Every finding on record at Elder's Journey Home Care of Wabash Valley, Inc

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102. Survey Dates: 12/17/2025 - 12/19/2025 & 12/22/2025 Active Census: 345 At this Emergency Preparedness survey, Elder's Journey was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 484.102

This visit was for a Federal/State complaint survey of a home health provider. Survey Dates: 12/17/2025 - 12/19/2025 & 12/22/2025 Complaint: 2685823 with unrelated deficiencies Complaint: 2684165 with related and unrelated deficiencies 12 Month Unduplicated Skilled Admissions: 82 A fully extended survey was announced on 12/18/2025. An Immediate Jeopardy related to §484.105 Organization and Administration of Services was identified and announced on 12/19/2025 at 1:20 PM. The immediate jeopardy began on 06/27/2025 when a home health aide failed to immediately contact emergency services upon a patient becoming unresponsive. The agency’s immediate jeopardy removal of the immediacy plan and actions were determined to have removed the immediacy component of the immediate jeopardy on 12/22/2025 at 12:05 PM. During this Federal Complaint Survey, Elder's Journey was found to be out of compliance with Conditions of Participation 42 CFR §484.105 Organization and Administration of Services and 42 CFR §484.65 Quality Assessment and Performance Improvement. Based on the Condition-level deficiencies identified during the 12/22/2025 survey, your home health agency was subject to an extended survey pursuant to section 1891(c)(2)(D) of the Social Security Act, on 12/18/2025. Therefore, and pursuant to section 1891(a)(3)(D)(iii) of the Act, your agency is precluded from operating or being the site of a home health aide training and/or competency evaluation programs for two years beginning 12/22/2025 and continuing through 12/21/2027. This deficiency report reflects State Findings cited in accordance with 410 IAC 17. QR Completed on 01/05/2025 by A4JG

Make complaints to the HHA CFR(s): 484.50(c)(3) Make complaints to the HHA regarding treatment or care that is (or fails to be) furnished, and the lack of respect for property and/or person by anyone who is furnishing services on behalf of the HHA; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to implement its grievance and complaint procedures, resulting in missing, incomplete, and untimely documentation of complaint investigations and outcomes for 205 of 208 complaints filed in 2025. Findings include: An undated policy titled "Client/Family Complaint/Grievance Policy" indicates that the assigned director documents the complaint/grievance on the client grievance/complaint form. The policy states the assigned director makes every effort to review and respond within seven calendar days, but no longer than thirty calendar days. The director completes the complaint form and combines it with the original resolution letter sent to the complainant, plus any additional documents related to the complaint, and provides it to the Administrator for QAPI. An undated document titled “Client Grievance/Complaint Form” indicates staff must provide a written response within 15 days, and the complainant has 30 days to appeal. Complaint intake documentation evidenced the receipt of 208 complaints from 01/02/2025 through 12/19/2025. The documentation failed to show the agency followed its complaint and grievance procedures for 205 of the 208 complaints received. During an interview on 12/22/2025 at 10:58 AM, the Performance Improvement Coordinator, with the Administrator present, stated she had no complaints with completed resolutions from the past six months. She reported that the type of complaint affects how long a complaint remains open. The Coordinator provided a 3‑ring binder containing one complaint form and an undated, untitled document placed in the front pocket. The Administrator stated the single complaint form in the binder was an example of the grievance packet she signs after staff complete a grievance. She confirmed staff had not completed all 2025 complaints and had not placed any 2025 grievance forms in the binder. The Administrator also confirmed the undated, untitled document in the front pocket was a list of all open grievances for 2025 and verified that staff had completed only three grievances from 01/02/2025 to the interview date. 410 IAC 17-12-3(b)(2)(B)

