Every finding on record at Enchanted Hearts Home Health Care LLC

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 494.62. Survey Dates: 06/24/2025, 06/25/2025, and 06/26/2025 Active Census:10 At this Emergency Preparedness survey, Enchanted Hearts Home Healthcare was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 494.62. QR completed by Area 3 on 6/29/2025.

This visit was for an Initial Federal Medicaid Certification of a Home Health provider. Survey Dates: 06/24/2025, 06/25/2025, and 06/26/2025 12 Month Unduplicated Admissions: 11 This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Refer to State Form for additional State Findings. Abbreviations: HHA Home Health Aide CNA Certified Nursing Assistant RN Registered Nurse DON Director of Nursing POC Plan of Care SOC Start of care\ ROC Resumption of Care SN Skilled Nursing DME Durable Medical Equipment HHA Home Health Aide OASIS Outcome and Assessment Information Set QR completed by Area 3 on 6/29/2025.

State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patients received information regarding the correct state toll free hot line for 3 of 3 patient admission packets reviewed during home visits. (Patients #: 5, 9 and 10) Findings Include: 1. Review of an agency policy dated 2/2025 titled "Rights & Responsibilities of Patients Policy" indicated but was not limited to, " … Voice and report grievances/complaints … to the Agency, accrediting body, and state or local agencies …" 2. Review of an agency admission packet indicated but was not limited to, " … To be advised of the toll-free home health hot line … and the purpose of the hotline to receive complaints … The [Entity 1, a state health department, complaint hot line] is …" The admission packet failed to evidence Entity 2's, a state health department, complaint hot line. 3. During a home visit on 06/25/2025 at 10:00 AM at Patient #5's residence, a review of the admission packet, for the patient's SOC of 05/18/2025, evidenced Entity 1's, a state health department, complaint hot line. The admission packet failed to contain Entity 2's, a state health department, complaint hot line. 4. During a home visit on 06/26/2025 at 9:00 AM at Patient #9's residence, a review of the admission packet, for the patient's SOC of 05/16/2025, evidenced Entity 1's, a state health department, complaint hot line. The admission packet failed to contain Entity 2's, a state health department, complaint hot line. 5. During a home visit on 06/26/2025 at 10:00 AM at Patient #10's residence, a review of the admission packet, for the patient's SOC of 05/08/2025, evidenced Entity 1's, a state health department, complaint hot line. The admission packet failed to contain Entity 2's, a state health department, complaint hot line. 6. During an interview on 06/26/2025 at 1:39 PM, the Administrator indicated they were not aware the wrong state complaint hot line was included in their admission packet. 410 IAC 17-12-3(b)(2)(C)

Patient's needs CFR(s): 484.55(c)(4) The patient's medical, nursing, rehabilitative, social, and discharge planning needs; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment included rehabilitative needs and/or discharge planning for 7 of 10 active clinical records reviewed. (Patients #: 2, 4, 5, 6, 7, 8, and 10) Findings Include: 1. Review of an agency policy dated 2/2025 titled "Assessments" indicated but was not limited to, " … THE COMPREHENSIVE ASSESSMENT MUST ACCURATELY REFLECT THE PATIENT'S STATUS AND MUST INCLUDE: … Patient medical, nursing, rehab, social, and discharge planning needs …" 2. Review of the clinical record for Patient #2 revealed a SOC certification assessment dated 05/30/2025 and signed by RN 1. The comprehensive assessment evidenced Patient #2 had but was not limited to, Diabetes (chronic condition where the body either cannot produce enough insulin or effectively use the insulin it does produce resulting in elevated blood sugar levels), Chronic Kidney Disease (condition where the kidneys are damaged and are unable to filter blood as well as they should) and Hyperlipidemia (condition where there are abnormally high levels of fat in the blood). The comprehensive assessment failed to evidence discharge plans for Patient #2. Review of the clinical record for Patient #2 revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 05/30/2025 for the certification period of 05/30/2025 through 07/28/2025 and signed by RN 1. The POC evidenced Patient #2 had but was not limited to, Chronic Kidney Disease (condition where the kidneys are damaged and are unable to filter blood as well as they should) and Hyperlipidemia (condition where there are abnormally high levels of fat in the blood ). The POC subsection titled "Goals/Rehabilitation Potential/Discharge plan," evidenced but is not limited to, " … Discharge plans: Discharge planning to include continued home health care support, follow-up with primary care physician, ensure patient and family understand medication regimen and safety measure, arrange for necessary medical equipment at home if needed …" 3. Review of the clinical record for Patient #4 revealed a SOC certification assessment dated 05/18/2025 and signed by RN 1. The comprehensive assessment evidenced Patient #4 had but was not limited to, Age-related nuclear cataract - bilateral (type of cataract that develops int eh center, nucleus, of the eye's lens as a result of aging), Chronic Pain Syndrome, Hypertension secondary to endocrine disorder (high blood pressure caused by an imbalance of hormones produced by endocrine glands), Asthma (chronic lung condition that causes inflammation and narrowing of the airways, which makes it difficult to breath), and bilateral primary Osteoarthritis of the left and right shoulder (degeneration of join cartilage and the underlying bone resulting in pain and stiffness).The comprehensive assessment failed to evidence the rehabilitation potential and discharge plans for Patient #4. 