Every finding on record at Deaconess Home Health, LLC

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR §484.102. Survey Dates: 04/14/2026 – 04/17/2026 and 04/20/2026 – 04/21/2026 Active Census: 468 At this Emergency Preparedness survey, Deaconess Home Health 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 on 05/01/2026 by A4JG

This visit was for a Federal Recertification and State Re-Licensure in conjunction with a Complaint survey of a Home Health Provider. Survey Dates: 04/14/2026 – 04/17/2026 and 04/20/2026 – 04/21/2026 12-Month Unduplicated Skilled Admissions: 2553 Complaint # 2959820 with related findings. Partially Extended on 04/20/2026 at 2:12 PM This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Abbreviations: CM Clinical Manager HHA Home Health Aide OT Occupational Therapist PT Physical Therapist RN Registered Nurse LPN Licensed Practice Nurse SN Skilled Nurse SOC Start of Care PTA Physical Therapist Assistant COTA Certified Occupational Therapist Assistant

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 provide the name and contact information for the agency's Clinical Manager for 9 of 9 home visits conducted (Patients #1, #2, #3, #4, #5, #7, #8, #9, and #25). Findings include: 3. During a home visit with Patient #2 on 04/15/2026 at 11:58 AM, a review of the patient's folder provided by the agency failed to evidence the agency informed the patient of the name and contact information for the clinical manager. During the home visit interview, Patient #2 expressed no knowledge of a clinical manager or their name. 4. During a home visit with Patient #3 on 04/16/2026 at 10:56 AM, a review of the patient's folder provided by the agency failed to evidence the agency informed the patient of the name and contact information for the clinical manager. During the home visit interview, Patient #3 expressed no knowledge of a clinical manager or their name. 5. During a home visit with Patient #4 on 04/16/2026 at 12:28 PM, a review of the patient's folder provided by the agency failed to evidence the agency informed the patient of the name and contact information for the clinical manager. During the home visit interview, Patient #4 and spouse expressed no knowledge of a clinical manager or their name. 6. During a home visit with Patient #5 on 04/17/2026 at 11:33 AM, a review of the patient's folder provided by the agency failed to evidence the agency informed the patient of the name and contact information for the clinical manager. During the home visit interview, Patient #5 expressed no knowledge of a clinical manager or their name. 7. During a home visit with Patient #7 on 04/15/2026 at 1:34 PM, a review of the patient's folder provided by the agency failed to evidence the agency informed the patient of the name and contact information for the clinical manager. During the home visit interview, Patient #7 expressed no knowledge of a clinical manager or their name. 8. During a home visit with Patient #8 on 04/20/2026 at 8:35 AM, there was no admission folder provided by the agency that evidenced the agency informed the patient of the name and contact information for the clinical manager. During the home visit interview, Patient #8 expressed no knowledge of a clinical manager or their name. 9. During an interview with Patient #9 on 04/17/2026 at 8:30 AM, a review of the patient's folder provided by the agency failed to evidence the agency informed the patient of the name and contact information for the clinical manager. During the home visit interview, Patient #9 and patient’s representatives expressed no knowledge of a clinical manager or their name. 1. Review of the agency’s admission packet evidenced a welcome letter provided by the agency to patients. The document specified patients should contact the agency with anything about their care they would like to discuss. The document specified management staff of the agency as the Director of Clinical Services (the title of the identified Administrator); the document failed to specify who the agency Administrator was and name/contact information for the Administrator. The packet failed to evidence the CM’s name and contact information. 2. During a home visit with Patient #1 on 04/15/2026 at 10:00 AM, a review of the patient's folder provided by the agency failed to evidence the agency informed the patient of the name and contact information for the clinical manager. During the home visit interview, Patient #1 expressed no knowledge of the clinical manager or their name. 10. During a home visit with Patient #25 on 04/20/2026 at 9:30 AM, a review of the patient's folder provided by the agency failed to evidence the agency informed the patient of the name and contact information for the clinical manager. During the home visit interview, Patient #25 expressed no knowledge of the clinical manager or their name. 11. During an interview on 04/15/2026 at 11:00 AM, RN 1 indicated he/she thought the Administrator was the Clinical Manager and didn’t realize she was also the Administrator of the home health. He/She indicated not being familiar with the name of the Clinical Manager for the home health agency.