Within 48 hours of the patient's return CFR(s): 484.55(d)(2) Within 48 hours of the patient's return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure a skilled nursing reassessment was completed on the physician-ordered resumption date prior to the resumption of home health services for 1 of 5 active records reviewed. (Patient #5) Findings Include: An undated policy titled “Client Reassessment / Update of Comprehensive Assessment” requires reassessment when there is a change in the patient’s condition and when services are resumed following a hold. A review of Patient #5's record evidenced the following: A 09/18/2025 order indicated services were placed on hold due to a Medicare episode with another agency. On 10/13/2025, a physician order was issued to resume home health services following the end of a Medicare episode with another agency. On 10/14/2025, home health aide services were resumed. The clinical record contained no evidence that a skilled nursing reassessment was completed on or prior to the ordered resumption date. During an interview on 12/19/2025 at 11:14 AM, the Director of Clinical Services confirmed that a skilled nursing reassessment should have been completed prior to the resumption of services and acknowledged that it was not performed.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review and interview, the agency provided home health services without a physician-signed plan of care or a detailed, patient-specific verbal order for 3 of 6 non-skilled patient records reviewed. ( Patients #1, #5, and #6) Findings include: 2. A review of Patient #1's record evidenced the following: A "Home Health Plan of Care & Certification" with a SOC date of 09/12/2025 for the certification period 09/12/2025 to 11/10/2025, signed by the physician on 12/17/2025. A 09/11/2025 "v.o. SOC" indicating "Start of Care visit completed. Elders' Journey to continue Current plan of care until updated care plan is signed per MD", signed by MD on 09/16/2025 A "Home Health Plan of Care & Certification" with a start of care date of 09/12/2025 for the certification period from 11/11/2025 to 01/09/2025 was signed by a physician on 12/17/2025. A 11/06//2025 "v.o. recert" indicating Recertification visit completed. Elders' Journey to continue the current plan of care until the updated care plan is signed per the MD. Emergency Preparedness Plan reviewed with the following changes: no changes", signed by Physician on 12/17/2025 The agency provided HHA services without a physician-signed detailed verbal order or signed POC from 09/12/2025 to 11/10/2025 and from 11/11/2025 to 12/17/2025. During an interview on 12/19/2025 at 11:14 AM, the Director of Clinical Services reviewed Patient #1's record and confirmed that Patient #1's start of care date is 09/12/2025, the first episode dates are 09/12/2025 to 11/10/2025, and the Physician signed the POC on 12/17/2025. She also confirmed the second episode dates are 11/11/2025 to 01/09/2025, and the Physician signed recertifications POC on 12/17/2025. The Director of Clinical Services confirmed the POC is the order the agency uses to provide care to the patients. She verified that the SOC and Recert verbal orders in Patient #1's chart are the same general verbal order used for all patients; no detailed verbal order will be found in the patient's charts. There are no detailed verbal orders to describe the care the agency will provide until POC is signed by the physician. 410 IAC 17-13-1(a) 1. An undated policy titled "Plan of Care" indicated that the agency develops an individualized POC signed by the physicians for each patient receiving services. 2. JM 3. A review of Patient #5's record evidenced the following: A "Home Health Plan of Care & Certification" with a SOC date 09/09/2025 for the certification period 09/09/2025 to 11/07/2025 was signed by the physician on 11/14/2025. The agency provided HHA services without a physician-signed verbal order or signed POC from 09/09/2025 to 09/18/2025 and from 10/14/2025 to 11/14/2025. A 09/11/2025 "V.O. SOC" indicated the agency completed the SOC visit and to continue the current plan of care until the physician signs it. The agency held services from 09/18/2025 to 10/13/2025 due to a hospital visit and a Medicare episode with another agency. A 10/13/2025 "HHA Order" indicated the agency could resume services. During an interview on 12/19/2025 at 11:14 AM, the Director of Clinical Services confirmed that staff did not obtain a detailed verbal order or signed POC before providing services. 4. A review of Patient #6's record evidenced the following: A "Home Health Plan of Care & Certification" with a SOC date 10/08/2025 for the certification period 10/08/2025 to 12/06/2025 was signed by the physician on 12/01/2025. The agency provided HHA services without a physician-signed verbal order or signed POC from 10/08/2025 to 12/01/2025. A 10/11/2025 "V.O. SOC" order indicated the agency completed the SOC visit and to continue the current POC until the physician signs it. During an interview on 12/19/2025 at 11:14 AM, the Director of Clinical Services stated that the agency completes an initial visit but does not start services until the PA (prior authorization) is approved. Once the PA was approved, the nurse obtained a verbal order to resume services as indicated in the "Home Health Certification and Plan of Care" developed during the initial visit. Once PA was approved, she stated that the "Home Health Plan of Care & Certification" was then developed, serving as the official SOC, and sent to the physician for signature. 1. An agency policy titled “Plan of Care” indicates the agency is responsible for ensuring that each patient has an individualized plan of care that is signed by the physician prior to or contemporaneous with the provision of services, and that all services are provided in accordance with that plan of care or an authorized detailed verbal orders prior to physician signature of the plan of care. 2. A review of Patient #1's record evidenced the following: A 12/17/2025 physician signed Home Health Plan of Care & Certification with a start‑of‑care date of 09/12/2025 for the certification period 09/12/2025–11/10/2025. A verbal order dated 09/11/2025 directed continuation of the current plan of care until physician signature; however, it also lacked patient‑specific detail regarding authorized services, frequencies, or disciplines. A 2025 visit calendar evidencing home health visits were provided on 09/12, 09/16, 09/17, 09/18, 09/19, 09/22–09/25, 10/01, 10/03, 10/08, 10/09, 10/14, 10/15, 10/16, 10/17, 10/20, 10/21, 10/24, 10/29, and 11/03–11/07 prior to obtaining a physician‑signed plan of care or a complete, patient‑specific verbal order authorizing services. A subsequent 12/17/2025 physician signed Home Health Plan of Care & Certification for the certification period 11/11/2025–01/09/2026. A verbal order dated 11/06/2025 directed continuation of the current plan of care until physician signature; however, it also lacked patient‑specific detail regarding authorized services, frequencies, or disciplines. A 2025 visit calendar evidencing home health visits were provided on 11/11-11/14, 11/19-11/21, 11/24, 11/26, 11/28, 12/04-12/05, 12/09-12/12, and 12/15-12/16 prior to obtaining a physician‑signed plan of care or a complete, patient‑specific verbal order authorizing services. During interview, the Director of Clinical Services confirmed that the same verbal order used for Patient #1 are used for all patients and that no patient‑specific verbal orders are obtained prior to physician signature of the plan of care. 3. A review of Patient #5's record evidenced the following: A 11/14/2025 physician‑signed Home Health Plan of Care & Certification with a start‑of‑care date of 09/09/2025 for the certification period 09/09/2025–11/07/2025. A verbal order dated 09/11/2025 directed continuation of the current plan of care until physician signature; however, it lacked patient‑specific detail regarding authorized services, frequencies, or disciplines. A 2025 visit calendar evidencing home health aide visits were provided on 09/09–09/11, 09/14–09/18, 10/14–10/17, 10/20–10/24, 10/27–10/31, 11/03–11/05, 11/10–11/14, 11/17–11/21, and 11/24–11/27 prior to obtaining a physician‑signed plan of care or a complete, patient‑specific verbal order authorizing services. During an interview on 12/19/2025 at 11:14 AM, the Director of Clinical Services confirmed that staff did not obtain a detailed, patient‑specific verbal order or a signed plan of care before providing services. 4. A review of Patient #6's record evidenced the following: A 12/01/2025 physician‑signed Home Health Plan of Care & Certification with a start‑of‑care date of 10/08/2025 for the certification period 10/08/2025–12/06/2025. A verbal order dated 10/11/2025 directed continuation of the current plan of care until physician signature; however, it lacked patient‑specific detail regarding authorized services, frequencies, or disciplines. A 2025 visit calendar evidencing home health aide visits were provided on 10/08, 10/13–10/17, 10/20–10/24, 10/27–10/31, and 11/03–11/05 prior to obtaining a physician‑signed plan of care or a complete, patient‑specific verbal order authorizing services. During an interview on 12/19/2025 at 11:14 AM, the Director of Clinical Services stated the agency completes an initial visit but does not begin services until prior authorization (PA) is approved. She explained that once PA is approved, the nurse obtains a verbal order to resume services based on the plan of care developed at the initial visit. She further stated that after PA approval, the “Home Health Plan of Care & Certification” is created as the official start‑of‑care document and sent to the physician for signature. 410 IAC 17-13-1(a)

Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA's governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA's performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This CONDITION is not met as evidenced by: Based on record review and interview the agency failed to use the QAPI program to identify, analyze, and correct repeated and systemic deficiencies. Findings include: Review of an undated agency policy titled “Quality Assessment and Performance Improvement Program” indicated the agency is responsible for ongoing measurement, analysis, and improvement of quality indicators, including patient complaints, clinical care processes, and service delivery outcomes, and for implementing corrective actions to address identified problem areas. Review of agency records revealed the agency received 208 complaints, of which only 3 complaints had documented investigation and resolution, leaving 205 complaints without evidence of review, follow-up, or written response. There was no evidence the agency tracked or trended complaint data, analyzed complaint themes, or incorporated complaint outcomes into QAPI activities. Further review of clinical records identified repeated deficiencies across multiple patients, including provision of home health services without a physician-signed plan of care or a detailed, patient-specific verbal order (Patients #1, #5, and #6) and failure to complete skilled nursing reassessments prior to resumption of services (Patient #5). These deficiencies were identified in at least three sampled patient records and occurred over extended periods of time, demonstrating ongoing noncompliance rather than isolated incidents. Despite the volume and recurrence of these issues, the agency was unable to provide documentation demonstrating that reassessment compliance, plan-of-care authorization, or clinical oversight were monitored as quality indicators, that root cause analyses were conducted, or that corrective actions were implemented and evaluated for effectiveness through the QAPI program During an interview on 12/22/2025 at 10:58 AM, the Performance Improvement Coordinator, with the Administrator present, stated she had no complaints with completed resolutions from the past six months. She reported that the type of complaint affects how long a complaint remains open. The Coordinator provided a 3‑ring binder containing one complaint form and an undated, untitled document placed in the front pocket. The Administrator stated the single complaint form in the binder was an example of the grievance packet she signs after staff complete a grievance. She confirmed staff had not completed all 2025 complaints and had not placed any 2025 grievance forms in the binder. The Administrator also confirmed the undated, untitled document in the front pocket was a list of all open grievances for 2025 and verified that staff had completed only three grievances from 01/02/2025 to the interview date. As a result, the agency failed to use its QAPI program to identify patterns of noncompliance, implement corrective actions, and prevent the continuation of systemic deficiencies affecting patient care and safety.410 IAC 17-12-2(a)

