Every finding on record at Covered Journey Health Services LLC

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR §484.102 Survey Dates: 01/13, 01/14, and 01/15/2026 Active Census: 10 At this Emergency Preparedness survey, Covered Journey Health Services, LLC was not found to be in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR §484.102. QR by Area 3 on 1/20/2026.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure they completed a facility-based and community-based risk assessment using an all hazards approach for 1 of 1 home health agency emergency preparedness program. Findings Include: 1. A review of a policy titled "Emergency Preparedness Plan" indicated but was not limited to, " … 1. Hazard Risk Analysis: one form/updated at least every other year. Agency will conduct a hazard risk analysis to identify potential for events likely to occur in the agency's service area. 2. A review of the Emergency Preparedness binder failed to evidence a completed All-hazards approach risk assessment. 3. During an interview with the Administrator and the Director of Skilled Services on 01/13/2026 at 4:05 PM, they indicated they had not completed a full all-hazards approach assessment for the facility. They only performed the hazard approach applying to the patients in their clinical records.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure they completed an analysis to the agency's emergency preparedness plan being enacted for 1 of 1 home health agency emergency preparedness program. Findings Include: 1. A review of a policy dated 11/02/2025 and titled "Emergency Preparedness Plan/Policy" indicated but was not limited to, " … 3. Analyze Covered Journey Health Services's response to and maintain documentation …" 2. A review of the Emergency Preparedness binder evidenced an emergency snow storm was called on 11/29/2025 and 12/01/2025. The documents evidenced patients were called and no care was interrupted. A review of the Quality Assurance Performance Improvement binder evidenced a document titled "Quality Assessment and Performance Improvement (QAPI) Meeting dated 01/07/2026. The document evidenced the Administrator, a Supervising Nurse, and Home Health Aide were involved in the meeting. The Supervising Nurse and Home Health Aide were not named. The document indicated they had activated their emergency preparedness plan with success and no incidents. No further information regarding analysis was included. During an interview with the Administrator, Alternate Administrator, Director of Skilled Services, and Quality Review RN on 01/14/2026 at 1:45 PM, they indicated the analysis was what was included in the QAPI meeting. They indicated they needed to add more detail in the after-action plan.

This visit was for an initial Federal Medicaid survey of a Home Health provider. Survey Dates: 01/13, 01/14, and 01/15/2026 12-Month Unduplicated Skilled Admissions: 9 This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Refer to State Form for additional State Findings. Abbreviations: HHA- Home Health Aide POC-Plan of Care SOC- Start of Care RN-Registered Nurse SN- Skilled Nursing OASIS- Outcome and Assessment Information Set ADL- Activities of Daily Living DME- Durable Medical Equipment CM-Clinical Manager QR completed by Area 3 on 1/20/2026.

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 ensure the Admission packet included the Administrator's name and contact information for 3 of 3 patient admission packets reviewed during home visits. (Patients #1, #2, and #3) Findings Include: 1. A review of the policy dated 11/05/2025 and titled "Patient Rights and Responsibilities" indicated but was not limited to, " … Prior to furnishing care/services to patient … Statement both verbally and in writing … Contact information for the home health Administrator, including the Administrator's name, business address, and business phone number in order to receive complaints. …" 2. A review of the agency admission packet failed to evidence the Administrator's name and contact information. 3. During a home visit at Patient #1's residence on 01/14/2026 at 9:02 AM, the admission packet was reviewed and failed to evidence the Administrator's name and contact information. 4. During a home visit at Patient #3's residence on 01/14/2026 at 10:29 AM, the admission packet was reviewed and failed to evidence the Administrator's name and contact information. 5. During a home visit at Patient #2's residence on 01/14/2026 at 11:57 AM, the admission packet was reviewed and failed to evidence the Administrator's name and contact information. 6. During an interview with the Administrator, Director of Skilled Services, and the Alternate Administrator on 01/14/2026 at 2:25 PM, they indicated they had not included the Administrator's name and contact information in the patients' admission packet.

