Every finding on record at Elite Home Healthcare, LLC

This visit was for a Federal/State complaint survey of a Home Health Provider. Survey Dates: 03/09/2026 & 03/10/2026 Complaint: 2740524 was investigated, with related and unrelated deficiencies cited. Complaint: 2736809 was investigated, with related and unrelated deficiencies cited. 12 Month Unduplicated Skilled Admissions: 46 Abbreviations: RN - Registered Nurse HHA - Home Health Aide DME - Durable Medical Equipment This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Refer to State Form for additional State Findings. QR Completed on 03/19/2026 by A4.

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: The agency failed to ensure home health aides demonstrated required competency in mechanical lift use and other tasks requiring a competency evaluation using a patient or pseudo‑patient as required for 3 of 5 personnel record reviews (HHA 5, HHA 6, and HHA 7), with the potential to affect all current HHA employees. Findings Include: 2. A review of personnel 6's record includes the following: A HHA Practice Lab Training Log with Agency letterhead that indicates HHA 6 practice lab day 1 date 05/08/2025, Practice lab day 2 date 05/09/2025, and Practice lab day 3 date 05/12/2025. Electrical signed by HHA 6 on 05/12/2025, signed by Contact RN 1 with no date. A IAHHC Home Health Hospice Aide Written Competency Assessment Exam Scoring Sheet dated 05/09/2025 that indicates Contract RN 1 observed HHA 6 do the following skills: Reading, writing, and verbal reporting; applicates score: 4/5, Vital Signs; applicates score: 4/5, Appropriate and safe techniques in performing personal hygiene and grooming; applicates score: 14/17, transfer techniques and ambulation; applicates score: 7/9, and range of motion and positioning; applicates score: 8/10. A Home Health Aide/Hospice Aide Competency Checklist on agency letter head, dated 05/12/2025, indicates Contract RN 1 certifies the competency testing was conducted in compliance with CFR 484.80 and the skills will * Asterisks have been conducted on a live patient/Pseudo-patient (a person trained to role play). The following items have asterisks: Reading, writing, and verbal reporting; vital signs; appropriate and safe techniques for personal hygiene and grooming; transfer techniques; ambulation techniques; and normal range of motion and positioning. A Job description signed by HHA 6 on 05/13/2025. A document titled "State of Indiana" issued a license dated 05/15/2025. A document titled "Section IV - Signatures and Certification of Application" indicates that the HHA 6, Contract RN 1, and Administrator affirm that the home health aide applicant named in this application has satisfactorily completed a competency evaluation program as required by 42 CFR 484.80. During an interview on 03/10/2026 at 8:57 AM, HHA 6 stated they completed their initial training virtually. HHA 6 reported that an agency nurse later visited Patient #1's home to observe their skills. They further confirmed that Contract RN 1 never observed them in the home. During an interview on 03/10/2026 at 2:34 PM, the Contract RN 1 indicated that he vaguely remembered HHA 6 and was unable to access the personnel record due to a low internet speed. 3. A review of personnel 7's record includes the following: A HHA Practice Lab Training Log with Agency letterhead that indicates HHA 7 practice lab day 1 date 02/03/2025, Practice lab day 2 date 02/04/2025, and Practice lab day 3 date 02/05/2025. Electrical signed by HHA 7 on 02/05/2025, signed by Contact RN 1 with no date. A IAHHC Home Health Hospice Aide Written Competency Assessment Exam Scoring Sheet dated 02/05/2025 that indicates Contract RN 1 observed HHA 7 do the following skills: Reading, writing, and verbal reporting; applicates score: 4/5, Vital Signs; applicates score: 4/5, Appropriate and safe techniques in performing personal hygiene and grooming; applicates score: 14/17, transfer techniques and ambulation; applicates score: 7/9, and range of motion and positioning; applicates score: 8/10. A Home Health Aide/Hospice Aide Competency Checklist on agency letterhead, dated 02/05/2025, indicates Contract RN 1 certifies the competency testing was conducted in compliance with CFR 484.80 and the skills will * Asterisks have been conducted on a live patient/Pseudo-patient (a person trained to role play). The following items are marked with an asterisk: Reading, writing, and verbal reporting; vital signs; appropriate and safe techniques for personal hygiene and grooming; transfer techniques; ambulation techniques; and normal range of motion and positioning. A Job description signed by HHA 7 on 02/06/2025. A document titled "State of Indiana" issued a license dated 04/22/2025. A document titled "Section IV - Signatures and Certification of Application" indicates that the HHA 7, Contract RN 1, and Administrator affirm that the home health aide applicant