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 follow infection control practices, including required hand hygiene, during 1 of 2 home visits. (Patient #7) Findings include: The agency’s “Handwashing/Hand Hygiene” policy (D‑330) states that handwashing or hand antisepsis is required between tasks on the same patient and after removing gloves. During a home visit on 12/19/2025 at 10:30 AM with Patient #7, RN #3 removed her gloves and reached into the clean supply drawer for gauze without performing hand hygiene. During an interview on 12/19/2025 at 11:15 AM, RN #3 stated that hand hygiene should be performed before and after touching a patient, before applying gloves, after removing gloves, and before accessing her nursing bag. 410 IAC 17‑12‑1(m)

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure home health aides performed services permitted under Indiana state law and consistent with home health aide training for 1 of 2 closed records reviewed (HHA 3). Findings include: Review of the policy titled “Home Health Aide Services” indicated its purpose was “to abide by state/federal guidelines and offer guidelines to the agency staff, physicians, and communication for the appropriate utilization of Home Health Aide services…” Review of Patient #4’s clinical record for the certification period 05/13/2025–07/11/2025 included emergency room documentation from Entity 1. The record showed the patient arrived to the emergency room after home health services contacted EMS to report the patient was unresponsive with a blood sugar level of 20 mg/dL and had been given chocolate ice cream by the individual who found the patient. The patient was intubated on arrival due to aspiration of chocolate ice cream. The report documented copious amounts of brown watery liquid suctioned from the patient’s trachea. A document titled “Patient Communication Log” evidenced the agency’s investigation of the incident. The document indicated that on 06/27/2025, HHA #3 reported entering Patient #4’s home and finding the patient struggling to breathe and talk. The aide assisted the patient in checking his/her blood sugar, which was 22 mg/dL. To raise the patient’s blood sugar, the aide fed the patient two bites of soft/soupy ice cream, which the patient swallowed, and then called 911. The aide also reported that the neighbor’s caregiver came to the home and stated the neighbor had been concerned and had checked on the patient earlier. During an interview on 12/17/2025 at 3:18 PM, HHA #3 stated that upon entering the home on 06/27/2025, the patient was “responsive, but not responsive,” and was struggling to talk and breathe. The aide reported panicking, checking the patient’s blood sugar (22 mg/dL), and giving the patient melted ice cream because he/she believed something was needed to raise the blood sugar. The aide stated the patient swallowed the ice cream. HHA #3 reported calling the office to report the patient’s condition and then calling 911 after being advised to do so by the nurse. The aide stated EMS arrived approximately five minutes later but could not recall whether EMS rechecked the patient’s blood sugar. The aide stated the neighbor’s caregiver also came over and reported concern earlier in the day. HHA #3 stated the agency trained aides to call 911 and the office but was unsure which should be called first. The aide stated there was no guidance on the aide plan of care regarding emergency procedures, that the plan of care on the phone contained limited information, and that the agency did not train aides to check blood sugars or treat low blood sugar. The aide stated he/she panicked and would respond differently if the situation occurred again. During an interview on 12/18/2025 at 10:12 AM, the Director of Clinical Services stated home health aides are trained to call 911 first when patients experience airway, breathing, or circulation issues, and then call the office. She reported speaking with RN #2, who received the call from HHA #3 on 06/27/2025. RN #2 reported that HHA #3 did not state the patient was unresponsive, only lethargic, and did not report obtaining a blood sugar reading at the time of the call. RN #2 advised the aide to call 911 based on the reported lethargy. 410 IAC 17-14-1(h)(1)-(14)