Retrieval of records CFR(s): 484.110(e) Standard: Retrieval of clinical records. A patient's clinical record (whether hard copy or electronic form) must be made available to a patient, free of charge, upon request at the next home visit, or within 4 business days (whichever comes first). This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure patient’s clinical records were made available to a patient within 4 business days of request for 1 of 1 active patient on the medical record request log (Patient #12). Findings include: Review of the agency’s Medical Record Daily Activity Log 2026 showed Patient #12’s Power of Attorney (POA) emailed Entity 1’s Medical Records Department on 02/26/2026 to request two years of medical records. The log showed the Medical Records Clerk documented that on 03/19/2026 the Administrator called for an update because the POA was inquiring about the status of the request. The log showed the records were pulled on 03/06/2026 but had not yet been released. The log further showed the Administrator emailed the clerk on 03/26/2026 to follow up on another inquiry from the POA. The clerk documented the records had been released to the POA on 03/19/2026. During an interview on 04/14/2026 at 10:55 AM, the Administrator stated the corporate medical records department did not notify the agency or follow up on medical record requests. She stated requestors sometimes contacted the agency when they had not received their records. She stated the corporate medical records department was responsible for sending records to patients, and she did not track requests before forwarding them to the corporate department. She stated the corporate medical records department was expected to follow the agency’s policy for record request completion and that she should be involved to ensure deadlines were met. During an interview on 04/15/2026 at 4:04 PM, the Administrator stated the request began on 02/26/2026 and the POA received the records on 03/19/2026. She stated Entity 1’s medical records department handled all home health record requests and the agency did not independently track or monitor them. She stated patients and their representatives received contact information to initiate medical record requests. She stated Entity 1 used a third‑party vendor to maintain medical records and the agency’s policy required records to be provided within 30 days of the request. 410 IAC 17-12-3(b)(3)

This visit was for a Federal/State complaint survey of a home health provider. Survey Date: 07/17/2025 Complaint: 116898 with unrelated deficiencies cited. 12 Month Unduplicated Skilled Admissions: 492 Abbreviations: SN-Skilled Nurse RN-Registered Nurse POC-Plan of Care QA by A4 on 07/22/2025

5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the start of care. This ELEMENT is not met as evidenced by: Based on record review and interviews, the agency failed to have a signed POC or a verbal POC order from the primary physician before providing services and treatments to patients for 2 of 3 closed record reviews. (Patients #1, #5) Findings include: 1. A 03/25/2024 policy titled "Plan of Care and Physician and Allowed Practitioner Orders" states that staff must keep unsigned POCs in the EMR until they receive a signed POC from a physician or allowed practitioner. The policy allows staff to implement the POC with a verbal order until they receive the signed POC. 2. A review of Patient #1's record for the certification period from 02/06/2025 to 04/06/2025 evidenced that the agency provided care without obtaining either a detailed verbal order or a physician-signed Plan of Care (POC) for visits on 02/10/2025, 02/13/2025, 02/14/2025, 02/17/2025, 02/21/2025, 02/24/2025, and 02/26/2025. The agency failed to secure these orders before delivering care. 3. A review of Patient #5's record for the certification period from 11/20/2024 to 01/18/2025 indicated that the agency provided care without a detailed verbal order or a physician-signed Plan of Care (POC) for the visits on 11/27/2025 and 12/03/2025. The agency failed to secure orders before providing care. 4. During an interview on 07/17/2025 at 11:32 AM, the Administrator stated that she did not know staff needed to obtain a signed POC or a detailed verbal order before providing direct care and treatment.

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102. Survey Dates: 06/20/2023 to 06/26/2023 Active Census: 462 QR on 06/29/2023 by A4

Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.542(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility's geographic area. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to develop and maintain an emergency plan for each hazard identified in the all-hazard risk assessment, outlined in the agencies emergency preparedness policy for 1 of 1 emergency preparedness plans reviewed. Findings include: A document dated 11/2017 titled Branch Emergency Management Business Continuity Plan Summary was provided on 06/20/23 at 3:25 PM, by the Alternate Administrator. The document identified the agencies hazard vulnerability analysis but failed to outline the procedure for each hazard. During an interview on 06/26/2023 at 11:04 AM the Administrator confirmed the agency did not have additional instructions for each hazard identified in the all-hazard risk assessment.

