clinical record evidenced a POC with a SOC of 11/20/2025 and a recertification from 03/20/2026 to 05/18/2026. The patient had the following diagnoses: Hypertensive Chronic Kidney Disease (when high uncontrolled blood pressure damaged the kidneys causing disfunction) with Stage 5 End Stage Renal Disease (the kidneys no longer function causing the need for Dialysis (a treatment used to filter waste and excess fluids from the body when the kidneys no longer function appropriately)) and Type 2 Diabetes Mellitus (the body was unable to produce or use insulin appropriately causing high blood sugar levels) with Diabetic Neuropathy (nerve damage in the kidneys caused by high blood sugar). Patient #9's clinical record failed to evidence the agency coordinated care with the patient's Dialysis center. During an interview with Patient #9 on 04/23/2026 at 2:27 PM, they indicated they received Dialysis from Entity 2, a dialysis center, on Mondays, Wednesdays, and Fridays. 6. A review of Patient #10's active clinical record evidenced a POC with a SOC of 03/13/2025 and a recertification from 03/08/2026 to 05/06/2026. The POC revealed the patient received homecare services from Entity 1, a personal service agency, Monday through Friday from 9:00 AM to 1:00 PM. Patient #10's clinical record failed to evidence coordination notes to the patient's homecare agency. 7. During an interview with RN 1 on 04/23/2026 at 10:26 AM, they indicated if they coordinated care, it would be included in the coordination tab in their electronic medical record system and record with whom they spoke. 8. During an interview with the Administrator/Director of Clinical Services on 04/23/2026 at 12:57 PM, they indicated coordination of care with other entities should be performed at least at the SOC, recertification, ROC, and any new changes in the patient's condition. 11. During an interview with RN 5 on 04/24/2026 at 2:05 PM, they indicated coordination of care with waiver agencies and Dialysis (a treatment used to filter waste and excess fluids from the body when the kidneys no longer function appropriately) centers were with the SOC, recertifications, and discharge. 410 IAC 17-14-1(a)(1)(F) #1. Review of an agency policy dated 07/28/2022 and titled "33.20, Case Conferences and Coordination of Services," indicated but is not limited to, " … 6. Care will be coordinated with other involved external organizations …" #2. Review of Patient #1's active clinical record revealed a SOC comprehensive assessment dated 04/06/2026. The comprehensive assessment indicated Patient #1 had but is not limited to, End Stage Renal Disease (ESRD, the final, permanent stage of chronic kidney disease requiring regular dialysis or a transplant of survival) and dependence on renal dialysis (life- saving medical treatment that mimics kidney function by filtering waste products, toxins, and excess fluid from blood when kidneys have failed). The comprehensive assessment indicated Patient #1 was on hemodialysis. The comprehensive assessment evidenced the patient received dialysis Mondays, Wednesdays, and Fridays. The clinical record failed to evidence coordination of care notes with Patient #1's dialysis center. During an interview on 04/21/2026 at 1:57 PM, Patient #1 indicated they started dialysis three weeks ago. During an interview on 4/23/2026 at 11:15 AM, the Administrator/Director of Clinical Services indicated the agency was aware the patient went to dialysis, but did not coordinate care with the dialysis facility. #3. Review of Patient #6's active clinical record revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 03/03/2026 for the certification period of 03/03/2026 through 05/01/2026. The POC failed to evidence Patient #6 received services from a Personal Services Agency. Review of Patient #6's active clinical record revealed a SOC comprehensive assessment dated 03/03/2026 and signed by RN 6. The comprehensive assessment evidenced Patient #6 received help 24/7 from a primary caregiver. The comprehensive assessment evidenced Patient #6 received assistance from non-agency caregivers. The comprehensive assessment failed to evidence Patient #6 received services from a Personal Services Agency services. The clinical record failed to evidence coordination of care notes with Entity 5, a personal service agency. During an interview on 04/23/2026 at 2:27 PM, Person 4 indicated they were a family member of Patient #6. Person 4 indicated they were a CNA for Patient #6 during the day time, and their partner provided care during the evening. Person 4 indicated they worked for Entity 5, a Personal Service Agency. During an interview on 4/24/2026 at 3:42 PM, the Administrator/Director of Clinical Services indicated the agency was not aware Person 4 worked for Entity 5, a Personal Service Agency. #9. During an interview on 04/24/2026 at 1:07 PM, PT 5 indicated they rarely coordinate care. When queried about if a patient receives dialysis, PT 5 indicated they schedule around the dialysis schedule, but they would not contact the dialysis facility if the patient was stable. When queried about if a patient received PSA services and coordination, PT 5 indicated they would coordinate with the patient's family to determine when the other agency schedule. #10. During an interview on 04/24/2026 at 1:27 PM, PT 6 indicated if a patient received waiver services, they would ask for the waiver company's name, and include the information on the POC.

