Every finding on record at Faithful Friends Home Healthcare Inc

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102. Survey Dates: May 20, 21, 22, and 23, 2025 Active Census: 64 At this Emergency Preparedness survey, Faithful Friends Home Healthcare 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 Recertification and State Re-Licensure survey of a Home Health Provider. Survey Dates: May 20, 21, 22, and 23, 2025 12-Month Unduplicated Skilled Admissions: 9 Survey Partially Extended on 5/21/2025 at 2:10 PM This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Refer to State Form for additional State Findings. Abbreviations RN-Registered Nurse HHA-Home Health Aide POC-Plan of Care OASIS-Outcome and Assessment Information Set QR 5/30/25 A2

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure OASIS transmissions were submitted on time for 1 of 1 agency. Findings include: 1. A review of the agency OASIS data transmission policy indicated the completed OASIS assessment would be transmitted within 30 days of the completion of the OASIS. 2. The “OASIS Error Summary by Agency Report” evidenced a 6.27% late submission rate for the period 1/01/24- 12/31/24. 3. The “OASIS Error Detail Report” evidenced 8 late submissions for the period 1/01/24- 12/31/24 as follows: Patient #5 had an OASIS assessment completed on 11/7/24. This assessment was transmitted on 12/17/2024,10 days late. Patient #9 had an OASIS assessment completed on 11/12/2024. This assessment was transmitted on 12/17/24, 4 days late. Patient #10 had an OASIS assessment completed on 4/15/24. This assessment was transmitted on 5/16/24, 1 day late. Patient #11 had an OASIS assessment completed on 11/15/24. This assessment was transmitted on 12/15/24, 2 days late. Patient #12 had an OASIS assessment completed on 4/11/24. This assessment was transmitted on 5/16/24, 5 days late. Patient #13 had an OASIS assessment completed on 6/27/24. This assessment was transmitted on 8/12/24, 16 days late. Patient #14 had an OASIS assessment completed on 11/8/24. This assessment was transmitted on 12/17/24, 9 days late. 4. During an interview on 5/21/24 at 11:40 AM, the Clinical Supervisor indicated the agency implemented a new electronic medical record on 11/24/24 which resulted in several issues with OASIS submissions. The Clinical Supervisor indicated the errors were fixed now.

Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This ELEMENT is not met as evidenced by: Based on observation, record review and interview, the agency failed to provide the physician-ordered services per the POC for 2 of 3 active patients who received HHA, attendant care, and homemaker services (Patients #2 and 3). Findings include: 1. A review of the agency policy on clinical documentation indicated “Services not provided and missed visits will be documented and reported to the physician.” 2. A review of the clinical record for Patient #2 evidenced an order for 60 hours of homemaker services (including household tasks such as cleaning, doing laundry, meal preparation, and shopping), which could be provided when needed. A review of Patient #2’s schedule from 4/6/25- 5/21/25 indicated they received homemaker services on 4/8, 4/15, 4/20, 4/22, and 5/20/25. A home visit observation occurred on 5/21/25 at 8 AM with Patient #2. The home was cluttered, had empty glasses and water bottles on an end table, cat vomit, and dirty laundry on the floor. During an interview on 5/23/25 starting at 2:45 PM, the Clinical Supervisor indicated the patient did have 60 hours of homemaker services available. They indicated they took notice of the condition of Patient #2’s home and that homemaker services should be restarted. 4. A review of Patient #3’s medical record evidenced a POC for certification period 5/6/25-7/4/25. The POC evidenced an order for 2 HHA visits per day, effective 5/6/25. A review of Patient #3’s schedule from 5/6/25- 5/20/25 indicated there were missed HHA visits on 5/6, 5/7 (2 visits), 5/8, and 5/11/25. There was no explanation for the missed visits. The schedule also identified a missed nursing visit on 5/16/25. During an interview on 5/22/25 beginning at 4:10 PM, the Clinical Supervisor indicated Patient #3 was initially resistant to the aide visits and canceled the appointments. The Clinical Supervisor indicated Patient #3’s daughter checked her blood sugar and administered the patient’s insulin when there was no nurse the morning of 5/16/25. The Clinical Supervisor indicated there should have been documentation in the chart of the reasons for the missed visits.