This visit was for a Federal Recertification and State Re-Licensure survey of a Home Health Provider. Survey Dates: 06/20/2023-06/23/2023 & 06/26/2023 12 Month Unduplicated Skilled Admissions: 1982 This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Refer to State Form for additional State Findings.

Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to resolve 4 of 4 complaints made in regard to not answering the telephone. (Patients #8, #11, #12, & #14) Findings include: 1. A policy titled Patient Complaints and Concerns was provided by the Administrator on 06/23/2023 at 11:25 AM. The policy indicated, but was not limited to, “7. Patient contact and follow-up will occur within five (5) calendar days. Document resolution of the complaint …” 2. Review of the 2023 Complaint log provided by the Administrator on 06/20/2023 at 10:10 AM failed to evidence a resolution to complaints filed by Patient #8, #11, #12, and #14, involving the agency not answering the phone during business hours. The agency failed to ensure complaints were resolved and follow-up was conducted with the patient regarding the resolution. 3. During a home visit on 06/21/2023 and 06/22/2023, Patients #8 and #14 both stated the agency does not answer the phone during business hours and were unable to leave a message. 4. During an interview on 06/23/2023 at 1:00 PM the Administrator stated he/she was unsure why there was no resolution documented for the complaints reviewed in the complaint log. The Administrator stated there was a problem with the phone lines at one time but would investigate the patients concern regarding the phone service. 410 IAC 17-12-3(c)(2)