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure effective organization and administration of patient care services. Specifically, the agency failed to ensure clinical management oversight of patient care services and personnel (see Tag G0958); failed to coordinate patient care to ensure consistent communication and guidance among staff involved in patient care (see Tag G0962); failed to assure that patient needs were continually assessed, including completion of skilled reassessments prior to resumption of services (see Tag G0966); and failed to assure the development, implementation, and updating of individualized plans of care, including ensuring services were provided only in accordance with valid physician orders or detailed, patient-specific verbal orders (see Tag G0968). An immediate jeopardy related to Condition of Participation §484.105: Organization and Administration of Services was identified and announced on 12/19/2025 at 1:20 PM. The immediate jeopardy began on 06/27/2025 when a home health aide failed to immediately contact emergency services upon a patient becoming unresponsive. The agency’s first immediate jeopardy removal of the immediacy plan and actions were determined to have removed the immediacy component of the immediate jeopardy on 12/22/2025 at 12:05 PM The cumulative effect of this problem resulted in being out of compliance with Condition of Participation §484.105 Organization and Administration of Services and has the likelihood to affect all current patients receiving services from this provider. Findings include: 1. According to the “Home Health Aide Care Plan” policy (C-751), the home health aide cannot be responsible for performing any procedures that is not assigned to him/her in writing by the registered Nurse/Therapist or that is beyond his/her ability. Prior to initiating care, the Home Health Aide shall be oriented by the Registered Nurse/Therapist to the client’s care needs and shall be updated on modifications or changes in the client’s care. 2. According to the “Competency Evaluation of Home Care Staff” policy (D-220), the Home Health Aide will have successfully completed the competency evaluation program if he/she demonstrates competency required in federal guidelines to include: basic elements of body functioning and changes in body function that must be reported to the Home Health Aide supervisor and recognizing emergencies and knowledge of instituting emergency procedures. 3. According to the “Home Health Aide Services” policy (C-220), the agency is responsible for training home health aide, as needed, for skills not covered in the basic checklist. The aide will follow the care plan and will not initiate new services or discontinue services without contacting the supervising nurse or therapist. 4. A document titled "EMS Call", indicated that HHA 3 called the agency on 06/27/2025 at 12:00 PM to report Patient #4 was lethargic. HHA 3 was instructed to call EMS. 5. An untitled document from Entity #2, dated 06/27/2025, indicated that EMS was contacted around 12:30 PM after Patient #4 was found unresponsive with a blood glucose level of 20 mg/dL. 6. An untitled document from Entity #2, dated 06/27/2025, indicated that Patient #4 arrived in the ER unresponsive, being bagged, and had brown-colored liquid was being suctioned out of the airway. 7. A document titled "Attention-Action Required 8/25" and dated 08/12/2025 indicated a mandatory in-service that was sent out to employees regarding CPR Reminders and Emergency Preparedness Event due by 08/29/2025. 8. A personnel record review for HHA #3, date of hire 12/09/2025, evidenced a document titled "Home Health Aide/Hospice Aide Competency Checklist" that indicated HHA #3 met requirements in recognizing emergency situations via oral answer. 9. During an interview on 12/17/2025 at 3:18 PM, HHA 3 indicated on 06/27/2025: I walked into the patient’s (Patient #4) home where I found him responsive, but not responsive, he was trying and struggling to talk and breathe. I panicked and checked his blood sugar, it was 22. I gave him some melted ice cream because I knew I needed to raise his blood sugar up, and he swallowed it. I called the office to report and then called 911 after talking to the nurse at the office. I think the EMS arrived about 5 minutes after the call, I can’t remember exactly and I don’t remember if they rechecked his blood sugar. The patient’s neighbor’s caregiver came over to check on the patient and said the neighbor was worried about him earlier. The agency trained me to call 911 and the office both, I’m not sure if they want me to call 911 first or not, the caregiver for the patient’s neighbor said to call 911. There is no guidance on the aide plan of care for what to do in emergency situations, I see it on my phone, it doesn’t give much info, I find my assigned tasks on there. The agency did not train me to check blood sugars or how to treat low blood sugar. I panicked and would not panic if I had to do it all over again. 10. During an interview on 12/18/2025 at 8:11 AM, RN 1 (case manager Patient #4), indicated during aide supervisory visits, HHA 3 appeared to know what she was doing when taking care of Patient #4. RN 1 indicated completing onsite supervisory visits with observation of HHA 3 performing assigned tasks for Patient #4 and the patient never voiced concerned about HHA 3 and was satisfied with the care provided. She indicated HHA 3 was involved in a similar situation with Patient #4 a couple of weeks prior to the 06/27/2025 incident when HHA 3 reported finding the patient with increased confusion due to hypoglycemia and the HHA 3 called 911 during that episode without any issues. After the 911 call the patient was hospitalized at the beginning of June and multiple order changes and communications with Patient #4’s primary physician ensued. The patient refused to continue to take the ordered Tresiba after the first hypoglycemic episode at the beginning of June 2025. RN 1 indicated the patient was often noncompliant and often overate, i.e. had eaten 6 large cinnamon rolls at one time and caused hyperglycemia before. RN 1 indicated the agency did not inform her of the required timeframes for aide supervisory visits, they add them to her schedule and she completes them. RN 1 indicated she often educated HHA 3 that due to the patient’s noncompliance, there was a higher probability that she would need to call 911 for his health and when or when not to feed a patient experiencing hypoglycemia. 11. During an interview on 12/18/2025 at 9:40 AM, HHA 3 indicated the agency trained her on hypoglycemia recognition and management by providing in-services and that fast carbs should be provided, recheck blood sugar within 15 minutes and follow with some juice or a snack. HHA 3 indicated she called 911 for a previous episode of hypoglycemia Patient #4 experienced at the beginning of June 2025 but couldn’t provide more details as she didn’t quite remember the details because a lot has happened since then. 12. During an interview on 12/18/2025 at 10:12 AM, the Administrator indicated home health aides are trained to call 911 in emergencies, if medical such as unresponsive, trouble breathing. The Director of Clinical Services added, aides are trained to call 911 if patients are experiencing trouble with airway, breathing, and/or circulation, aides should call 911 first and then call the office to report. The Director of Clinical Services indicated she spoke with the nurse (J. Price RN) who received the call from HHA 3 on 06/27/2025 related to Patient #4’s medical emergency, and the nurse indicated HHA 3 did not report Patient #4 as unresponsive, only lethargic, and no indication the patient’s blood sugar reading was collected at the time the aide called the office; the RN then advised the aide to call 911 due to the reported lethargy. 13. During an interview on 12/18/2025 at 1:04 PM, the Education Nurse indicated that competency training on emergency situations depends on if it is the initial or annual training. She would give a situation and ask how the employee would respond or ask the employee what their definition is of an emergency. Employees are taught to call 911 immediately for instances like chest pain, unresponsiveness, and difficulty breathing, then call the office and updated the office.

Clinical manager CFR(s): 484.105(c) Standard: Clinical manager. One or more qualified individuals must provide oversight of all patient care services and personnel. Oversight must include the following-- This STANDARD is not met as evidenced by: Based on record review and interviews, the agency failed to ensure oversight of patient care services and personnel, resulting in a home health aide performing tasks outside the scope of practice, inadequate supervision, inconsistent emergency response practices, and a serious adverse patient event. Findings include: Review of the policy titled “Home Health Aide Care Plan” indicated aides may not perform procedures not assigned in writing and must be oriented to the patient’s care needs.Review of the policy titled “Competency Evaluation of Home Care Staff” indicated aides must demonstrate competency in recognizing emergencies and initiating emergency procedures. Review of the policy titled “Home Health Aide Services” indicated aides must follow the care plan and may not initiate or discontinue services without contacting the supervising nurse. A Review of HHA #3’s personnel file showed documentation of competency in emergency recognition; however, the aide’s actions during the 06/27/2025 event were inconsistent with agency policy and documented competencies .A review of Patient #1's record evidenced the following: A verbal order dated 11/06/2025 directed continuation of the current plan of care until physician signature; however, it also lacked patient‑specific detail regarding authorized services, frequencies, or disciplines. A review of Patient #5's record evidenced the following: A verbal order dated 09/11/2025 directed continuation of the current plan of care until physician signature; however, it lacked patient‑specific detail regarding authorized services, frequencies, or disciplines. A review of Patient #6's record evidenced the following: A verbal order dated 10/11/2025 directed continuation of the current plan of care until physician signature; however, it lacked patient‑specific detail regarding authorized services, frequencies, or disciplines. A review of Patient #4's record evidenced the following: EMS documentation dated 06/27/2025 showed Patient #4 was found unresponsive with a blood glucose level of 20 mg/dL and had been fed chocolate ice cream, resulting in aspiration and intubation. Review of the agency’s investigation documented that HHA #3 checked Patient #4’s blood sugar (22 mg/dL), fed the patient melted ice cream, and then called 911.During an interview on 12/17/2025 at 3:18 PM, HHA #3 stated she panicked, was unsure whether to call 911 first, and was not trained to check blood sugars or treat hypoglycemia. During an interview on 12/18/2025 at 8:11 AM, RN #1 reported HHA #3 had previously encountered a similar hypoglycemic episode earlier in June but received no additional training or supervision following that event. During an interview on 12/18/2025 at 10:12 AM, the Director of Clinical Services stated aides are trained to call 911 first in emergencies; however, RN #2 reported HHA #3 did not report the patient as unresponsive or provide a blood sugar reading during the call on 06/27/2025. During interview on 12/19/2025 at 11:14 AM, the Director of Clinical Services confirmed that the agency uses the plan of care as the order for services and does not obtain detailed, patient-specific verbal orders prior to physician signature. As a result, the agency failed to assure that services were implemented in accordance with an individualized and authorized plan of care.410 IAC 17-14-1-(a)(1)(K)