4. Review of the clinical record for Patient #5 revealed a SOC certification assessment dated 05/18/2025 and signed by RN 1. The comprehensive assessment evidenced Patient #4 had but was not limited to, Type 2 Diabetes Mellitus with hyperglycemia, Acute on Chronic systolic (congestive) heart failure (sudden worsening symptoms in a patient who already has chronic systolic heart failure, which is a condition where the heart's left ventricle (responsible for pumping blood to the rest of the body), is weakened and can't contract effectively), and Chronic Kidney Disease. The comprehensive assessment failed to evidence the rehabilitation potential and discharge plans for Patient #5. 5. Review of the clinical record for Patient #6 revealed a SOC certification assessment dated 05/17/2025 and signed by RN 1. The comprehensive assessment evidenced Patient #6 had but was not limited to, Type 2 Diabetes Mellitus with diabetic neuropathy (Diabetes resulting in the dysfunction of one more peripheral nerves causing numbness or weakness), Hypothyroidism (abnormally low activity of the thyroid gland, resulting in metabolic changes in adults), Hyperlipidemia, Benign Prostatic Hyperplasia without lower urinary tract symptoms (enlarged prostate without urinary symptoms, such as frequency). The comprehensive assessment failed to evidence the rehabilitation potential for Patient #6. 6. Review of the clinical record for Patient #7 revealed a SOC certification assessment dated 05/17/2025 and signed by RN 1. The comprehensive assessment evidenced Patient #7 had but was not limited to, Type 2 Diabetes Mellitus with unspecified diabetic retinopathy with macular edema (Type 2 Diabetes Mellitus causing an eye condition which can result in vision loss or blindness and can affect the macula (part of the eye that process what you see), leading to swelling and fluid accumulation), Primary Hypertension (persistently high blood pressure, where no secondary cause can be identified), Systolic (chronic) Heart Failure, and Chronic Kidney Disease - stage 3. The comprehensive assessment failed to evidence the patient's discharge plans. 7. Review of the clinical record for Patient #8 revealed a SOC certification assessment dated 05/15/2025. The comprehensive assessment evidenced Patient #8 had but was not limited to, Type 2 Diabetes Mellitus, Open wound to abdominal wall, Open angle glaucoma (chronic, progressive eye disease characterized by the gradual damage of the optic nerve, leading to vision loss), and dependence on supplemental oxygen. The comprehensive assessment failed to evidence Patient #8's rehabilitation potential. 8. Review of the clinical record for Patient #10 revealed a SOC certification assessment dated 05/08/2025. he comprehensive assessment evidenced Patient #10 had but was not limited to, Stiff Person Syndrome (rare autoimmune neurological disorder characterized by fluctuating muscle rigidity and painful spasms), Stroke (medical emergency that occurs when blood flow to the brain is interrupted by a blockage or a ruptured vessel), and Seizure. The comprehensive assessment failed to evidence the discharge plan. Review of the clinical record for Patient #10 revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 05/08/2025 for the certification period of 05/08/2025 through 07/06/2025 and signed RN 1. The POC subsection titled "Goals/Rehabilitation Potential/Discharge Plan," evidenced but is not limited to, " … Discharge when patient no longer needs services or max potential has been met …" 9. During an interview on 06/26/2025 at 1:28 PM, the Administrator indicated the comprehensive assessment and POC should match. The Administrator indicated rehabilitation potential and discharge plans should be documented on the comprehensive assessment. 410 IAC 17-14-1(a)(1)(B)