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 medication, treatments, mental status, and labs were listed on the current plan of care for 9 of 18 active record reviews (Patients #4, #5, #6, #7, #9, #14, #15, #16, #17); and failed to ensure all entities providing care were listed on the current plan of care for 10 of 10 active record reviews involving outside entities. (Patients #6, #13, #15, #18, #19, #20, #21, #22, #23, #24) Findings include: 1. A 01/11/2023 policy titled Plan of Care and Physician and Allowed Practitioner Orders was provided by the Alternate Administrator on 06/21/2023 at 12:01 PM. 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. The POC must include: … Patients mental status … Types of services …All medications, All treatments … other relevant patient information …” 2. During a home visit on 06/21/2023 at 11:00 AM Registered Nurse (RN) 1 reviewed the current medications along with Patient #4. RN 1 discovered Patient #4 was taking Trimethaphan (medication for high blood pressure emergencies) 10 milligrams (mg) daily and Percocet (pain medication) 5 mg that was not on the current plan of care or the medication profile. At that time, Patient #4 stated he/she had been taking Trimethaphan for 4 years and Percocet 5 mg 2 weeks ago. RN 1 stated the medication should have been on the plan of care and was unsure why it was not listed. The agency failed to ensure all medications were listed on the current plan of care and medication profile. 3. During a home visit on 06/21/2023 at 1:30 PM Physical Therapist (PT) 1 reviewed the current medications along with Patient #8. PT 1 discovered Patient #8 was taking Norco (pain medication) in the morning and evening and Carafate (ulcer medication) at meals and bedtime. At that time, Patient #8 stated he/she had been taking Norco for a while and Carafate since June 1, 2023. PT 1 stated the medications should be listed on the plan of care. The agency failed to ensure all medications were on the plan of care. During an interview on 06/20/2023 at 2:15 PM the Administrator and Alternate Administrator stated all medications and treatments should be on the plan of care and the medication bottles should be looked at when reviewing the medications in the home. 4. The clinical record for Patient #14, Start of Care (SOC) date 02/14/2023, certification date 06/14/2023 to 08/12/2023, was reviewed on 06/22/2023 which included a POC that described Patient #14’s mental status as “oriented”. No evidence of Patient #14’s psychosocial assessment. The agency failed to specify Patient #14’s mental status on the POC as indicated, but not limited to, the patient’s orientation to person, place, and time. The agency failed to complete a psychosocial assessment (interpersonal relationships in the immediate family, financial status, homemaker/household needs, family social problems, and transportation needs) on Patient #14’s POC. During a home visit on 06/22/2023 at 9:45 AM Patient #14 stated Registered Nurse (RN) 1 checked her anticoagulation (blood thinner) level last Tuesday because he/she was on Warfarin (blood thinner medication). Review of the current plan of care provided by the agency failed to indicate if the agency was managing Patient #14’s lab and blood thinner medication. During an interview on 06/21/2023 at 2:50 PM the Administrator stated they had provided education in April about the details of orientation and psychosocial assessment that need to be included on the POC. On 06/26/2023 at 9:20 AM the Administrator stated the clinic manages the anticoagulation level and the plan of care was to include who manages the anticoagulation level and medication. 5. During a home visit on 06/22/2023 at 1:00 PM observed PTA 1 conversing with a home health aide from Entity 1. Reviewed the plan of care in the home which failed to indicate another Entity was providing Personal Care Services (PSA) for Patient #13 in the home. The home health aide from Entity 1 stated he/she was in Patient #13’s home 5 days a week from 9:00 AM to 4:00 PM. The agency failed to ensure all other Entities providing care were included on the current plan of care. During an interview on 06/22/2023 at 4:08 PM the Administrator and Alternate Administrator stated they were unaware of all patients receiving care from other Entities and would call the clinicians to find out which patients were receiving care from other entities. 410 IAC 17-13-1(a)(1)(D)(i-xiii) 6. A list of patients receiving care from other Entities were provided by the Administrator on 06/22/2023 at 09:54 AM. Review of the plan of care (POC) for Patients #6, #15, #18, #19, #20, #21, #22, #23, #24, failed to include other Entities on each patient’s POC. During an interview on 06/22/2023 at 5:08 PM with Alternate Administrator and Administrator, both agreed other agencies involved in home care with patients should be included as pertinent information on the POC. 7. During a home visit on 06/21/2023 at 4:42 PM, Registered Nurse (RN) 1 administered Intravenous (IV) medication provided by Entity 2 to Patient #9. The IV medication dose on current Plan of Care (POC) did not match the dose of IV medication provided by Entity 2. RN 1 confirmed medications should be reviewed during every visit. RN 1 compared medication list on electronic device to medication being administered to Patient #9. RN 1 agreed medication dose on medication list and POC, did not match the dose of medication being administered to Patient #9 during home visit. During interview on 06/21/2023 at 4:42 PM with Patient #9, Patient confirmed IV medication dose has been the same dose for over a year. 8. The patient record for Patient #6, start of care (SOC) date 07/23/21, certification date 05/14/2023 to 07/12/2023, was reviewed on 06/20/2023 which included a plan of care (POC) that was missing orders for wound care, Port-a-Cath (a device place under skin used to draw blood and give treatments, intravenously), and intravenous medications; all being provided to the patient by agency 9. The clinical records for Patients #5, #6, #7, #9, #15, #16, #17 were reviewed from 06/20/2023 to 06/26/2023. Each patients’ Plan of Care (POC) dated after 04-20-2023 had inadequate evaluation of mental, psychosocial, and cognitive status. During an interview on 06/23/2023 at 2:01 PM the Alternate Administrator, acknowledged mental status was not being captured for all mental, psychosocial, and cognitive status during evaluation. Alternate Administrator was involved in survey at sister location in Vincennes Indiana in March 2023. That location was cited not capturing all mental status requirements. Alternate Administrator provided education to staff at Deaconess Home Health LLC on 4-20-2023 and again on 05-22-2023. Alternate Administrator confirmed additional training is needed. 10. During a home visit on 06/21/2023 at 4:42 PM, License Practical Nurse (LPN) 1 compared the medication in home with medication on EMR (Electronic Medical Records). The EMR was missing, Fluticasone Propionate and Salmeterol inhaler 100/56 mg / hal every 12 hours for asthma and Singular 10 mg 1 tab daily ,both medications were found in Patient #15’s home but not on EMR. Patients’ daughter indicated patient had been on Fluticasone for as long as she could remember. There were two bottles of Singular, oldest bottled had pharmacy fill date of 02-17-2023. During an interview on 06/22/2023 at 12:00 PM, the LPN 1 acknowledged medication should be reviewed every visit. A change or new medication should be added to medication list on EMR. The Doctor should be notified on day of new or changed medication being found in home. During an interview on 06/22/2023 at 5:08 PM, the Alternate Administrator confirmed medication reconciliation should be done at time of Outcome and Assessment Information Set (OASIS) (a group of standard data elements home health agencies (HHAs) integrate into their comprehensive assessment, to collect and report quality data to the Centers for Medicare & Medicaid Services) and medication should be reviewed with each nursing visit. New or changed medication should be updated and entered into Home Care Home Base (HCHB) (computer system being used for clinical documentation) same day as reviewed.