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 the discharge and transfer summaries included the goals the patient met and had not met and the frequency of the services for 1 of 1 active clinical records (Patient #5) reviewed with a transfer summary completed and 5 of 5 inactive clinical records reviewed. (Patients #13, #14, #15, #16, and #17) Findings Include: 4. Review of Patient #15's inactive clinical record revealed a document titled "Discharge/Transfer Report" dated 04/02/2026 and signed by RN 9. The report evidenced Patient #15's SOC date was 03/29/2026 and was discharged 04/02/2026. The report evidenced the physician responsible for homecare, Patient #15's condition at discharge, status of goals, and the service provided. The report failed to evidence the reason for admission to home health, patient medication list, frequency and duration of PT services provided, and discharge instructions for the patient or family. 5. Review of Patient #16's inactive clinical record revealed a document titled "Discharge-Transfer Summary Report" dated 04/16/2026 and signed by PT 8. The report evidenced Patient #16's SOC date was 04/03/2026, discharge date was 04/16/2026, the physician responsible for homecare, medication list, service provided, and status of goals. The report failed to evidence the reason for home health, frequency and duration of PT services, and discharge instructions for the patient or family. 6. Review of Patient #17's inactive clinical record revealed a document titled "Episode Summary Report" dated 02/16/2026. The report evidenced Patient #17's SOC date was 06/25/2024, discharge date was 02/16/2026, the physician responsible for homecare, services provided, and medication list. The report failed to evidence the reason for home health, frequency and duration of services provided, discharge condition, outcome in meeting goals, and patient or family discharge instructions. 10. During an interview on 04/24/2026 at 1:07 PM, PT 5 indicated the discharge summary included the patient status, services provided, and pertinent patient information. PT 5 indicated there was a discharge form they follow. 11. During an interview on 04/24/2026 at 1:27 PM, PT 6 indicated the discharge summary included a comparative analysis of the goals, including if the goal met or partially met. PT 6 indicated the discharge summary included the admission date, and included the date when outpatient PT begins. 1. A review of Patient #5's active clinical record evidenced an "Episode Summary Report" with a transfer date of 03/06/2026 completed by RN 7 on 03/11/2026. The fax revealed the transfer summary was sent on 03/17/2026. The document revealed the patient received 1 visit with OT, 1 visit with PT, and 3 visits with SN for wound care and strengthening and balance. The document evidenced the patient met 27 goals and had not met 26 of the goals. The Summary failed to evidence the frequency of the services, the specific goals met or not, the reason for home health services, and was sent to the appropriate facilities within 2 business days of hearing about the transfer. 2. A review of Patient #13's inactive clinical record evidenced a Discharge/Transfer summary with a SOC of 01/29/2026 and a discharge date of 03/26/2026. The section titled "Disciplines and Services Provided" evidenced the patient received 7 PT visits for strength. Patient #13's POC evidenced an SOC date of 01/29/2026 and an initial certification period from 01/29/2026 to 03/29/2026. The POC revealed the patient received services once a week for nine weeks. The discharge summary failed to include the frequency of services provided. 3. A review of Patient #14's inactive clinical record evidenced a Discharge/Transfer summary with a SOC of 12/08/2025 and a discharge date of 04/03/2026. The summary included the patients 11 SN visits for wound care. The discharge summary failed to include the frequency of services provided. 