Coordinate patient care CFR(s): 484.105(c)(2) Coordinating patient care, This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to coordinate patient care for 1 of 2 closed records reviewed (Patient #4). Findings Include: During an interview on 12/18/2025 at 8:11 AM, RN 1 stated she was not informed of required supervisory visit timeframes and relied on the agency to schedule them. Review of the aide plan of care showed limited information regarding the patient’s diabetes management, despite the patient’s repeated hypoglycemic episodes and known instability. During an interview on 12/18/2025 at 10:12 AM, the Director of Clinical Services stated aides are trained to call 911 first in emergencies; however, RN 2 reported HHA 3 did not provide critical information during the call on 06/27/2025, including the patient’s blood sugar reading or unresponsiveness. During an interview on 12/17/2025 at 3:18 PM, HHA 3 stated she was unsure whether to call 911 or the office first and received inconsistent guidance.

Assure patient needs are continually assessed CFR(s): 484.105(c)(4) Assuring that patient needs are continually assessed, and This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to assure that patient needs were continually assessed for 1 of 6 active records reviewed. (Patient #5) Findings Include: Review of an undated agency policy titled “Client Reassessment / Update of Comprehensive Assessment” indicated that the agency is responsible for reassessing patients when there is a change in condition and when services are resumed following a hold. Review of Patient #5’s clinical record revealed home health services were placed on hold and later resumed by physician order. The clinical record contained no evidence that a skilled nursing reassessment was completed on or prior to the resumption of services. As a result, the patient’s current condition, needs, and appropriateness for continued services were not evaluated prior to care being resumed. During interview on 12/19/2025 at 11:14 AM, the Director of Clinical Services confirmed that a skilled nursing reassessment should have been completed prior to the resumption of services and acknowledged that the reassessment was not performed.

Assure implementation of plan of care CFR(s): 484.105(c)(5) Assuring the development, implementation, and updates of the individualized plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to assure the development, implementation, and updating of individualized plans of care for 4 of 8 records reviewed. (Patients #1, #4, #5, and #6) Findings include: Review of an undated agency policy titled “Plan of Care” indicated that the agency is responsible for developing an individualized plan of care for each patient and ensuring services are provided in accordance with a physician-signed plan of care or authorized verbal orders. A review of Patient #1's record evidenced the following: A 2025 visit calendar evidencing home health visits were provided on 09/12, 09/16, 09/17, 09/18, 09/19, 09/22–09/25, 10/01, 10/03, 10/08, 10/09, 10/14, 10/15, 10/16, 10/17, 10/20, 10/21, 10/24, 10/29, and 11/03–11/07 prior to obtaining a physician‑signed plan of care or a complete, patient‑specific verbal order authorizing services. A 2025 visit calendar evidencing home health visits were provided on 11/11-11/14, 11/19-11/21, 11/24, 11/26, 11/28, 12/04-12/05, 12/09-12/12, and 12/15-12/16 prior to obtaining a physician‑signed plan of care or a complete, patient‑specific verbal order authorizing services. During an interview, the Director of Clinical Services confirmed that the same verbal order used for Patient #1 are used for all patients and that no patient‑specific verbal orders are obtained prior to physician signature of the plan of care. A review of Patient #4's record evidenced the following: An agency investigation document indicating that HHA #3 checked the patient’s blood sugar and administered melted ice cream, tasks not included in the aide plan of care and not assigned by the supervising nurse. An aide plan of care for the certification period of 05/13/2025-07/11/2025 showed no instructions for hypoglycemia management, emergency procedures, or recognition of changes in condition, with the patient’s known history of unstable blood glucose. During an interview on 12/17/2025 at 3:18 PM, HHA #3 stated she relied on her own judgment because the aide plan of care “didn’t give much information” and did not include instructions for emergency response. During an interview on 12/18/2025 at 8:11 AM, RN #1 stated she relied on the aide’s judgment and did not update the plan of care after the patient’s earlier hypoglycemic episode.A review of Patient #5's record evidenced the following: A 2025 visit calendar evidencing home health aide visits were provided on 09/09–09/11, 09/14–09/18, 10/14–10/17, 10/20–10/24, 10/27–10/31, 11/03–11/05, 11/10–11/14, 11/17–11/21, and 11/24–11/27 prior to obtaining a physician‑signed plan of care or a complete, patient‑specific verbal order authorizing services. During an interview on 12/19/2025 at 11:14 AM, the Director of Clinical Services confirmed that staff did not obtain a detailed, patient‑specific verbal order or a signed plan of care before providing services. A review of Patient #6's record evidenced the following: A 2025 visit calendar evidencing home health aide visits were provided on 10/08, 10/13–10/17, 10/20–10/24, 10/27–10/31, and 11/03–11/05 prior to obtaining a physician‑signed plan of care or a complete, patient‑specific verbal order authorizing services. During an interview on 12/19/2025 at 11:14 AM, the Director of Clinical Services confirmed that the agency uses the plan of care as the order for services and does not obtain detailed, patient-specific verbal orders prior to physician signature. As a result, the agency failed to ensure that services were implemented in accordance with an individualized and authorized plan of care.

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102 Survey Dates: 06/05/2023 - 06/08/2023 Active Census: 362 At this Emergency Preparedness survey, Elders Journey Home care was not found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 484.102

Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [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 [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to provide guidance in the agency’s emergency preparedness plan on the use of volunteers during a disaster for 1 of 1 emergency preparedness review. Findings include: 1. An undated policy titled Emergency Preparedness Management Policy was provided by the Administrator on 06/07/2023 at 3:20 PM. The policy did not indicate how or if the agency would use volunteers during a disaster. 2. On 06/07/2023 at 2:40 PM, the Performance Improvement Manager confirmed, the agency would use volunteers during a disaster. 3. On 06/08/2023 at 11:50 AM, the Administrator indicated the use of volunteers by having Indiana State Police check on patients during active disaster on 03/31/2023. On 06/08/2023 at 12:15 PM, the Administrator indicated no volunteers would be used due to concerns regarding Health Insurance Portability and Accountability Act (HIPPA).