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 obtain physician orders for services being provided for patient care for 2 of 24 records reviewed. (Patient #7, #16) Findings Include: 1. A policy dated 01/31/1992, revision date 12/19/2022 titled Obtaining Laboratory Specimens through Venipuncture was provided on 06/26/2023 at 9:34 AM, by the Alternate Administrator. The policy indicated, but was not limited to,” … 2. Action: Obtain and verify the physician or allowed practitioner’s order …” 2. The clinical record for Patient #7, start of care (SOC) date 02/04/2023, certification date 06/04/2023 to 08/02/2023, was reviewed on 06/20/2023 which included a plan of care (POC), and coordination notes reports. The POC failed to identify any wounds for Patient #7 and failed to include wound care orders. The coordination notes on 06-05-2023 entered by Licensed Practical Nurse (LPN) 1 read “… WOUND RT ARM HEALED. DRESSINGS REMOVED AND LEFT OPEN TO AIR.” No documentation found for wound care orders or notification made to doctor that dressing was removed and wound left open to air. During an interview with LPN 1, on 06/22/2023 at 12:00 PM, LPN 1 indicated if a dressing was found on a patient, with no wound care orders, LPN 1 would remove dressing to evaluate wound. If the wound was healed the dressing would be left off and the doctor would be notified the wound was healed and left open to air. 3. The clinical record for Patient #16, start of care (SOC) date 05/24/2023, certification date 05/24/2023 to 07/22/2023, was reviewed on 06/22/2023 which included a Patient Information Report, Client Coordination Note Report, Plan of Care (POC) and Doctors orders. A doctor’s order was included for a nurse to collect a lipid panel (a blood test that measures the amount of certain fat molecules called lipids in your blood) on 06/02/2023. On 06/02/2023 the coordination note indicates unable to draw labs due to patient eating prior to nurse arrival. The Nurse Practitioner’s (NP) office was notified, and another attempt would be scheduled for 06/05/2023. There was no doctors order for rescheduled lab draw for 06/05/2023. The coordination notes from 06/05/23 indicates there was no nursing visit on calendar, the agency missed collecting lipid panel and patient had lipid panel collected at NP’s office on 06/06/2023. During an interview on 06/22/2023 at 5:08 PM the Alternate Administrator confirmed when lab draws are missed, a new order should be obtained for labs to be collected the next day. It was the skilled nurse’s responsibility to notify the doctor of missed labs and collect new orders, from doctor, for new collection date. The nurse obtaining the orders was responsible for placing order in EMR (electric medical record) and scheduling visit on calendar. 410 IAC 17-13-1(a)