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the POC contained all of the necessary elements including pertinent diagnosis, nutritional requirements, seizure plan, DME, safety precautions, rehabilitation potential and discharge plans for 9 of 10 active clinical records reviewed. (Patients #: 1, 2, 3, 4, 5, 6, 7, 8, and 10) Findings Include: 1. Review of an agency policy dated 2/2025 titled "Plan of Care (POC)" indicated but was not limited to, " … POC INCLUDES: … All pertinent diagnosis … Types of services, supplies, and equipment needs … Rehab Potential … Safety measures to protect against injury … Patient and caregiver education/training to facilitate timely discharge … Any additional items the Agency or physician may choose to include …" 2. Review of the clinical record for Patient #1 revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 05/31/2025 for the certification period of 05/31/2025 through 07/29/2025 and signed by the Administrator. The POC evidenced Patient #1 had but was not limited to, Complete traumatic amputation at the knee level, right lower leg (removal of the right lower leg at the knee level, which could be from trauma, medical illness, or a surgical measure to control or a disease process), Other obesity (chronic condition characterized by excessive accumulation of body fat that present a risk to health), Chronic Pain Syndrome (condition where pain persists for an extended period, usually beyond 3 months, and significantly impacts a person's physical, emotional, and social well-being), and Incisional Hernia without obstructions or gangrene (a condition where abdominal tissue or organs protrude through a weakened area in the abdominal wall at the site of a previous surgical incision, and the protrusion occurs without an intestinal blockage or tissue death). The POC subsection titled "DME and Supplies," evidenced but is not limited to, "Dexcom G7 Mobile CGM Receiver [Continuous Glucose Monitor, a method used primarily for managing Diabetes, which involves a small sensor inserted under the skin to track glucose levels in real-time], Dexcom G7 Mobile CGM Sensor, Pressure Reduction Mattress, Wheelchair, and Prosthetics" Review of the clinical record for Patient #1 revealed a SOC certification assessment dated 05/31/2025 and signed by the Administrator. The assessment indicated Patient #1 used a blood sugar glucometer (device used to measure the concentration of glucose, sugar, in the blood by placing a drop of blood on a disposable test strip) twice a day to check their blood sugar, had an amputation of the left and right extremities, and uses a bedside commode, walker, hospital bed,. The comprehensive assessment failed to evidence Patient #1 uses diabetic supplies. The POC failed to evidence the diagnosis of a right lower extremity amputation, and DME: diabetic supplies, bedside commode, walker, and hospital bed. 3. Review of the clinical record for Patient #2 revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 05/30/2025 for the certification period of 05/30/2025 through 07/28/2025 and signed by RN 1. The POC evidenced Patient #2 had but was not limited to, Chronic Kidney Disease (condition where the kidneys are damaged and are unable to filter blood as well as they should) and Hyperlipidemia (condition where there are abnormally high levels of fat in the blood). Review of the clinical record for Patient #2 revealed a SOC certification assessment dated 05/30/2025 and signed by RN 1. The comprehensive assessment evidenced Patient #2 had Diabetes (chronic condition where the body either cannot produce enough insulin or effectively use the insulin it does produce resulting in elevated blood sugar levels). The POC failed to evidence the diagnosis of Diabetes. During an interview on 06/26/2025 at 11:46 AM, RN 1 indicated the Diabetes diagnosis should be included on the POC. 4. Review of the clinical record for Patient #3 revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 05/23/2025 for the certification period of 05/23/2025 through 07/22/2025 and signed by RN 1. The POC evidenced Patient #3 had but was not limited to, Moderate Intellectual Disabilities (observable developmental delays which may be accompanied by physical impairments), Depression (mental health condition described as persistent low mood, loss of interest or pleasure in activities, and changes in behavior or thinking), Seizures (sudden temporary disruption in brain activity that causes involuntary changes in behavior, movement, sensation, or consciousness), Chronic Obstructive Pulmonary Disease (group of lung disease that cause persistent airflow obstruction and breathing problems), Traumatic Brain Injury (a brain injury that occurs when external force impacts the head causing damage to the brain), and Gastrostomy Status (medical condition where a surgical procedure has been performed to create an opening in the stomach through the abdominal wall, often referred to as a g-tube). The POC subsection titled "DME and Supplies," evidenced but was not limited to, "Walker, wheelchair, hospital bed, oxygen supplies, and g-tube supplies" The POC subsection titled "Safety Measures," evidenced but is not limited to, "Ensure proper functioning of G-tube [gastrostomy tube] … Fall precautions …" The POC subsection titled Goals/ Rehabilitation Potential/Discharge Planning," evidenced but is not limited to, " … Patient/caregiver will demonstrate correct medication administration … Patient/caregiver will verbalize the name … of each prescribed medication … Patient/caregiver will verbalize at least 3 common side effect of each prescribed med … Patient/caregiver will verbalize understand of fall prevention …" Review of the clinical record for Patient #3 revealed a SOC certification assessment dated 05/23/2025 and signed by RN 1. The comprehensive assessment evidenced Patient #3 had seizure precautions, and DME: grab bars, hospital bed, tub/shower bench, wheelchair, walker, exam gloves, gauze pads, oxygen supplies, and g-tube supplies, a fair rehabilitation potential, and the agency plans to discharge Patient #3 when " … skilled care was no longer need … when goals/maximum potential are reached by and patient and all disciplines have discharge to care of physician" The POC failed to evidence DME: grab bars, tub shower bench, gauze, and exam gloves, a seizure plan, seizure precautions, aspiration precautions, rehabilitation potential, and discharge plans. 