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 included patient- specific and measurable goals for 6 of 6 active patients (Patients #1, 2, 3, 4, 5, and 6). Findings include: 1.A review of an undated agency policy on the plan of care indicated the POC was required to be individualized. 2. A review of the clinical record for Patient #1 evidenced an Aide care plan for certification period 4/16/25 – 46/14/25. The plan evidenced a goal of “Patient’s personal care needs will be met.” The goal failed to include a measurable outcome and was not individualized. 3. A review of the clinical record for Patient #2 evidenced a POC for certification period 4/6/25-6/4/25. The POC evidenced goals which included, but were not limited to, “Patient’s personal care needs will be met … Maintain clean, safe environment … Patient/ caregiver will demonstrate necessary behaviors to maintain good safety awareness and minimize the risk of falls and/or injury.” The goals failed to include a measurable outcome and were not individualized. 4. A review of the clinical record for Patient #3 evidenced a POC for certification period 5/6/25-7/4/25. The POC evidenced goals of “Patient’s personal care needs will be met” and “Patient/caregiver will demonstrate medication compliance with use of pill reminder.” The goals failed to include a measurable outcome and were not individualized. 5. A review of the clinical record for Patient #4 evidenced a POC for the certification period 4/22/25 -6/20/25. The POC evidenced goals which included, but were not limited to, “Promote safe personal care and hygiene” and “Client will have ADL/IADL [activities of daily living/ instrumental activities of daily living] needs met each visit.” The goals failed to include a measurable outcome and were not individualized. 6. A review of the clinical record for Patient #5 evidenced a POC for the certification period 5/8/25-7/6/25. The POC evidenced a goal which included, but was not limited to, “Skin integrity will be maintained and problems managed as disease process will allow.” The goal failed to include a measurable outcome and was not individualized. 7. A review of the clinical record for Patient #6 evidenced a POC for the certification period 5/6/25-7/4/25. The POC included a goal of “Patient/ caregiver understand signs/ symptoms of complications related to diabetes and when to report.” 8. During an interview on 5/22/25 beginning at 9:30 AM, the Clinical Supervisor indicated the RN would measure the patient goals when they saw the patient for the 60-day review. The Clinical Supervisor indicated the RN would ask the patient if their showers were OK. This would indicate if personal care needs were being met. The Clinical Supervisor indicated the assessment at the 60-day review would measure if the medical goals were met. Patients #1-6 POC goals were reviewed, and the Clinical Supervisor indicated the POCs needed to be more specific in what they were looking for and needed to be specific to each patient. 410 IAC 17-13- 1(a)C(xiii)

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure supervisory visits for HHAs occurred every 14 days for 1 of 4 active patients who received HHA services (Patient #2). Findings include: 1. A review of an undated agency policy, “Home Health Aide Supervision,” indicated the RN would make supervisory visits at the patients’ home at least every 14 days for patients who received skilled nursing services and HHA services. Additionally, the policy indicated the purpose of the supervisory visit was “… to assess relationships and determine whether goals are being met.” 2. On 5/22/25 at 9:30 AM, the Clinical Supervisor provided a list of supervisory visits for Patient #2. Upon review, HHA 2 received supervisory visits for Patient #2. HHAs 3, 4, 5, and 6 did not have supervisory visits. 3. A review of the clinical record for Patient #2 evidenced a POC for certification period 4/6/25 – 6/4/25, which included skilled nurse and HHA services. A review of HHA notes indicated HHA 3 provided services to Patient #2 on 4/6, 4/7, 4/13, 4/14, 4/21, 4/22, 4/25, 4/28, 5/3, 5/5, 5/9, 5/12, 5/19, and 5/22/25. HHA 4 provided services to Patient #2 on 5/18/25. HHA 5 provided services to Patient #2 on 4/8, 4/22, 4/29, and 5/20/25. HHA 6 provided services to Patient #2 on 4/12, 4/17, 4/18, 4/19, 5/3, 5/6, 5/10, 5/16, and 5/17/25. A review of skilled nurse visits indicated RN 5 provided services to Patient #2 on 4/15, 4/29, 5/3, 5/16, 5/17, and 5/23/25. The notes failed to include a supervisory visit evaluation for HHA 3, 4, 5, or 6. A review of skilled nurse visits indicated RN 6 provided services to Patient #2 on 4/16, 4/19, 4/22, 4/23, 4/24, 4/27, 4/28, 4/29, 4/30, 5/1, 5/5, 5/6, 5/7, 5/8, 5/13, 5/14, 5/16, 5/17, 5/18, and 5/20/25. The notes failed to include a supervisory visit evaluation for HHA 3, 4, 5, or 6. During an interview on 5/21/25 at 1:29 PM, RN 4 indicated they were responsible for the supervisory visits for HHAs who provided services to Patient #2 and no other RN completed the supervisory visits. RN 4 indicated supervisory visits were required every 14 days. RN 4 indicated HHA 2 was the “primary” aide they did supervisory visits for them. RN 4 indicated they did not think they did supervisory visits for HHA 3, 4, 5, or 6. RN 4 indicated supervisory visits were required for any HHA who provided services to Patient #2, even if it was one visit. During an interview on 5/22/25 at 11:25 AM, the Clinical Supervisor indicated HHA 2 received the required supervisory visits and HHAs 3, 4, 5, and 6 had no supervisory visits.