named in this application has satisfactorily completed a competency evaluation program as required by 42 CFR 484.80. The personnel record for HHA 7, hire date 02/05/2025, included a Home Health-Hospice Aide Written Competency Assessment Exam Scoring Sheet dated 02/05/2025 that failed to indicate she demonstrated competence on the use of a Hoyer (mechanical lift) using a live patient/pseudo-patient. The record failed to evidence any follow-up training on the use of a mechanical lift before assignment, which increases the risk of potential harm. During an interview on 03/10/2026 at 3:38 PM, HHA 7 stated she had no prior experience as an HHA. She stated training consisted of online modules and Zoom (remote video/audio) calls. Although the agency offered 2–3 days of in-person, on-camera classroom training, she did not attend. Instead, they used a mannequin in a bed for the training demonstrations. HHA 7 recalled receiving her license after her first day of work. A male colleague assisted with her initial orientation, though she doesn't recall his name. The Zoom sessions regarding Durable Medical Equipment (DME) were particularly helpful. HHA 7's stated her responsibilities included setting up the g-tube, but she did not perform feedings while on the clock.. She confirmed she received dementia training and instruction on g-tube site care. She stated we have a regular on-site nurse whose presence has increased, along with a second person who monitors our work. HHA 7 stated she bathed and dressed Patient #1, but received no Hoyer lift training from the agency; instead, the equipment delivery personnel provided that instruction. During an interview on 03/10/2026 at 2:34 PM, Contract RN 1 stated that he vaguely remembered HHA 7 and was unable to access the personnel record due to slow internet. He indicates that once he completes the TEAMS training, he will sign off on the training documentation. He indicates that after he signs the training documents, the administrator receives them and signs off on training, and then Human Resources (HR) has the new home health aide sign the completed training document. Once HR has all signatures, they receive the completed form. The Contract RN 1 indicates that the TEAM's video training normally takes 4 days, then the document goes to HR, and the field nurse goes out with the HHA during the admission and completes a check-off. He indicates providing training twice per week to individuals seeking aide licensure. During an interview on 03/10/2026 at 4:10 PM, the Administrator indicated she doesn't think the RN's do training; Lee is responsible for all home Health aide check-offs. She confirmed that home health aide training for licensure requires 75 hours and that new hires must come in person, and agreed it was difficult to determine from the provided documents that the required 75 hours were being met. The Administrator confirmed that all persons attending Contract RN 1's aide training for licensure must complete the checkoff in person, but she could not confirm whether she has seen any new hires in the agency complete in-person competency check-offs in the last 2 years. The agency failed to ensure compliance with 42 CFR 484.80. 410 IAC 17-14-1(1)(A) 1. A review of Personnel 5's record includes the following: A HHA Practice Lab Training Log with agency letterhead shows HHA 5 practice lab day 1 on 12/08/2025, day 2 on 12/09/2025, and day 3 on 12/10/2025. HHA signed electronically on 12/12/2025. Contact RN 1 signed but did not date. An IAHHC Home Health Hospice Aide Written Competency Assessment Exam Scoring Sheet, dated 12/10/2025, shows Contract RN 1 observed HHA 5. The skills observed, and applicant's scores were: Reading, writing, and verbal reporting (5/5); Vital Signs (5/5); Appropriate and safe techniques in personal hygiene and grooming (15/17); transfer techniques and ambulation (9/9); and range of motion and positioning (10/10). A Home Health Aide/Hospice Aide Competency Checklist on agency letterhead, dated 12/10/2025, shows Contract RN 1 certifies that the competency testing met CFR 484.80 and that HHA 5 completed the skills with an asterisk on a live or pseudo-patient. Asterisked skills include reading, writing, and verbal reporting; vital signs; personal hygiene; transfer techniques; ambulation; and range of motion and positioning. A Job description signed by HHA 5 on 12/12/2025 A document titled "State of Indiana" indicates HHA 5's license with an issue date of 02/05/2026. A document titled "Section IV - Signatures and Certification of Application" indicates that HHA 5, Contract RN 1, and Administrator affirm that the home health aide applicant has satisfactorily completed a competency evaluation program as required by 42 CFR 484.80. During an interview on 03/10/2026 at 9:15 AM, HHA 5 explained that her training was entirely virtual, led by Contract RN 1, using TEAMS/Google for simulations over several weeks, as she