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 test the emergency preparedness plan annually for 1 of 1 emergency preparedness plan reviewed. Findings include: An undated policy titled Emergency Preparedness Management Police was provided by the Administrator on 06/07/2023 at 3:20 PM. The policy indicated, but was not limited to,” (… 2. All staff members will be oriented to the emergency management plan and their associated responsibilities. Reviews will be held at least annually. … Agency staff members will participate in an annual desktop drill to determine the effectiveness and efficiency of the current plan and any forms developed for use in a disaster.” An undated policy titled Emergency Disaster Plan Orientation and Training was provided by the Administrator on 06/07/2023 at 3:20 PM. The policy indicated, but was not limited to, “… 3. Emergency Disaster Preparedness Training will be provided at least annually. The agency will maintain documentation of all Emergency Disaster Preparedness Training provided.” On 06/08/2023 at 11:50 AM, the Performance Improvement Manager confirmed the agency did not perform annual exercise to test emergency plan.

This visit was for Federal Recertification and State Re-Licensure survey of a Home Health Provider Survey Dates: 06/05/2023 - 06/08/2023 12 Month Unduplicated Skilled Admissions: 578 Partially Extended Survey Announced 06/06/2023 at 4:25 PM. These deficiencies reflect State findings in accordance with 410 IAC 17 QR Completed on 6/19/2023 by A4

Written notice within 4 business days CFR(s): 484.50(a)(4) Provide written notice of the patient's rights and responsibilities under this rule and the HHA's transfer and discharge policies as set forth in paragraph (d) of this section to a patient-selected representative within 4 business days of the initial evaluation visit. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure patients were provided a written copy of the agency discharge and transfer policies for 5 of 5 record reviews with home visits, potentially affecting all 362 active patients. (Patients #5, #6, #7, #8, #9) Findings include: 1. An undated policy titled Client Discharge Process was provided on 06/05/2023 at 4:25 PM. The policy indicated, but was not limited to, “Policy … Purpose … Discharge Criteria …2. Criteria for transferring …” 2. On 06/05/2023 and 06/06/2023 home visits were conducted with Patients #5, #6, #7, #8, and #9. Review of the admission packet failed to include a copy of the agency’s discharge and transfer policy as required by federal regulation §484.50(a)(4). 3. During an interview on 06/08/2023 at 9:00 AM the Administrator stated the patients do not receive a written copy of the Client Discharge Process policy.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure all medication and treatments were listed on the current plan of care for 1 of 2 skilled nursing observations. (Patient #5) Findings include: An undated policy titled Plan of Care was provided by the Administrator on 06/07/2023 at 11:10 AM. The policy indicated, but was not limited to, “2. The Plan of Care shall be completed in full to include: … l. Medications, treatments, and procedures. m. Medical supplies and equipment required. … t. other appropriate items. … u. All of the above items must always be addressed in the Plan of Care. … 3. … The physician shall be consulted to approve additions or modifications to the original plan. … 10. Professional staff shall promptly alert the physician to any changes that suggest a need to alter the Plan of Care.” During a home visit observation on 06/06/2023 at 9:45 AM Registered Nurse (RN) 1 performed a medication set-up for Patient #5. Home Health Aide (HHA) 3 and Patient #5 stated he/she had been taking Melatonin 10 milligrams (mg) as a sleep aid and Aleve for pain relief for a couple of weeks. Review of the plan of care and medication list did not include the medication nor did RN 1 have it recorded in the electronic tablet. The agency failed to ensure all medications were up to date on the plan of care.

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 provide written documentation of future scheduled discipline visits or an updated medication list for 2 of 5 home visits. (Patient #8 and #9) Findings include: 1. An undated document titled Patient Bill of Rights was provided on 06/05/2023 at 10:30 AM, by General Manager. The document indicated, but was not limited to, “… (i)… (2) … (D) Be informed about the care to be furnished and of any change in the care to be furnished as follows: … (BB) frequency of visits proposed to be furnished … (ii) …(BB) Changes in the care or treatment. 2. During an interview with Patient #8’s mother on 06/06/2023 at 9:00 AM, the mother indicated the agency had not provided her a calendar of the next scheduled nursing visit. Patient #8's mother did not know date of next nursing visit. Mother was unable to provided current medication list from agency. 3. During an interview with License Practical Nurse (LPN) 1, on 06/06/2023 at 11:08 AM, LPN 1 was not able to produce any form of written documentation from agency while in the home of Patient #9. LPN 1 revealed she had requested twice, a new plan of care from the office, but it was not provided. LPN 1 nor patient #9 were able to locate written agency instructions in home.

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 regarding bag technique for 1 of 2 skilled nursing home observations (LPN 1); failed to ensure standard infection control precautions were followed regarding showering for 2 of 2 home health aide observations (HHA 1, HHA 2); failed to ensure hand hygiene was performed after glove removal for 3 of 5 home visit observations (HHA 1, HHA 2, RN 1): and failed to follow manufacturer's instructions on disinfecting equipment for 2 of 5 home visit observations. (RN 1, LPN 1) Findings include: 8. On 06/06/2023 at 11:08 AM, Licensed Practical Nurse (LPN) 1 was observed during a home visit with Patient #9. LPN 1 changed gloves multiple times while in Patient #9’s home: hand hygiene was not performed between each glove change. 9. On 06/06/2023 at 11:08 AM, LPN 1 was observed during a home visit with Patient #9. LPN 1 placed a clip board and equipment bag on the floor at patient #9’s feet. There was no barrier used between LPN 1’s items and the floor. 10. During an interview on 06/07/2023 at 2:50 PM the Administrator indicated if the nurse is unable to hang nursing bags from a chair then a barrier must be used to place the bag on a surface. 410 IAC 17-12-1 (m) 1. Review of the Indiana State Department of Health Nurse Aide Curriculum Created: July 1998 Revised: November 19, 2015 indicated, but was not limited to, “Procedure #33: … Perineal Care … 28. Clean anal area from front to back. … Change gloves … Use clean washcloth … linen contaminated after washing anal area. 2. An undated policy titled Exposure Control Plan: OSHA Regulations was provided on 06/07/2023 at 11:10 AM. The policy indicated, but was not limited to “Nurse, Home Health Aide … 1. … A barrier may be used under the bag …Nursing Bag Technique … 2. Upon entering the home, place the bag on a clean surface; paper towels or plastic bag may be used to create a clean area …” 3. An undated policy titled Handwashing / Hand Hygiene was provided by the Administrator on 06/07/2023 at 11:10 AM. The policy indicated, but was not limited to, “3. Indications for handwashing and hand antisepsis: … c. When there is prolonged or intense contact with the client (bathing the client). d. Between tasks on the same client. e. Before touching a wound. f. After removing gloves. g. After touching objects that are potentially contaminated. … k. After assisting the client to the bathroom. … p. Decontaminate hands after contact … non-intact skin and wound dressings. … r. … after removing gloves. … 3. Multiple use cloth towels are not recommended for use in health care settings.” 4. During a home visit observation on 06/05/2023 at 1:15 PM Home Health Aide (HHA) 2 applied gloves and cleaned Patient #6’s buttock after toileting. HHA 2 then assisted Patient #6 to the shower without removing gloves and performing hand hygiene. HHA 2 applied soap to a clean washcloth to assist with washing the patient’s hair, back, buttocks/anal area, and then used the same washcloth to wash the patient’s legs and feet. HHA 2 failed to change wash clothes after washing the buttocks/anal area. HHA 2 failed to remove gloves and perform hand hygiene after the end of the shower and before touching clean personal items such as a walker, clothes, and admission packet. 5. During a home visit observation on 06/06/2023 at 8:00 AM HHA 1 applied gloves, then used a soapy washcloth to clean Patient #7’s hair, back, underarms, and then buttocks. HHA 1 used the same soapy washcloth to wash the patient’s legs and feet. HHA 1 failed to change washcloths after cleaning the patient’s buttocks and failed to change gloves and perform hand hygiene after cleaning the buttocks. HHA 1 assisted the patient back to the bedroom to help him/her dry off and proceeded to obtain items from a drawer and applied clean clothes while still gloved. HHA 1 failed to remove gloves and perform hand hygiene after the shower and before touching clean items. 6. During a home visit observation on 06/06/2023 at 9:45 AM Registered Nurse (RN) 1 applied gloves and removed Patient #5’s soiled wound dressing to right foot. RN 1 opened and removed a 4 x 4 gauze to clean wound. RN 1 then applied Medihoney ® (medication) from a tube directly onto the soiled glove and applied the medication to the open area on Patient #5’s right heel wound. RN 1 opened clean 4 x 4 gauze dressings, Kerlix ™ roll gauzes, and a Coban ™ dressing with soiled gloves to wrap Patient #5’s right heel wound. RN 1 failed to change gloves and perform hand hygiene after removing the soiled dressing, before applying medication, and touching clean items. 7. During an interview on 06/06/2023 at 4:20 PM the Administrator and the Director of Clinical Services stated the expectation was for staff to perform hand hygiene after removing gloves, before touching clean supplies, and performing wound care. On 06/07/2023 at the Administrator stated multiple wash clothes are used for an acute setting and the agencies policy does not require staff to use multiple wash towels during a bath / shower in a home setting.