5. Review of the clinical record for Patient #4 revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 05/18/2025 for the certification period of 05/18/2025 through 07/17/2025 and signed by RN 1. The POC evidenced Patient #4 had but was not limited to, Age-related nuclear cataract - bilateral (type of cataract that develops int eh center, nucleus, of the eye's lens as a result of aging), Chronic Pain Syndrome, Hypertension secondary to endocrine disorder (high blood pressure caused by an imbalance of hormones produced by endocrine glands), Asthma (chronic lung condition that causes inflammation and narrowing of the airways, which makes it difficult to breath), and bilateral primary Osteoarthritis of the left and right shoulder (degeneration of join cartilage and the underlying bone resulting in pain and stiffness). The POC subsection titled Goals/ Rehabilitation Potential/Discharge Planning," evidenced but is not limited to, " … Patient/caregiver will verbalize the name … of each prescribed medication … Patient/caregiver will demonstrate correct medication administration and adherence to prescribed scheduled … Patient/caregiver will verbalize at least 3 common side effect of each prescribed med … Patient/caregiver will verbalize understand of fall prevention … Patient will report decreased join pain … Patient will demonstrate understanding of hypertension management …" Review of the clinical record for Patient #4 revealed a SOC certification assessment dated 05/18/2025 and signed by RN 1. The comprehensive assessment failed to evidence the rehabilitation potential and discharge plans for Patient #4. The POC failed to evidence the rehabilitation potential and discharge plans for Patient #4. During an interview on 06/26/2025 at 11:36 AM, RN 1 indicated the rehabilitation potential for Patient #4 was good, and the discharge plan would be to discharge once doing better, and able to maintain medication set-up on their own. When queried if rehabilitation potential and discharge planning should be included on the POC and the comprehensive assessment, RN 1 indicated yes, they have to match. 6. Review of the clinical record for Patient #5 revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 05/18/2025 for the certification period of 05/18/2025 through 07/17/2025 and signed by RN 1. The POC evidenced Patient #5 had but was not limited to, Type 2 Diabetes Mellitus with hyperglycemia, Acute on Chronic systolic (congestive) heart failure (sudden worsening symptoms in a patient who already has chronic systolic heart failure, which is a condition where the heart's left ventricle (responsible for pumping blood to the rest of the body), is weakened and can't contract effectively), and Chronic Kidney Disease. The POC subsection titled "DME and Supplies," evidenced but is not limited to, "Rollator Walker, Cane, and Gloves" The POC subsection titled "Goals/Rehabilitation Potential/Discharge Plans" evidenced but is not limited to, "Patient will verbalize understanding of Type 2 Diabetes … Patient will verbalize understanding of medications … Patient will demonstrate the ability to correctly fill a weekly pill planner … Patient will remain free from falls … The patient will verbalize at least 2 methods of maintaining foot care …" Review of the clinical record for Patient #5 revealed a SOC certification assessment dated 05/18/2025 and signed by RN 1. The comprehensive assessment evidenced Patient #5 had the following DME: walker, cane, diabetic supplies, and exam gloves. The comprehensive assessment failed to evidence the rehabilitation potential and discharge plans for Patient #5. The POC failed to evidence DME: diabetic supplies, rehabilitation potential, and discharge plans for Patient #5. 7. Review of the clinical record for Patient #6 revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 05/17/2025 for the certification period of 05/17/2025 through 07/16/2025 and signed by RN 1. The POC evidenced Patient #6 had but was not limited to, Type 2 Diabetes Mellitus with diabetic neuropathy (Diabetes resulting in the dysfunction of one more peripheral nerves causing numbness or weakness), Hypothyroidism ((abnormally low activity of the thyroid gland, resulting in metabolic changes in adults), Hyperlipidemia, Benign Prostatic Hyperplasia without lower urinary tract symptoms (enlarged prostate without urinary symptoms, such as frequency). The POC subsection titled "Goals/Rehabilitation Potential/Discharge Plan," evidenced but is not limited to, "Patient will verbalize understanding of prescribed medications … Patient will demonstrate proper use of a glucometer … Patient will verbalize understanding of diabetes management … Patient will report any new or worsening symptoms of neuropathy … Patient will demonstrate proper daily foot inspection …" Review of the clinical record for Patient #6 revealed a SOC certification assessment dated 05/17/2025 and signed by RN 1. The comprehensive assessment evidenced Patient #6 had a pacemaker (artificial device implanted in the chest to stimulate the heart muscle and regulate the contractions) placed in 2016, and discharge plans of discharging the patient when skill care is no longer needed. The comprehensive assessment failed to evidence the rehabilitation potential for Patient #6. The POC failed to evidence presence of a pacemaker, rehabilitation potential, and discharge plans. 