State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patients received the correct state toll free hot line for 3 of 3 patient admission packets reviewed during home visits. (Patients #1, #2, and #3) Findings Include: 1. A review of the policy dated 11/05/2025 and titled "Patient Rights and Responsibilities" indicated but was not limited to, " … The Patient Rights and Responsibilities Statement will include but is not limited to the patient's right to: … 9. Be advised of the state toll-free home health telephone hotline …" 2. A review of the agency admission packet evidenced a number they designated as the state home health hotline number. An attempt to call the state hotline number was made on 01/13/2026 at 12:29 PM, the automated voice message indicated the number was disconnected. 3. During a home visit at Patient #1's residence on 01/14/2026 at 9:02 AM, the admission packet was reviewed and evidenced the disconnected state hotline number. The admission packet failed to include the correct state home health hotline number. 4. During a home visit at Patient #3's residence on 01/14/2026 at 10:29 AM, the admission packet was reviewed and evidenced the disconnected state hotline number. The admission packet failed to include the correct state home health hotline number. 5. During a home visit at Patient #2's residence on 01/14/2026 at 11:57 AM, the admission packet was reviewed and evidenced the disconnected state hotline number. The admission packet failed to include the correct state home health hotline number. 6. During an interview with the Administrator, Director of Skilled Services, and the Alternate Administrator on 01/14/2026 at 2:25 PM, they indicated they were unaware they included a disconnected number as the state home health hotline number on the admission packet. 410 IAC 17-12-3 (b)(2)(C)

Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure they provided contact information for the Federally and state funded entities in 3 of 3 patient admission packets reviewed during home visits. (Patients #1, #2, and #3) Findings Include: 1. A review of the policy dated 11/05/2025 and titled "Patient Rights and Responsibilities" indicated but was not limited to, " … The Patient Rights and Responsibilities Statement will include but is not limited to the patient's right to: … 10. Be advised of the names, addresses, and telephone numbers of the following federally funded and state-funded entities that serve the area where the patient resides: Agency on Aging. Center for Independent Living. Protection and Advocacy Agency. Aging and Disability Resource Center. Quality Improvement Organization. …" 2. A review of the agency admission packet failed to evidence the names, addresses, and telephone numbers of the federally funded and state-funded entities. 3. During a home visit at Patient #1's residence on 01/14/2026 at 9:02 AM, the admission packet was reviewed and failed to evidence the names, addresses, and telephone numbers of the federally funded and state-funded entities. 4. During a home visit at Patient #3's residence on 01/14/2026 at 10:29 AM, the admission packet was reviewed and failed to evidence the names, addresses, and telephone numbers of the federally funded and state-funded entities. 5. During a home visit at Patient #2's residence on 01/14/2026 at 11:57 AM, the admission packet was reviewed and failed to evidence the names, addresses, and telephone numbers of the federally funded and state-funded entities. 6. During an interview with the Administrator, Director of Skilled Services, and the Quality Review RN on 01/15/2026 at 12:50 PM, they indicated they were unable to find the names, addresses, and telephone numbers of the federally and state-funded entities in their admission packet.