7. During an interview with RN 7 on 04/23/2026 at 10:02 AM, when queried regarding the discharge summary, RN 7 indicated they completed a Discharge OASIS assessment and was unsure if they sent a transfer or discharge summary. 8. During an interview with RN 8 on 04/24/2026 at 12:00 PM, they indicated they collected discharge information and completed the transfer summary and explained they were not a part of the process to send the transfer summary. 9. During an interview with PT 4 on 04/24/2025 at 12:51 PM, they explained when completing the discharge/transfer summary it needed to include the reason the patient needed home health. 12. During an interview with RN 5 on 04/24/2026 at 2:05 PM, they indicated the discharge summary included the form of care the patient received, goals met, physician notified, and the patient's status. 13. During an interview with the Administrator/Director of Clinical Services on 04/24/2026 at 4:24 PM, they indicated the clinicians completed the discharge summary and used the template to complete the form. They explained the summary included the services provided, education completed, discharge date, labs, frequency of services, goals, and the reason for home health. The Administrator indicated the electronic medical record system picked up the summary the night it was completed and was sent to the appropriate entities within 24 hours. They explained they would need to look into the system to see why the summaries were sent late. 410 IAC 17-15-1(a)(7)

An Emergency Preparedness survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102 for a Home Health Provider and Supplier. Survey Dates: 08-07, 08-08, 08-09, and 08-10-2023 Active Census: 652 Unduplicated Skilled Census: 4688 At this Emergency Preparedness Survey, Community Health at Home was found to be in compliance with Conditions of Participation 42 CFR 484.102 Emergency Preparedness requirements for Medicare Participating Providers and Suppliers. QR completed by A3 on 08-15-2023.

This visit was for a Federal Recertification and State Re-Licensure survey of a Home Health Provider. Survey Dates: 08-07-2023,08-8-2023,08-09-2023, and 08-10-2023. Active Census: 652 12-Month Unduplicated Skilled Admissions: 4,688 This deficiency report reflects State Findings cited in accordance with 410 IAC 17. QR completed by A3, 08/15/2023.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure all durable medical equipment (DME) was included on the plan of care (POC) for 4 of 7 (Patients #2, 7, 8, and 9) active patient records reviewed with home visits. Findings Include: 1. On 08-09-2023 at 11:49 AM, a “CommonSpirit Health at Home” policy titled “Plan of Care and Physician and Allowed Practitioner Orders” Policy #33.24 was provided by the Clinical Supervisor. The policy indicated but was not limited to, “ … 2. The POC should be based upon a current assessment of the patient’s needs for care … Types of supplies, Types of equipment …” 2. On 08-07-2023 at 12:30 PM, a home observation was conducted at Patient #2’s residence. Patient #2 had an electric wheelchair, non-rolling walker, wheelchair, cane, and grab bars in their home. On 08-08-2023 at 9:05 AM, Patient #2’s clinical record was reviewed. The clinical record evidenced a plan of care with a start of care date of 06-15-2023 and a certification period of 06-15-2023 to 08-13-2023. The plan of care evidenced the following DME a walker-rolling, wheelchair, and wound care. The plan of care failed to evidence it included all the DME and supplies Patient #2 possessed in the home for meeting the plan of care goals. 