This visit was for a Federal and State complaint survey of a Home Health Provider. Survey Dates: January 24, 25, 26, and 29, 2024. Complaint: IN103882 with related and unrelated deficiencies cited. 12 Month Unduplicated Skilled Admissions: 10 QR: 2/7/24 A 1

Have a confidential clinical record CFR(s): 484.50(c)(6) Have a confidential clinical record. Access to or release of patient information and clinical records is permitted in accordance with 45 CFR parts 160 and 164. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to protect the confidentiality for 1 of 4 clinical records reviewed (Patient #4). Findings include: 1. An agency policy titled “Client Security and Privacy” indicated any patient photos taken are for the purpose of documentation and are only taken with the patient’s written consent. An agency policy titled “Consent for Filming or Recording” indicated the agency requires patient consent to photograph patient. 2. A review of a complaint completed by the Director of Nursing (DON) on 05/03/2023 indicated Home Health Aide (HHA) 1 provided nail care to Patient #4 and posted a photo of patient’s fingernails on social media. The clinical record for Patient #4 failed to evidence the agency received a written consent to photograph patient. 3. During an interview on 01/26/2024 at 1:00 PM, the DON indicated staff are not to post patient information nor photos on social media. 410 IAC 17-12-3(b)(4)

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to notify family members of changes in patient health or current needs in 1 of 4 active patient records reviewed (Patient #1). Findings include: The clinical record for Patient #1 failed to evidence documentation of interactions and communication with Patient’s family. The emergency plan for Patient #1 identified Person 2 as Patient's emergency contact. During a phone interview on 01/24/2024 at 8:30 AM, Person 1 (a family member) indicated Patient #1 was moved to a nursing home, organized by agency staff member registered nurse (RN)1; RN 1 nor other agency notified the family. Person 1 relayed they did not know where RN 1 had moved Patient 1. During an interview on 01/25/2024 at 12:30 PM, RN 1 was unable to provide documentation of coordination or communication with Patient #1’s family. RN 1 indicated there were conversations, though none were documented in the clinical record. During a phone interview on 1/29/2024 at 10:23 AM, Person 2 (a family member) the agency did not include them in any treatment decisions nor patient updates. 410 IAC 17 - 14 - 1(a)(1)(F)