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 record review and interview, the agency failed to ensure the POC indications for all as needed medications, the duration of services, and measurable goals were included in 5 of 10 active clinical records reviewed. (Patients #2, #5, #6, #7, and #9) Findings Include: 1. A review of a policy dated 11/02/2025 and titled "Plan of Care" indicated but was not limited to, " … The initial plan of care includes but is not limited to, " … Medications: dose/frequency/route … Orders for all disciplines include … duration of visits to be made. Equipment and supply needs … Patient-specific interventions and education, measurable outcomes, and goals …" 2. A review of Patient #2's active clinical record evidenced an initial POC with a SOC date of 11/18/2025 and a certification period from 11/18/2025 to 01/16/2026. The POC included the following diagnoses: Moderate intellectual disabilities, Dementia (a condition where the individual loses intellectual functioning impacting memory, thinking and personality change), Aphasia (a condition causing difficulty speaking, understanding, and reading caused by brain damage), Depression, and Hypoxic Ischemic Encephalopathy (brain injury caused by a lack of oxygen and blood going to the brain). The POC evidenced in the section titled "Goals/Rehabilitation Potential/Discharge Plans" indicated but was not limited to, " … Patient's medical condition will remain stabilized within (sic blank) … Patient/caregiver will comply with prescribed medications within (sic blank) 1. Patient/caregiver will verbalize understanding of all medication, potential side-effects, and when to notify the RN/physician. 2. Patient/caregiver will demonstrate ability to maintain a safe medication environment (organized pillbox, secure storage, no expired medications) … Patient/caregiver will demonstrate correct use of pillbox or medication set-up system during RN visit. … 7. Patient will demonstrate ability to recognize and report early signs of complications (e.g. dizziness, swelling, change in mental status, bleeding). …" The POC failed to include measurable goals. 3. A review of Patient #5's active clinical record evidenced an initial POC with a SOC date of 11/19/2025 and an initial certification period from 11/19/2025 to 01/17/2026. The POC included the following diagnosis: Multiple Sclerosis (a disease of the brain, spinal cord, and nerves, where the individual's immune system attacks the nerves causing vision problems, numbness, and weakness). The POC evidenced in the section titled "Goals/Rehabilitation Potential/Discharge Plans" indicated but was not limited to, " … Patient/caregiver will comply with prescribed medications within (sic blank). … Patient/caregiver will verbalize knowledge of the signs and symptoms of respiratory and when to contact agency or 911 within (sic blank). Patient/caregiver will verbalize understanding of pain control measures within (sic blank). …" A review of Patient #6's active clinical record evidenced an initial POC with a SOC date of 12/11/2025 and an initial certification period from 12/11/2025 to 02/13/2026. The POC included the following diagnoses: Hypertension (high blood pressure) and Hyperlipidemia (high levels of fat in the blood). The medication section evidenced the patient took 108 micrograms (mcg), 2 puffs of Albuterol Sulfate inhalation aerosol powder (a medication used to relax and open narrowed airways) daily. The POC evidenced in the section titled "Goals/Rehabilitation Potential/Discharge Plans" indicated but was not limited to, " … Patient will have improved pain status as evidenced by decrease in pain level within (sic blank). Patient/Caregiver will demonstrate compliance with pain medications, as prescribed by doctor within (sic blank). Patient's medical condition will remain stabilized within (sic blank). …" A review of the document titled "Medication Profile" in Patient #6's active clinical record evidenced the patient was to take Albuterol 2 puffs daily as needed for wheezing. 4. A review of Patient #7's active clinical record evidenced an initial POC with a SOC date of 11/19/2025 and an initial certification period from 11/19/2025 to 01/17/2026. The POC included the following diagnoses: Hypertension (high blood pressure), repeated falls, mild intermittent asthma (a disease causing airways to become swollen and narrowed making it difficult to breath and causing shortness of breath), and Polyosteoarthritis (a condition where five or more joints were inflamed and cause pain and stiffness). The POC evidenced the patient had SN services every 14 days for medication set-up. The POC failed to evidence the duration of the SN services. 5. A review of Patient #9's active clinical record evidenced an initial POC with a SOC date of 12/09/2025 and an initial certification period from 12/09/2025 to 02/08/2026. The POC included the following diagnoses: Chronic Obstructive Pulmonary Disease (a disease causing constricted airways and difficulty breathing, Diabetes (a condition where the body is unable to produce enough insulin or use it appropriately) with Diabetic chronic kidney disease (damage to the kidneys due to high levels of blood sugar), Gastro-esophageal reflux (condition where acid from the stomach goes back up the tube and into the mouth), Spinal Stenosis (a condition where the spaces in the spine narrow causing pain and weakness), and chronic pain. The POC evidenced in the section titled "Goals/Rehabilitation Potential/Discharge Plans" indicated but was not limited to, " … Patient/caregiver will comply with prescribed medications within 30 (sic blank). … Patient/caregiver will verbalize knowledge of the signs and symptoms of respiratory distress and when to contact agency or 911 within (sic blank). Patient/caregiver will demonstrate proper use of blood glucose monitoring and log keeping within 14. Patient/caregiver will verbalize understanding of medication regimen, actions, side effects, and adverse reactions within (sic blank). Patient/caregiver will verbalize understanding of Infection Control and precautions within (sic blank). …" 6. During an interview with the Administrator, Director of Skilled Services, and Quality Review RN on 01/15/2026 at 1:30 PM, the Administrator indicated the POC for all patients should include measurable goals, as needed medication indications, and duration. 410 IAC 17-13-1 (a)(1)(D)(iii, ix, and xiii)