Competency evaluation CFR(s): 484.80(c)(1)(2)(3) Standard: Competency evaluation. An individual may furnish home health services on behalf of an HHA only after that individual has successfully completed a competency evaluation program as described in this section. (1) The competency evaluation must address each of the subjects listed in paragraph (b)(3) of this section. Subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section must be evaluated by observing an aide's performance of the task with a patient or pseudo-patient. The remaining subject areas may be evaluated through written examination, oral examination, or after observation of a home health aide with a patient, or with a pseudo-patient as part of a simulation. (2) A home health aide competency evaluation program may be offered by any organization, except as specified in paragraph (f) of this section. (3) The competency evaluation must be performed by a registered nurse in consultation with other skilled professionals, as appropriate. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to evaluate Home Health Aide (HHA) competencies by direct observation as required on a patient or a pseudo patient, for 2 of 2 HHA personnel files reviewed. (HHA 1 & HHA 2) Findings include: 1. An undated policy titled Competency Evaluation of Home Care Staff was obtained from the agency’s policy binder . The policy indicated, but was not limited to, “… 4. The Home Health Aide must demonstrate evidence of: … b. … Reading and recording temperature, pulse, and respiration. * … Appropriate and safe techniques in personal hygiene and grooming including: * … Safe transfer techniques and ambulation. * … Note: subject areas with an * must be evaluated after observation of the Home Health Aide’s performance of the tasks with a client. The other subject areas may be evaluated through written examination, oral examination and/or after observation of a Home Health Aide with a client.” 2. A document titled Home Health Aide/Hospice Aide Competency Checklist was provided by the Administrator on 06/07/2023 at 08:45 AM. The document indicated but is not limited to, “… Evaluation, Initial and Date, Evaluation Scoring for Competency Assessment …” The document failed to evidence the required competencies were conducted under direct observation by the Evaluator for 2 of 2 Home Health Aide Competencies Reviewed. 3. On 06/06/2023 at 3:30 PM, Human Resource (HR) Director acknowledged the Home Health Aide/Hospice Aide Competency Checklist document did not have the marked documentation of demonstration evaluations for the home health aide. The HR Director indicated no demonstration was performed on the patient since all topics were covered verbally during the classroom training. 410 IAC 17-14-1(I)(1)(A)

An Emergency Preparedness Survey was conducted by the Indiana State Department of Health in accordance with 42 CFR 484.102. Survey Dates: 2/17/21-2/19/21 Facility: 014228 Active Census: 281 At this Focused Infection Control Emergency Preparedness survey, in regards to staffing and implementation of staffing, Elder's Journey Home Care was found to be in compliance with 42 CFR 484.102 Emergency Preparedness Requirements for Medicare Participating Providers and Suppliers for Home Health Agencies.

This visit was for a Federal/State complaint investigation in conjunction with an Infection Control focused survey. Complaint IN00339451: Substantiated, federal and unrelated state deficiencies cited A Partially extended survey was announced on 2/19/21 at 9:05 a.m. Survey Dates: 2/17/21-2/19/21 Facility ID: 014228 Unduplicated Census last 12 months: 493 Active Census: 281 These deficiencies reflect State Findings cited in accordance with 410 IAC 17. Refer to State Form for additional State findings. Quality Review completed on 3/5/2021 A4