Written instructions to patient include: CFR(s): 484.60(e) Standard: Written information to the patient. The HHA must provide the patient and caregiver with a copy of written instructions outlining: This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure a copy of written instructions for emergency preparedness, written instruction sheet on safety, and explanation of service coverage was provided to patients for 5 of 7 home visit observations. (Patients #4, #7, #8, #14, #15) Findings include: 1. A 02/24/2023 policy titled Bill of Rights and Responsibilities was provided by the Administrator on 06/23/2023 at 11:45 AM. The policy indicated, but was not limited to, “Be fully informed in advance about care and services to be provided, including disciplines, including the disciplines that furnish care and the frequency of visits, as well as any modifications to the Plan of Care (POC). Be informed, both verbally and in writing, in advance of care being provided, of the charges.” 2. During a home visit on 06/21/2023 at 11:00 AM Patient #4’s admission packet was reviewed. The agency failed to ensure for emergency preparedness, written instruction sheet on safety, explanation of service coverage, and admission consent forms were filled out and in the home. At that time, Registered Nurse (RN) 1 stated the contents of the admission packet should be filled out and was unsure why it was not. 3. During a home visit on 06/21/2023 at 1:30 PM Patient #8’s admission packet was reviewed. The agency failed to ensure for emergency preparedness, written instruction sheet on safety, explanation of service coverage, and admission consent forms were filled out and in the home. 4. During a home visit on 06/22/2023 at 9:45 AM Patient #14’s admission packet was reviewed. The agency failed to ensure for emergency preparedness, written instruction sheet on safety, explanation of service coverage, and admission consent forms were filled out and in the home. At that time, Patient #14 was made aware the contents of the admission packet were not filled out. Patient #14 was asked it the agency provided education or instructions on emergency preparedness to which he/she responded “no”. 5. During an interview on 06/21/2023 at 1:00 PM the Administrator stated that the expectation was for staff to complete the contents of the admission packet, so the patient has a copy of it. 6. During a home visit on 06/22/2023 at 12:00 PM Patient #15’s daughter provided an admission packet, which included a blank medication document. During an interview with License Practical Nurse (LPN) 1, on 06/22/2023 at 12:00 PM, LPN 1 indicated all paperwork in the admission packet for Patient #15 should have been filled out by the admission nurse at time of admission. 7. During an interview with Patient #7’s son, on 6/20/2023 at 3:00 PM, the son confirmed no documentation was provided in admission packet or any time after for cost of service. 8. During an interview on 06/23/23 at 11:16 AM, Alternate Administrator confirmed if the admission nurse fails to fill out documents in the admission packet, the patient received no written instructions from the agency until Plan of Care was locked, which could take up to 30 days before written instructions were mailed to patient.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure standard infection control precautions were followed for 3 of 7 home visit observations. (Patient #7, #9, & #15) Findings include: 1. A 11/03/2023 policy titled Bag Technique was provided by the Alternate Administrator on 06/22/2023 at 9:47 AM. The policy indicated, but was not limited to, “10. Hand hygiene should be performed before entering/re/entering the bag, and before, and after patient and / or equipment contact. 11. Remove necessary items for the visit and keep bag closed during the visit.” 2. A 09/07/2022 policy titled Performing a Bed Bath or Partial Bed Bath was provided on 06/22/2023 at 9:47 AM. The policy indicated, but was not limited to, “ … After a bed bath is performed: … Pertinent observations made during the process, such as skin condition, patient’s needs, outcome, etc. Notification of supervisor for any significant findings.” 3. During a home visit observation on 06/21/2023 at 11:00 AM Registered Nurse (RN 1) failed to perform hand hygiene after removing gloves and before applying new gloves three times during a wound care procedure. 4. During a home visit observation on 06/22/2023 at 9:45 AM Home Health Aide (HHA) 1 cleaned his/her tablet with an alcohol wipe then placed the tablet in a bag wet. The agency failed to ensure the tablet was allowed to air dry before placing it in the bag. During an interview on 06/22/2023 at 4:15 PM the Administrator stated the if equipment was cleaned with an alcohol wipe, the equipment should air dry before placing it in the bag. 410 IAC 17-12-1(m) 5. During a home visit observation on 06/20/2023 at 3:00 PM with Patient #7, Home Health Aide (HHA)1 used an alcohol wipe to clean equipment (blood pressure cuff, thermometer, and oximeter (electronic device that measures the saturation of oxygen carried in your red blood cells). HHA 1 failed to allow equipment to dry per recommendations before placing in nursing bag. HHA 1 left all zipper compartments to supply bag open during entire visit. HHA1 assisted Patient #7 with sponge bath. HHA 1 used wash clothes to clean genitalia area which had been used on other parts of body during sponge bath. HHA 1 was concerned about doing this but had no other wash clothes available. HHA 1 reused one wash cloth to wash and rinse genitalia area. 6. During a home visit observation on 06/21/2023 at 4:42 PM with Patient #9, Registered Nurse (RN) 1 was not consistent with performing hand hygiene with glove change. RN 1 removed gloves from supply bag multiple times; then applied gloves with no hand hygiene performed. All zipper compartments of supply bag were left open during visit; no hand hygiene performed prior or after entering supply bag. 7. During a home visit observation on 06/22/2023 at 12:00 PM with Patient #15, License Practical Nurse (LPN) 1 did not performed hand hygiene after the use of ink pen, and prior to applying gloves. 8. During an interview on 06/22/2023 at 5:08 PM the Alternate Administrator confirmed supply bags should not be left unzipped during home visits. The Alternate Administrator also acknowledged training was provided on bag technique which requires zipper compartments to be left closed except when accessing compartment. Alternate Administrator confirmed equipment (blood pressure cuff, thermometer, and oximeter) should be allowed to dry, per manufactures instructions, prior to returning to supply bag.