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure they received orders in a timely manner for 4 of 4 active clinical records reviewed with late orders. (Patients #1, #5, #8, and #10) Findings Include: 1. A review of a policy dated 11/02/2025 and titled "Plan of Care" indicated but was not limited to, " … Covered Journey Health Services will obtain physician or allowed practitioner orders prior to initiation of the care/services … the physician or allowed practitioner will be consulted to approve additions or modifications to the original plan. …" 2. A review of Patient #1's active clinical record evidenced a document titled "Verbal Order" dated by the Administrator, the patient's CM, on 11/20/2025 and indicated the agency admitted the patient to be seen for SN services every 14 days for two months and HHA services once a week for 2 months. The order was signed by the patient's physician, Person 1, on 12/10/2025. Patient #1's active clinical record included a document titled "Patient Communication Log" failed to evidence the agency received Verbal orders to provide care to the patient before they received the signed Verbal order form from the physician. Patient #1's active clinical record evidenced the patient was seen by the SN on 12/04/2025. Patient #1's active clinical record evidenced the patient was seen by the HHA on 11/22, 11/29, and 11/06/2025. During an interview with the Administrator and the Alternate Administrator on 01/14/2026 at 2:25 PM, they indicated another communication note should have been added to Patient #1's clinical record when the nurse called them back to receive the Verbal order for services. They confirmed there was no communication note evidencing they received orders to continue services after the SOC and before the physician signed the orders. 3. A review of Patient #5's active clinical record evidenced a document titled "Order" evidenced orders to admit the patient for SN services every 14 days starting 11/19/2025. The Order evidenced the patient's nurse practitioner, Person 2, signed the order on 01/13/2026. A review of the document titled "Patient Communication Log", in Patient #5's clinical record, revealed the Administrator, the patient's CM, called Person 2's office and left a message regarding the POC after the SOC assessment. The clinical record failed to evidence they received orders from the patient's physician office after completing the SOC assessment and before they received the signed order from the physician. Patient #5's active clinical record evidenced the patient was seen for SN services on 12/03, 12/17, and 12/31/2025. During an interview with the Administrator, Director of Skilled Services, and the Quality Review RN on 01/15/2026 at 1:30 PM, the Administrator confirmed they had not documented they received a call back from the physician's office and received the verbal order before the physician signed the order. They indicated they needed to work on documentation. 4. A review of Patient #8's active clinical record evidenced a document titled "Verbal Order" dated 12/26/2025. The order was unsigned and undated by the Alternate Administrator, the patient's CM, and the patient's physician, Person 3. The order evidenced they were placing the patient's SN services on hold while the patient travelled out of town until 01/18/2026. Patient #8's active clinical record evidenced the patient had a SOC assessment completed by the Alternate Administrator on 12/12/2025. A review of the document titled "Patient Communication Log" and dated 12/26/2025 by the Alternate Administrator evidenced Patient #8 informed the Alternate Administrator of needing services being placed on hold while they were out of town. Patient #8's active clinical record failed to evidence the agency informed and received an order to hold the patient's services from the patient's physician. During an interview with the Administrator, Alternate Administrator, Director of Skilled Services, and the Quality Review RN on 01/15/2026 at 11:43 AM, they confirmed they were unable to find a verbal order or communication to Patient #8's physician notifying them of the SN services placed on hold. 5. A review of Patient #10's active clinical record evidenced a document titled "Verbal Order" dated 11/18/2025 by the Administrator, the patient's CM. The order evidenced the patient was admitted for SN services every 14 days. The order was signed by Person 4, the patient's physician on 12/09/2025. A review of the documents titled "Patient Communication Logs" for Patient #10 failed to evidence the agency received a verbal order from the physician to provide services after the SOC assessment and before the physician signed the orders. Patient #10 was seen for SN services on 12/02/2025 before the physician signed the order to continue services. During an interview with the Administrator, Alternate Administrator, Director of Skilled Services, and Quality Review RN on 01/15/2026 at 11:43 AM, they indicated they were unable to find a verbal order communication note before they received the signed order from the physician. 410 IAC 17-14-1 (a)(F)(H)