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 ensure the existence of patient expression of dissatisfaction were documented as complaints, as required by agency policy for 1 of 1 (Patient 1) patients whose clinical record was reviewed. Findings include: An undated policy titled, "Client/Family Complaint/Grievance Policy," was provided by the Director of Clinical Services, Employee D, on 2/17/2021 at 2:00 p.m. The policy indicated, but was not limited to: "A complaint is defined as any expression of dissatisfaction by a client/family regarding care or services that can be addressed at the time of complaint by staff present. A grievance is any formal or informal written or verbal expression of dissatisfaction with care or service that is expressed by the client/family that is not solved at that time by staff present. Client complaints will be documented on a client complaint form and filed with the complaint log in an administrative file. A grievance...will be documented on the grievance form by the person receiving the complaint/grievance and forwarded as soon as possible to the appropriate director or to the management team for investigation action and trending. A grievance is considered resolved when the client is satisfied with the actions taken on their behalf." A review of the Complaint Log for 1/2020 through 12/2020 evidenced that it did not include a documented complaint for Patient 1. During an interview on 2/19/2021 at 11:30 a.m., Patient 1 stated she was no longer a patient with the agency due to staffing issues. Patient 1 indicated that she filed a complaint with the agency "several times," speaking with three different personnel members, as well as a personnel member from human resources. Patient 1 stated, "I was basically told [by the agency] to deal with it-I would have to deal with the aide's limited availability. I would have to take another caregiver because my normal aide was unavailable." Patient 1 stated that the agency would often send the same aide to her house that frequently had car trouble. Patient 1 contacted the agency and the agency offered to pick the aide up and bring her to Patient 1's home. "They didn't have anybody else to send." Patient 1 stated that she would be left without help "sometimes up to 4 days per week. My son didn't live with me at the time because he lived on campus at ISU. He didn't have a car and would have to find a ride to come home just to help me." Referring to the agency calling before visits and upcoming unscheduled visits, Patient 1 stated, "sometimes they would-sometimes they wouldn't. More times than not, I would have to call and ask where my aide was at because she didn't show." Patient 1 stated that aides would wear masks during visits but would show up without gloves or with an inadequate supply of gloves, and Patient 1 would send the aides back to the agency for more supplies. "They always had inadequate supplies and I never saw hand sanitizer." Referring to hand sanitizer use and hand washing, Patient 1 stated, "I never saw that done." Patient 1 stated," I'm a big girl and caregivers are not trained to wash big people. The aides did not lift up my folds to thoroughly clean me and didn't clean my peri area very good. One time they sent me a lady with a cast on her wrist. You can't give me a good bath with a cast-you can't even get it wet. They sent me another lady with more ailments than me! They can't clean me!" Patient 1 reported that if she knew an aide could not adequately provide care, "I canceled them." During an interview on 2/19/2021 at 10:36 a.m., in reference to frequent missed visits for Patient 1, the General Manager C stated that Patient 1 was "very specific with caregivers [term used interchangeably with aide]-she sent caregivers home early nearly every day." Patient 1's caregiver was having car trouble and she did not want another caregiver. Patient 1 was hopeful the caregiver's car would be fixed and she would return to visits. The General Manager C was unsure how Patient 1's needs were met during the day when the caregiver was not in the home. 17-12-3(c)(2)

Update of the comprehensive assessment CFR(s): 484.55(d) Standard: Update of the comprehensive assessment. The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient's condition warrants due to a major decline or improvement in the patient's health status, but not less frequently than- This STANDARD is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure the comprehensive assessment reflected the patient's current status for 1 of 1 home observation visits. (Patient 2) Findings include: An undated policy titled "Comprehensive Client Assessment" was provided by the Administrator on 2/18/21 at 3:15 p.m. The policy indicated, but was not limited to, "The Comprehensive Assessment must accurately reflect the client's status ... Reassessments are conducted based on client needs, physician orders, professional judgement and /or OASIS or other regulatory requirement ... " During a home visit on 2/17/21 at 1:00 p.m., Employee I, a HHA (home health aide), was observed providing a shower for patient 2. Employee I assisted patient 2 into a bathtub and onto a shower chair. Patient 2 was able to wash under both underarms, under both breast and abdominal folds. Patient 2 was able to hold the shower hose and rinse off. Employee I was observed washing patient 2's hair, back, and buttocks. Employee I indicated patient 2 has been taking showers for the past few months and receives a shower on Monday, Wednesday, and Friday. The complete clinical record for patient 2 was reviewed on 2/17/21, start of care date 11/25/19, for the certification period 1/18/21 to 3/18/21 with orders for HHA and attendant care services. The record contained the following: A 1/15/21 Aide Plan of Care indicated patient 2 was to receive a shower. An Oasis Assessment Details dated 1/15/21 indicated "(M1830) Bathing: Ability to wash entire body ... [checked box] 4 - Unable to use the shower or tub, but able to bathe self independently with or without use of devices at the sink, in chair, or on commode." The assessment did not reflect the home visit observation. During an interview on 2/17/21 at 9:50 a.m. the Administrator in Training B and Director of Clinical Services D was made aware of the home visit observation and reviewed the Oasis Assessment Details record and agreed the assessment should have been changed. 17-14-1(a)(1)(B)

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure services were provided according to the plan of care for 1 of 1 home health aide visits. (Patient 2) Findings include: An undated policy titled Home Health Aide Services was provided by the Administrator on 2/18/21 at 3:15 p.m. The policy indicated, but was not limited to, "1. a. Providing personal care services including bathing ... skin care ... as directed by the plan of care ... maintain a safe environment for the client ... The Aide will follow the care plan ..." A revised November 2015 Indiana State Department of Health Nurse Aide Curriculum indicated, but was not limited to, "Procedure #32 Shower/Shampoo ... 11. ... Assist as needed to wash and rinse the entire body going from head to toe. 5. Give resident towel and assist to pat dry. Ensure to thoroughly pat dry ... between toes." The complete clinical record for patient 2 was reviewed on 2/17/21, start of care date 11/25/19, for the certification period 1/18/21 to 3/18/21 with orders for HHA (home health aide) services 8 hours a day, 5 days a week. The plan of care included orders for the "HHA to observe ... Integumentary system ... 60 day summary ... Patient needs assistance with all Major ADLS [Activities of Daily Living] of bathing ... skin care and inspection ..." During a home visit on 2/17/21 at 1:00 p.m. Employee I, a HHA (home health aide), was observed during a shower with patient 2. Employee I assisted patient 2 into a bathtub and onto a shower chair. Patient 2 was able to wash under both underarms, under both breasts and abdominal folds. Patient 2 was able to hold the shower hose and rinse off. Employee I was observed washing patient 2's hair, back, and buttocks. Employee I failed to wash patient 2's feet/toes and failed to offer the patient assistance with washing feet/toes. Once patient 2's shower was completed, Employee I assisted him/her out of the shower and dried patient 2's hair, back, and buttock. Employee I failed to dry patient 2's feet and toes. During an interview on 2/17/21 at 4:00 p.m. the Administrator in Training B and Director of Clinical Services D were made aware of patient 2's home visit observation. The Director of Clinical Services D indicated the home health aide should have washed patient 2's feet and dried them unless it was the patient's preference not to wash and dry feet and toes. 17-14-1(g)

Information to the state survey agency CFR(s): 484.100(a) Standard: The HHA also must disclose the following information to the state survey agency at the time of the HHA's initial request for certification, for each survey, and at the time of any change in ownership or management: This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to notify the Indiana Department of Health, in writing, of the new service (attendant and respite care), the date the service was intended to be offered, and all supporting documentation that showed the home health agency was qualified to provide the additional services. Findings include: A 2/27/2018 letter titled "Medicaid Waiver Service Provider Certification" from the Indiana Family & Social Services Administration (FSSA) was provided by the Administrator on 2/18/2021 at 11:25 a.m. The agency failed to provide an approval letter from the Indiana Department of Health for agency to provide additional services of attendant and respite care services. During an interview with the Administrator A on 2/18/2021 at 11:35 a.m., Administrator A stated based on the FSSA letter received, Administrator A was under the impression IDOH was aware of the attendant care/respite services the agency provided. 17-10-1(1)