lived far from the agency. She confirmed that there was no in-person skills check-off. HHA 5 stated she finished her Home Health Aide training at the end of December 2025. On 02/12/2026, she notified the agency that she had obtained an approval letter for family member insurance coverage and requested services to start immediately. She was confused when the agency said they needed to send for her license, as she had already completed her training and received proof of completion from Contract RN 1. HHA 5 received her license before the RN visited for the start of care on 02/12/2026. During an interview on 03/10/2026 at 2:34 PM, Contract RN 1 reviewed HHA 5's record. He confirmed conducting TEAMS video training with HHA 5 using PowerPoint, IACHH handouts, and practical demonstrations on 12/08/2025, 12/09/2025, and 12/10/2025. He explained that after completing TEAMS training, he signs the necessary documentation, then the Administrator and Human Resources (HR) provide additional signatures. He indicated that HR returns the document to him when all required signatures are collected. He described that TEAMS training typically takes four days, after which the field nurse performs an in-person skills check-off during the admission. During an interview on 03/10/2026 at 4:10 PM, the Administrator indicated she doesn't think the RN's do training; the Contract RN is responsible for all home Health aide check-offs. She confirmed home health aide training for licensure requires 75 hours and that new hires are required to come in person, and agreed it was difficult to determine from the provided documents that HHAs were meeting the required 75 hours. The Administrator confirmed that all persons attending Contract RN 1's aide training for licensure are required to complete check-offs in person. Still, she could not confirm she's seen any new hires in the agency for in-person competency check-offs in the last 2 years.

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102. Survey Dates: 01/23/2024-01/26/2024 Active Census: 203 At this Emergency Preparedness survey, Elite Home Healthcare was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 484.102. QR was completed on 02/01/2024 by A4.

This visit was for a Federal Recertification and State Re-Licensure survey of a Home Health Provider. Survey Dates: 01/23/2024-01/26/2024 12-Month Unduplicated Skilled Admissions: 55 Survey was fully extended on 01/26/2024. During this Federal Recertification Survey, Elite Home Healthcare was found to be out of compliance with Conditions of Participation 484.105 Condition of Participation: Organization and Administration of Services. Based on the Condition-level deficiencies during the 01/26/2024 survey, your HHA was subject to a partial or extended survey pursuant to section 1891(c)(2)(D) of the Social Security Act on 01/26/2024. Therefore, and pursuant to section 1891(a)(3)(D)(iii) of the Act, your agency is precluded from operating a home health aide training, skills competency and/or competency evaluation programs for a period of two years beginning 01/26/2024 and continuing through 01/25/2026. This deficiency report reflects State Findings cited in accordance with 410 IAC 17.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure the Plan of Care (POC) included a current/complete list of Durable Medical Equipment (DME) and Supplies in the patient’s home for 1 of 3 home visit patients (Patient #2) and failed to ensure the POC included patient/caregiver stated goals for 7 of 8 patient records reviewed (Patient #1, #2, #3, #4, #5, #6, #8). Findings include: 1. A document titled “Plan of Care” was provided by the Administrator on 1/25/2024 at 9:48 AM. The document included but was not limited to: “The Plan of Care is based on a comprehensive assessment and information provided by the client/family…The plan will be consistently reviewed to ensure that client needs are met, and will be updated as necessary…To reflect the client’s ability to make choices and actively participate in following the plan designated to attain personal health goals…The Plan of Care shall be completed in full to include…Medical supplies and equipment required…Other appropriate items…” 2. The Plan of Care (POC) for Patient #2, certification period, 12/10/2023-02/07/2024, was reviewed on 01/24/2024. The POC failed to include a current list of durable medical equipment (DME). Missing DME from POC: Feeding pump and pole (for Gastrostomy tube feedings), Gastrostomy tube (G-tube) supplies, and a spacer for inhaled medications. The POC failed to include patient-specific goals identified by the patient/caregiver. During a home visit on 01/24/2024 at 9:00 AM, Patient #2’s caregiver indicated the feeding pump and pole, G-tube supplies, and spacer for inhaled medications were present in the home and currently being used for patient care. 3. The POC for Patient #1, certification period 12/28/2023-02/25/2024, was reviewed on 01/24/2024. The POC failed to include patient-specific goals identified by the agency and the patient. 