3. On 08-08-2023 at 12:04 PM, a home observation was conducted at Patient #7’s residence. Patient #7 had a hospital bed, electric scooter, Hoyer lift, Hoyer sling, handheld urinal, elevated toilet seat, grab bars, gait belt, disposable under pads, wheelchair, gloves, and 4-wheeled walker in their home. On 08-09-2023 at 8:40 AM, Patient #7’s clinical record was reviewed. The clinical record evidenced a plan of care with a start of care date of 07-28-2023 and a certification period of 07-28-2023 to 09-25-2023. The plan of care evidenced the following DME a walker-rolling, wheelchair, and personal care. The plan of care failed to evidence all the DME Patient #7 had in their home. On 08-10-2023 at 10:10 AM, the Clinical Supervisor provided an updated plan of care for Patient #7 and indicated it underwent Quality Review. The plan of care evidenced a start of care date of 07-28-2023 and a certification period of 07-28-2023 to 09-25-2023. The plan of care evidenced the following DME a Hospital bed, lift, orthotics, rails/grab bars, ROHO wheelchair with cushion, scooter, shower/tub equipment, supports/braces, walker-rolling, wheelchair, and personal care. The plan of care failed to include all the DME at Patient #7’s residence. 4. On 08-08-2023 at 2:00 PM, a home observation was conducted at Patient #8’s residence. Patient #8 had an electric wheelchair, wash basin, soap solution, non-stick pads, Intensive skin therapy, and original healing cream in their home. On 08-09-2023 at 9:45 AM, Patient #8’s clinical record was reviewed. The clinical record evidenced a plan of care with a start of care date of 05-22-2023 and a certification period of 05-22-2023 to 07-20-2023. The plan of care evidenced the following DME a quad cane, walker-rolling, wheelchair, and a wheelchair-powered. The plan of care failed to evidence all the DME Patient #8 had in their home. On 08-09-2023 at 9:45 AM, Patient #8’s clinical record was reviewed. The clinical record evidenced a plan of care with a start of care date of 05-22-2023 and a certification period of 07-21-2023 to 09-18-2023. The plan of care evidenced the following DME a quad cane, walker-rolling, wheelchair, and a wheelchair-powered. The plan of care failed to evidence all the DME Patient #8 had in their home. 5. On 08-08-2023 at 3:22 PM, a home observation was conducted at Patient #9’s residence. Patient #9 had an upright walker, wheelchair-powered, wheelchair, antifungal greaseless cream, normal saline, secura cream, 4x4 pads, abdominal pads, threeflex layer 1 bandage, threeflex layer 2 bandage, threeflex layer 3 bandage, and orthotic post-op recovery sandals in their home. On 08-09-2023 at 12:30 PM, Patient #9’s clinical record was reviewed. The clinical record evidenced a plan of care with a start of care date of 01-03-2023 and a certification period of 07-02-2023 to 08-30-2023. The plan of care evidenced the following DME a cane, shower/tub equipment, walker, solution/skin prep, and wound care. The plan of care failed to evidence all the DME Patient #9 had in their home. 6. During an interview with the Clinical Supervisor on 08-09-2023 at 4:38 PM, they indicated all equipment and supplies should be listed in the plan of care. 410 IAC 17-13-1(a)(1)(D)(ii)

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on record review and interview the Agency failed to notify the physician of changes in the patient's condition in 2 of 2 patient's records indicating a change in the patient's status. (Patient's # 2 and 3) Findings include: 3. On 08-08-2023 at 9:05 AM, Patient #2’s clinical record was reviewed. The clinical record evidenced a plan of care with a start of care date of 06-15-2023 and a certification period of 06-15-2023 to 08-13-2023. The plan of care evidenced a Skilled Nursing (SN) order that indicated but was not limited to, “ … obtain CBC with Diff, CMP, Free T4 and TSH week of July 17 by venipuncture and fax results to (sic Person D, Patient #2’s physician) … “ The clinical record failed to evidence the labs were completed the week of July 17. On 08-09-2023 at 11:03 AM, requested from the Clinical Supervisor the visit note when the labs were completed. The agency failed to provide the visit note that included when the labs were performed and faxed to the physician. On 08-09-2023 at 3:29 PM, requested from