8. Review of the clinical record for Patient #7 revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 05/17/2025 for the certification period of 05/17/2025 through 07/16/2025 and signed by RN 1. The POC evidenced Patient #7 had but was not limited to, Type 2 Diabetes Mellitus with unspecified diabetic retinopathy with macular edema (Type 2 Diabetes Mellitus causing an eye condition which can result in vision loss or blindness and can affect the macula (part of the eye that process what you see), leading to swelling and fluid accumulation), Primary Hypertension (persistently high blood pressure, where no secondary cause can be identified), Systolic (chronic) Heart Failure, and Chronic Kidney Disease - stage 3. The POC subsection titled "Goals/Rehabilitation Potential/Discharge Plan," evidenced but is not limited to, "Patient/caregiver will verbalize understanding of prescribed medications … Patient will verbalize understanding of diabetes management … Patient will demonstrate safe mobility practices …" Review of the clinical record for Patient #7 revealed a SOC certification assessment dated 05/17/2025 and signed by RN 1. The comprehensive assessment evidenced the patient's rehabilitation potential was fair. The comprehensive assessment failed to evidence the patient's discharge plans. The POC failed to evidence Patient #7's rehabilitation potential and discharge plans. 9. Review of the clinical record for Patient #8 revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 05/15/2025 for the certification period of 05/15/2025 through 07/13/2025 and signed by the Administrator. The POC evidenced Patient #8 had but was not limited to, Type 2 Diabetes Mellitus, Open wound to abdominal wall, Open angle glaucoma (chronic, progressive eye disease characterized by the gradual damage of the optic nerve, leading to vision loss), and dependence on supplemental oxygen. The POC subsection titled "Nutritional Requirements," evidenced but was not limited to, "Regular Diet" The POC subsection titled "DME and Supplies," evidenced but is not limited to, "hospital bed, walker, diabetic supplies, oxygen supplies, and chux pads" The POC subsection titled "Goals/Rehabilitation Potential/Discharge Plan," evidenced but is not limited to, "Patient/caregiver will verbalize and demonstrate understanding of their medication regimen … Abdominal wound will demonstrate significant healing …" Review of the clinical record for Patient #8 revealed a SOC certification assessment dated 05/15/2025. The comprehensive assessment evidenced Patient #8 followed a diabetic diet, used a bedside commode, wheelchair, walker, chux/underpads, diabetic supplies, BiPap (type of noninvasive ventilation therapy used to help people with breathing problems), and oxygen supplies, and the discharge plan for Patient #8 was to discharge to the care of family when skill care was no longer needed and the patient had reached their maximum potential. The POC failed to evidence a diabetic diet, DME: bedside commode, bed pan, BiPap, and wheelchair, and wound care supplies, rehabilitation potential, and discharge plan. 10. Review of the clinical record for Patient #10 revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 05/08/2025 for the certification period of 05/08/2025 through 07/06/2025 and signed RN 1. The POC evidenced Patient 10 had but was not limited to, Stiff Person Syndrome (rare autoimmune neurological disorder characterized by fluctuating muscle rigidity and painful spasms), Stroke (medical emergency that occurs when blood flow to the brain is interrupted by a blockage or a ruptured vessel), and Seizure. The POC subsection titled "Safety Measure" evidenced but was not limited to, "fall, diabetic, universal precautions, infection control measure" Review of the clinical record for Patient #10 revealed a SOC certification assessment dated 05/08/2025. The comprehensive assessment evidenced Patient #10 required seizure precautions. The comprehensive assessment failed to evidence the discharge plans. The POC failed to evidence a seizure plan and seizure precautions. 11. During an interview on 06/25/2025 at 3:14 PM, the Administrator indicated the POC should include pertinent diagnosis, nutritional plan, seizure plan, safety precautions, DME, rehabilitation potential, and discharge plans. The Administrator indicated the comprehensive assessment and POC should match. 410 IAC 17-13-1(a)(1)(D)(iii, iv, v, xiii)