4. The POC for Patient #3, certification period 01/06/2024-03/05/2024, was reviewed on 01/24/2024. The POC failed to include patient-specific goals identified by the patient/caregiver. 5. The POC for Patient #4, certification period 11/25/2023-01/23/2024, was reviewed on 01/24/2024. The POC failed to include patient-specific goals identified by the patient/caregiver. 6. The POC for Patient #5, certification period 11/23/2023-01/21/2024, was reviewed on 01/24/2024. The POC failed to include patient-specific goals identified by the patient/caregiver. 7. The POC for Patient #6, certification period 06/13/2022-08/11/2022, was reviewed on 01/25/2024. The POC failed to include patient-specific goals identified by the patient/caregiver. 8. The POC for Patient #8, certification period 11/20/2023-01/18/2024, was reviewed on 01/25/2024. The POC failed to include patient-specific goals identified by the patient/caregiver. 9. During an interview on 01/24/2024 at 3:52 PM, the Administrator indicated all patients’ POCs should include the most up-to-date list of DME used in the home and indicated that the goals listed on current POCs appear to have been assigned by the skilled nurse and not patient stated goals. 410 IAC 17-13-1(a)(1)(C)(ii) 410 IAC 17-13-1(a)(1)(C)(xiii)

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 record review and interview, the agency failed to ensure there was not a conflict of interest related to aide supervision, failed to ensure the Alternate Clinical Manager was able to safely provide care to all patients, failed to ensure the Alternate Clinical Manager was able to fulfill the requirements included in their job description, and failed to ensure proper oversight of patient care. The cumulative effect of these systemic problems resulted in the agency’s inability to ensure patients received appropriate care and services which could result in the agency not providing quality health care, thus being out of compliance with Condition of Participation 42 CFR 484.105 Condition of participation: Organization and Administration of Services. Findings include: 1. A policy revised 03/20/2023, titled "Conflict of Interest” was provided by the Clinical Supervisor on 01/26/2024 at 2:06 PM. The policy indicated, but was not limited to, “an actual or potential conflict of interest occurs when a person is in a position to influence a decision that may result in a personal gain for that employee or for a relative as a result of the Agency’s business dealings”. 2. A job description for Alternate Clinical Supervisor was provided on 01/26/2024 at 2:00 PM by the Clinical Supervisor. The job description indicated, but was not limited to, “available at all times during regular business hours and as needed to provide support and assure quality care delivery to home care clients…recognizes and responds appropriately to potentially unsafe situations”. 3. A job description for Clinical Supervisor was provided on 01/26/2024 at 2:00 PM by the Clinical Supervisor. The job description indicated, but was not limited to, “ensure proper staffing of qualified, competent personnel…recognizes and responds appropriately to potentially unsafe situations”. 4. The record for Patient #5 was reviewed on 01/24/2024 and evidenced the following: For the certification period of 11/23/2023-01/21/2024, Home Health Aide (HHA) supervisory visits for HHA 2 were completed by the Alternate Clinical Supervisor (spouse of HHA 2) on 11/28/2023, 12/09/23, 12/12/2023, 12/26/2023, and 01/09/2024. Visits without HHA 2 present indicated the family was satisfied with the care. The family included (Alternate Clinical Manager & Parent of Patient #5 & Patient #8) and the aide (HHA 2, Parent of Patient #5 and Patient #8, and spouse of the Alternate Clinical Manager) being the same individual evaluating care for HHA 2. 5. The record for Patient #8 was reviewed on 01/25/2024 and evidenced the following: For the certification period of 11/23/2023-01/21/2024, Home Health Aide (HHA) supervisory visits for HHA 2 were completed by the Alternate Clinical Supervisor (spouse of HHA 2) on 11/28/2023, 12/09/23, 12/12/2023, 12/26/2023, and 01/09/2024. Visits without HHA 2 present indicated the family was satisfied with the care. The family included (Alternate Clinical Manager & Parent of Patient #5 & Patient #8) and the aide (HHA 2, Parent of Patient #5 and Patient #8, and spouse of the Alternate Clinical Manager) being the same individual evaluating care for HHA 2. 6. During a record review of Patient #5 and Patient #8, RN visit notes reflected that, on 12/25/2024, 12/26/2024, and 12/27/2024, the Alternate Clinical Supervisor provided care to Patient #5 from 6:00 AM to 6:00 PM and Patient #8 from 12:00 AM to 6:00 AM and from 10:00 PM to 11:59 PM, for a total of 20 hours a day for three days. 7. During an interview on 01/25/2024 at 3:21 PM, the Administrator and Clinical Supervisor indicated family members facilitating an HHA supervisory visits could be a conflict of interest. 