the Clinical Supervisor, communication notes to Person D, Patient #2’s physician, and the visit note when the labs were performed and faxed to the physician. The agency failed to provide communication notes to the physician indicating the labs were late and the visit note that included when the labs were completed and faxed to the physician. During an interview with the Clinical Supervisor on 08-09-2023 at 11:03 AM, when queried regarding what the clinicians were to do when labs were ordered for a specific time period and they completed late, the Clinical Supervisor indicated the clinician was to call the physician as soon as they realized the labs were late. During an interview with the Clinical Supervisor on 08-10-2023 at 10:10 AM, they indicated there were no communication notes in Patient #2’s clinical record indicating the physician was notified that the labs were drawn late. 410 IAC 17-13-1(a)(2) 1. A policy received from the Clinical Supervisor on 08-09-2023 at 10:59 AM titled “Case conferences and Coordination of Services” indicated but was not limited to “1. Agency employees regularly communicate to ensure that their efforts are coordinated effectively and support the objectives outlined in the Plan of Care…”. 2. A review of the clinical record of Patient #3 indicated a start of care (SOC) of 03-08-2022 and a certification period of 07-01-2023 to 08-29-2023 with diagnoses including but not limited to pressure ulcer stage 3 of the sacrum (injury to the skin and underlying tissue extending through deeper tissue and fat), Type 2 Diabetes(condition affecting the processing of blood sugar), and cardiomyopathy, (disorder of the heart muscle, reducing pumping ability). The plan of care indicated but not limited to Patient #3, “… skilled nursing 1WK8, #PRN (1 time a week for 8 weeks and 3 visits as needed) for the following reason… dressing dislodgement and to observe and assess integumentary (skin) status to identify changes and intervene to minimize complications… Changes to skin integrity status will be identified and reported to the physician for prompt intervention…”. A review of documents titled “Visit Note Report” for Patient # 3 evidenced the following: 07-01-2023 Employee #1, Registered Nurse (RN) “…PERFORMED WOUND CARE AS ORDERED. …WOUND IS DIMINISHING IN SIZE…”. 07-08-2023 Employee #1, Licensed Practical Nurse (LPN) “SKILLED NURSING VISIT FOR WOUND CARE AND ASSESSMENT…MORE REDNESS AND DRAINAGE NOTED…” 07-14-2023 LPN 1 visit note report, “SKILLED VISIT FOR WOUND CARE AND ASSESSMENT…MORE REDNESS AND DRAINAGE NOTED…” 07-22-2023 Registered Nurse 1 (RN) visit note report indicated but not limited to, “VISIT NEEDED FOR WOUND CARE, NURSING ASSESSMENT, LPN SUPERVISORY VISIT…PT (SIC) HAS NO ADDTL (SIC) SKIN BREAKDOWN… 07-28-2023 LPN 1 reported “…WOUND CARE…MORE REDNESS AND DRAINAGE NOTED…”. 08-04-2023 LPN 1 reported“…WOUND CARE…MORE REDNESS AND DRAINAGE NOTED…”. During an interview on 08-09-2023 at 10:55 AM LPN reported the redness and drainage was noted 3-4 weeks ago but sometimes Patient #3 has had a shower and the wound looks “macerated” (change of color) and they indicated the wound did not look that way now. When queried why the notes in July and August indicated redness and drainage, they reported they had just copied and pasted from the previous visit and the wound has improved. LPN 1 reported they did not report the changes initially but had spoken to Entity B ( wound clinic for Patient #3) in July but had not documented that communication. LPN 1 further indicated that should have been documented. During an interview on 08-0-2023 at 12:49 PM, RN 1, case manager for Patient #3, they indicated they will call Entity B if there are changes to Patient #3’s wounds. When asked where that documentation was, they indicated they would check. On 08-10-2023 at 9:34 AM the Clinical Supervisor reported that they could not locate any communication to Patient #3’s physician or Entity B.

Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient's updated comprehensive assessment, and contain information concerning the patient's progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the plan of care was revised to include the diet restrictions for 1 of 7 active patient records reviewed with a home visit. (Patient #8) Findings Include: 1. On 08-09-2023 at 11:49 AM, a “CommonSpirit Health at Home” policy titled “Plan of Care and Physician and Allowed Practitioner Orders” Policy #33.24 was provided by the Clinical Supervisor. The policy indicated but was not limited to, “ … 8. … Clinicians are responsible for alerting the physician … any changes in patient care or condition that suggests a need to alter the POC …” 2. On 08-09-2023 at 9:45 AM, Patient #8’s clinical record was reviewed. The clinical record evidenced a plan of care with a start of care date of 05-22-2023 and a certification period of 07-21-2023 to 09-18-2023. The plan of care evidenced the patient’s nutritional requirements include low fat, low cholesterol, and a low sodium diet. The clinical record evidenced a Skilled Nurse (SN) document titled “Visit Note Report” with a date of 06-14-2023. The narrative indicated but was not limited to, “ … APPT (sic appointment) … with NP (sic Nurse Practitioner) at cardiologist office, instructed in cardiac diet and 2000mL (sic milliliter) fluid restriction. … “. On 08-10-2023 at 10:10 AM, the Clinical Supervisor provided a document titled “After Visit Summary” from Person E, Patient #8’s Nurse Practitioner, with a date of 06-13-2023. The note indicated but was not limited to, “ … Limit your sodium (salt) intake to 2000mg per (sic throughout) day. Try to limit your fluid intake to 2 liters (64 ounces) per day; 24-32 of these ounces should be water. … “. The updated plan of care for the certification period of 07-21-2023 to 09-18-2023 failed to include the new nutrition requirements for Patient #8. 3. During an interview with the Clinical Supervisor on 08-09-2023 at 4:38 PM, when queried regarding when a physician updated a patient’s diet during the previous certification period and the patient had been recertified, the Clinical Supervisor indicated they would update the diet and nutritional requirements on the updated and recertified plan of care.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to include a complete assessment of a Patient's status in 1 of 7 active records reviewed. (Patient #3). Findings include: 1. A review of the clinical record of Patient #3 indicated a start of care (SOC) of 03/08/2022 and a certification period of 07/01/2023 to 08/29/2023 with diagnoses including but was not limited to pressure ulcer stage 3 of the sacrum (injury to the skin and underlying tissue extending through deeper tissue and fat), Type 2 Diabetes(condition affecting the processing of blood sugar), and cardiomyopathy, (disorder of the heart muscle, reducing pumping ability). The plan of care indicated but not limited to Patient #3, “… skilled nursing 1WK8, #PRN (1 time a week for 8 weeks and 3 visits as needed) for the following reason… dressing dislodgement and to observe and assess integumentary (skin) status to identify changes and intervene to minimize complications… “ 2. A review of documents titled “Visit Note Report” evidenced the following: 07/08/2023 Employee #1, Licensed Practical Nurse (LPN) “SKILLED NURSING VISIT FOR WOUND CARE AND ASSESSMENT…MORE REDNESS AND DRAINAGE NOTED…” 07/14/2023 LPN 1 visit note report, “SKILLED VISIT FOR WOUND CARE AND ASSESSMENT…MORE REDNESS AND DRAINAGE NOTED…” 07/28/2023 LPN 1 reported “…WOUND CARE…MORE REDNESS AND DRAINAGE NOTED…”. 08/04/2023 LPN 1 reported“…WOUND CARE…MORE REDNESS AND DRAINAGE NOTED…”. 3. During an interview on 08/09/2023 at 10:55 AM LPN 1 reported the redness and drainage was noted 3-4 weeks ago but sometimes Patient #3 has had a shower and the wound looks “macerated” (change of color) and they indicated the wound did not look that way now. When queried why the notes in July and August indicated redness and drainage, they reported they had just copied and pasted from the previous visit and the wound has improved. LPN 1 said “ I know I should document, and my notes don’t show that.” IAC 17-15-1(a)(7)