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 ensure the Admission packet evidenced the Clinical Manager's name and contact information for 3 of 3 patient admission packets reviewed during home visits. (Patients #1, #2, and #3) Findings Include: 1. A review of the agency admission packet failed to evidence the CM's name and contact information. 2. During a home visit at Patient #1's residence on 01/14/2026 at 9:02 AM, the admission packet was reviewed and failed to evidence the CM's name and contact information. 3. During a home visit at Patient #3's residence on 01/14/2026 at 10:29 AM, the admission packet was reviewed and failed to evidence the CM's name and contact information. 4. During a home visit at Patient #2's residence on 01/14/2026 at 11:57 AM, the admission packet was reviewed and failed to evidence the CM's name and contact information. 5. During an interview with the Administrator, Director of Skilled Services, and the Alternate Administrator on 01/14/2026 at 2:25 PM, they indicated they had not included the CM's name and contact information in the patients' admission packet.

Administrator appointed by governing body CFR(s): 484.105(b)(1)(i) Standard: Administrator. The administrator must: (i) Be appointed by and report to the governing body; This ELEMENT is not met as evidenced by: Based on record review and interview, the Administrator failed to ensure they were appointed as Administrator by the Governing Body for 1 of 1 Administrator. Findings Include: 1. A review of the policy dated 11/05/2025 and titled "Governing Body/Owner" indicated but was not limited to, " … The scope of responsibilities of the governing body/owner includes but is not limited to: … Appoint a qualified Administrator …" 2. A review of the agency document titled "Governing Body Inaugural Meeting" dated 11/11/2025 indicated but was not limited to, " … 6. Administrator and Clinical Director and back-ups appointed …" The document failed to evidence who the agency appointed as the Administrator. 3. During the Entrance conference with the Director of Skilled Services, Administrator, and the Quality Review RN on 01/13/2026 at 11:47 AM, they indicated the Administrator was the Administrator. During an interview with the Administrator and the Director of Skilled Services on 01/13/2026 at 4:05 PM, the Administrator explained the governing body document had said they appointed them as the Administrator, but confirmed the document failed to identify who the Administrator was. 410 IAC 17-12-1 (b)(1)

Ensures qualified pre-designated person CFR(s): 484.105(b)(2) When the administrator is not available, a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator. The pre-designated person may be the clinical manager as described in paragraph (c) of this section. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure they included who they appointed as Alternate Administrator by the Governing Body for 1 of 1 Alternate Administrator. Findings Include: 1. A review of the agency document titled "Governing Body Inaugural Meeting" dated 11/11/2025 indicated but was not limited to, " … 6. Administrator and Clinical Director and back-ups appointed …" The document failed to evidence who the agency appointed as the Alternate Administrator. 2. During the Entrance conference with the Director of Skilled Services, Administrator, and the Quality Review RN on 01/13/2026 at 11:47 AM, they indicated the Alternate Administrator was the Alternate Administrator. 3. During an interview with the Administrator and the Director of Skilled Services on 01/13/2026 at 4:05 PM, the Administrator explained the governing body document had said they appointed back-up for the Administrator, but confirmed the document failed to identify who the Alternate Administrator was. 410 IAC 17-12-1 (d)(8)