8. During an interview on 01/26/2024 at 12:08 PM, the Alternate Clinical Supervisor indicated completing HHA supervisory visits on HHA 2 and did not see conflict of interest in performing this task. 9. During an interview on 01/23/2024 between 9:39 AM and 10:06 AM, the Administrator, Alternate Administrator, Clinical Supervisor, and Alternate Clinical Supervisor indicated that the Alternate Clinical Supervisor worked a remote, full-time position. It was indicated that normal business hours are Monday through Friday 8:00 AM-4:00 PM. 10. During an interview on 01/25/2024 at 3:21 PM, the Administrator and Clinical Supervisor indicated remote workers were full-time with the same hours as clinical staff and worked Monday through Friday 8:00 AM-4:30 PM. The Administrator then indicated the Alternate Clinical Supervisor was a remote position, but rarely required to go in the field. The Administrator indicated the Alternate Clinical Supervisor works a few hours daily on administrative duties in addition to providing care for Patient #5 and Patient #8. 11. During an interview on 01/26/2024 at 12:08 PM, the Alternate Clinical Supervisor indicated working 20+ hours a day, providing services to Patient #5 and Patient #8 without sleep before shifts, in addition to working remotely for the agency performing administrative tasks. The Alternate Clinical Supervisor indicated all hours documented in charts are hours worked during patient care and that the Alternate Clinical Supervisor takes prescription medication to aid in alertness related to chronic lack of sleep. The alternate Clinical Supervisor indicated a willingness to drive on no sleep to provide patient care if the need arises because currently does so for patients #5 and #8 and can do it for other patients as well.

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 interview, the Clinical Supervisor failed to ensure there was an Alternate Clinical Supervisor that was always available during regular business hours to safely provide patient care for 1 of 1 position. Findings include: A job description for Alternate Clinical Supervisor was provided on 01/26/2024 at 2:00 PM by the Clinical Supervisor. The job description indicated, but was not limited to, “available at all times during regular business hours and as needed to provide support and assure quality care delivery to home care clients…recognizes and responds appropriately to potentially unsafe situations”. A job description for Clinical Supervisor was provided on 01/26/2024 at 2:00 PM by the Clinical Supervisor. The job description indicated, but was not limited to, “ensure proper staffing of qualified, competent personnel…recognizes and responds appropriately to potentially unsafe situations”. A record review for Patient #5 on 01/24/2024 indicated that the Alternate Clinical Supervisor provided care for patient #5 for 12 hours per day, 7 days per week. from the hours of 4:00 AM- 3:30 PM or 6:00 AM-6:00 PM A record review for Patient #8 on 01/25/2024 indicated that the Alternate Clinical Supervisor provided care for Patient #8 for 8 hours per day, 7 days per week from the hours of 4:30 PM-12:00 AM or 10:00 PM-6:00 AM. During an interview on 01/23/2024 between 9:39 AM and 10:06 AM, the Administrator, Alternate Administrator, Clinical Supervisor, and Alternate Clinical Supervisor indicated that the Alternate Clinical Supervisor worked a remote, full-time position. It was indicated that normal business hours are Monday through Friday 8:00 AM-4:00 PM. During an interview on 01/25/2024 at 3:21 PM, the Administrator and Clinical Supervisor indicated remote workers were full-time with the same hours as clinical staff and worked Monday through Friday 8:00 AM-4:30 PM. The Administrator then indicated the Alternate Clinical Supervisor was a remote position, but rarely required to go in the field. The Administrator indicated the Alternate Clinical Supervisor works a few hours daily on administrative duties in addition to providing care for Patient #5 and Patient #8. During an interview on 01/26/2024 at 12:08 PM, the Alternate Clinical Supervisor indicated working 20+ hours a day, providing services to Patient #5 and Patient #8 without sleep before shifts, in addition to working remotely for the agency performing administrative tasks. The Alternate Clinical Supervisor indicated all hours documented in charts are hours worked during patient care and that the Alternate Clinical Supervisor takes prescription medication to aid in alertness related to chronic lack of sleep. Alternate Clinical Supervisor indicated a willingness to drive on no sleep to provide patient care if the need arises because currently does so for patients #5 and #8 and can do it for other patients as well. 410 IAC 17-12-1(d)