HHA maintains documentation of training CFR(s): 484.80(b)(4) The HHA must maintain documentation that demonstrates that the requirements of this standard have been met. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to maintain Home Health Aid (HHA) competency documentation to ensure employee meets qualifications required for job performance for 1 of 7 personnel file review. (HHA 1) The personnel records were provided on 06/22/2023 at 4:44 PM, by Human Resources Director on 06/23/2023. Home Health Aide (HHA)1 had a hire date of 11/04/2019. The employee file was missing test/skills competency documents dated after 11/04/2019. During an interview on 06/26/2023 at 1:09 PM the Human Resources Director confirmed test/skills competency documentation were not available in HHA 1’s personnel records reflecting their hire date of 11/04/2019. 410 IAC 17-14-1(l)(2)

HH aide supervision elements CFR(s): 484.80(h)(4)(i-vi) Home health aide supervision must ensure that aides furnish care in a safe and effective manner, including, but not limited to, the following elements: (i) Following the patient's plan of care for completion of tasks assigned to a home health aide by the registered nurse or other appropriate skilled professional; (ii) Maintaining an open communication process with the patient, representative (if any), caregivers, and family; (iii) Demonstrating competency with assigned tasks; (iv) Complying with infection prevention and control policies and procedures; (v) Reporting changes in the patient's condition; and (vi) Honoring patient rights. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure the home health aide reported skin integrity issues to the nurse, failed to follow the aide plan of care, and failed to follow agency policy on bag technique for 1 of 2 home health aide observations. (HHA 1) Findings include: A 11/03/2023 policy titled Bag Technique was provided by the Alternate Administrator on 06/22/2023 at 9:47 AM. The policy indicated, but was not limited to, “10. Hand hygiene should be performed before entering/re/entering the bag, and before, and after patient and / or equipment contact. 11. Remove necessary items for the visit and keep bag closed during the visit.” A 09/07/2022 policy titled Performing a Bed Bath or Partial Bed Bath was provided on 06/22/2023 at 9:47 AM. The policy indicated, but was not limited to, “ … After a bed bath is performed: … Pertinent observations made during the process, such as skin condition, patient’s needs, outcome, etc. Notification of supervisor for any significant findings.” The clinical record for Patient #14 was reviewed on 6/22/2023 and included an Aide Care Plan Report for the certification period date 06/14/2023 to 8/12/2023. The Aide Plan Report indicated the patient was to receive a sponge bath, shampoo, hair care, skin care, and foot care every visit. During a home visit on 06/22/2023 at 9:45 AM Home Health Aide (HHA) 1 unzipped the bag that contained a tablet, gloves, and hand sanitizer. HHA 1 left the bag unzipped during the home visit. HHA 1 assisted Patient #14 with a sponge bath. Redness under bilateral abdominal folds were observed. HHA 1 instructed Patient #14 to tell the nurse. HHA 1 did not wash Patient 14’s hair or remove the patient’s shoes to wash the feet. After the bath was completed, Patient #14 informed the surveyor HHA 1 knew about the redness last week but thinks he/she forgot to report it to the nurse. Patient #14 stated the aide washes his/her feet and hair every other week. HHA 1 failed to follow agency policy on bag technique, failed to report pertinent observations such as redness on skin, to the nurse and failed to follow the Aide Care Plan Report regarding shampoo, feet, and skin care to be done weekly. During an interview on 06/22/2023 at 4:08 PM the Administrator stated the expectation was for the HHA to follow the bag technique policy and report skin integrity concerns such as redness, to the nurse. The Administrator stated the Aide Care Plan Report should reflect the care provided at the home visit. 410 IAC 17-14-1(n)