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure potential or actual conflicts of interest and oversight of staff who were engaged in dual roles with patients and followed accepted standards regarding boundaries and agency policies regarding conflicts of interest and ethics in 2 of 4 active records reviewed (Patients #1 and 5). Findings include: 11. During the entrance conference on 01/24/24 at 9:40 AM, Registered Nurse (RN) 1 introduced self as the Compliance Director; wore a name badge that identified individual as the Compliance Director. 1. A review of the American Nurses Association (ANA) code of ethics statement, available at https: //www.nursingworld.org /practice-policy /nursing-excellence /ethics/ code-of-ethics -for-nurses/ indicated “… nurses must examine the conflicts …” and “… Nurses who bill services … must be especially aware of the potential conflicts of interest.” Additionally, the code of ethics statement indicated “… nurses must maintain appropriate personal relationship boundaries.” 2. A review of a conflict-of-interest policy indicated “All staff shall conduct business practice in such a manner that no conflict of interest, real or implied could be construed.” Additionally, the policy indicated “… an actual or potential conflict of interest occurs when an [a] person is in a position to influence a decision that may result in a personal gain ….” 3. A review of a corporate compliance policy indicated ethical issues were a focus of their compliance plan. 4. A review of the abuse prevention plan policy indicated clients with limited caregiver support would be referred to social services for supervision and/ or money management services. 5. A review of a clinical decision-making policy indicated an agency code of ethics prohibited clinical staff from engaging in financial incentives. 6. A review of the ethics committee policy indicated the role of the ethics committee was to educate staff in the identification of ethical issues. 7. During an interview on 1/25/2024 beginning at 9:25 AM, the director of nursing (DON) indicated registered nurse (RN) 1 was the financial power of attorney (POA) for Patient #1. The DON indicated there was a copy of the POA, however it was not in Patient's clinical record. The DON relayed that RN 1 was not acting as POA, on behalf of the agency, therefore the document did not need to be in the clinical record. The DON indicated RN 2 was the designated health care representative (HCR) for Patient #5 and the paperwork was not in Patient #5’s clinical record as the HCR was not on behalf of the agency. 8. The clinical record for Patient #1 failed to evidence a financial or medical decision – maker for the patient. The record indicated the patient had a diagnosis of dementia since 2018. The record evidenced documents initialed by the patient which were very shaky. A review of the POA agreement between RN 1 and Patient #1 evidenced a notary stamp dated August 15, 2022. The document was signed by RN 1 and Patient #1 placed their initials to sign the document. The document indicated Patient would need to provide a written notice to revoke the POA. 9. The clinical record for Patient #5 failed to evidence a medical – decision maker. The record evidenced Patient #1 received 133 nurse visits during the time frame of 12/13/23 to 1/24/24. Of those visits, 128 were provided by RN 2 (Patient's healthcare representative) and licensed practical nurse (LPN) 1 (spouse of the healthcare representative). The record evidenced RN 2 completed the supervisory visits of LPN1, their spouse. 10. During an interview on 1/26/24 beginning at 1 PM, the DON and RN 1 indicated they did not believe there were any ethical issues or conflicts of interests with their staff, RN 1 and RN 2, in the role of patients' POA or HCR for Patient #1 and #5. When asked, RN 1 indicated Patient #1 had attended school through the 8th grade and indicated Patient was able to read and understand the POA document despite their dementia diagnosis and their limited education. RN 1 indicated Patient #1 can make their own decisions and the dementia diagnosis did not impair Patient's judgment. When asked about Patient #1’s ability to write a notice of revocation of the POA, RN 1 indicated it would be very difficult for Patient. DON and RN 1 relayed they did not think it was an ethical issue that RN 2 was the health care representative and the primary RN for Patient #5 nor did they see a conflict of interest that RN 2 supervises the LPN, their spouse. The DON and RN 1 indicated the agency did not have a process to review potential or actual ethical or conflict of interest situations. They indicated they did not believe the agency needed a process and responded that their policies reviewed were not relevant. DON indicated there were no more cases of employees acting as any clinical or financial decision – maker for any of their other patients. RN 1 indicated the agency did not have a social worker on staff and when asked, RN 1 indicated they were not aware of any community resources who might be able to assist their patient(s).

This visit was for a Federal Recertification and State Re-licensure survey of a Home Health Provider in conjunction with one complaint. This survey was partially extended on 7/07/2022. Complaint: 29524 - Unsubstantiated. Federal and State deficiencies were not cited. Survey Dates: 7/5,7/6, 7/7, and 7/8 2022 Facility Number: 003961 Census: 72 This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Refer to State Form for additional State Findings. QR: A2 on 7/22/22

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 observation, record review and interview, the agency failed to ensure the skilled nurse visit assessments accurately reflected the patient status in 1 of 3 home visit patient observations of patients with physician orders and received skilled nurse services (Patient #9). Findings include: During an home visit observation, on 7/6/2022 at 10 AM, Patient #9 exhibited contractures (shortening and hardening of muscles and tendons, ultimately resulting in a total loss of movement) in both hands and the left knee. A review of Skilled Nurse Visit Notes dated from 6/01/2022 – 7/03/2022, included 104 skilled nurse visits were provided. Of the 104 visits, 75 of the nurse visit notes failed to document Patient #9’s contractures. During an interview with the Clinical Supervisor, on 7/7/2022 at 4:15 PM, he / she confirmed the documentation should include the contractures and should accurately reflect the patient's status and needs. 410 IAC 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 and interview, the agency failed to ensure Home Health Aide (HHA) bed baths were completed in a manner consistent with aide training in 1 of 1 patient observed who received a bed bath (Patient #9). Findings include: During a home observation of HHA #2 who provided a bed bath for Patient #9, on 7/6/2022, HHA #2 failed to reposition Patient #9 in allow the aide to provide and wash Patient #9’s posterior / back side. While Patient #9 laid was on their back, HHA #2 pushed a washcloth underneath Patient and moved it towards the buttocks. HHA #2 did not observe the posterior pf Patient #9 nor provide hygiene to the posterior of Patient #9, throughout the bathing procedure. Review of a Mount Sinai web site, “Bathing a Patient in Bed” included instructions to “… roll your patient to one side and wash their back …” at https://www.mountsinai.org/health-library/selfcare-instructions/bathing-a-patient-in-bed. During an interview with HHA #2 on 7/6/2022 at 10 AM, HHA #2 relayed patients should be repositioned to their side when giving a bed bath and was necessary to visualize the skin, as well as cleaning their back. During an interview on 7/6/2022 at the end of day conference, the Clinical Supervisor confirmed patients needed to be rolled to the side when receiving a bed bath to provide a complete bath and visualize the patent's skin.