Every finding on record at First Choice Quality Care Home Health Corp

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR §484.102. Survey Dates: 11/10, 11/12, and 11/13/2025. Active Census: 8 At this Emergency Preparedness survey, First Choice Quality Care Home Health Corporation was found to be in compliance with Emergency Preparedness Requirements for a Medicaid Participating Providers and Suppliers, 42 CFR §484.102. QR by Area 3 on 11/17/2025.

This visit was for an Initial Federal Certification and State Licensure survey for a Home Health provider. Survey Dates: 11/10, 11/12, and 11/13/2025. 12 Month Unduplicated Admissions: 11 This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Abbreviations: HHA Home Health Aide ADLs Activities of Daily Living RN Registered Nurse SOC Start of care CM Clinical Manager SN Skilled Nursing POC Plan of Care QR completed by Area 3 on 11/17/2025.

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 failed to ensure services were provided per the POC in 3 of 8 active clinical records reviewed (Patients: #2, 4, and 8) and failed to ensure wound assessments were completed as ordered on the POC in 1 of 1 active patient receiving wound care. (Patient: #6) Findings Include: 1. A review of an undated agency policy titled “Care Follows the Plan of Care” indicated, but was not limited to, “ … 1. The agency will ensure that there is evidence in the patient record that: a. Care delivered, in accordance with the plan of care … ” 2. A review of an undated agency policy titled “Wound Management” indicated, but was not limited to, “ … Wound Assessment … 2. Wounds are measured weekly, preferably at the first skilled home visit of the week. If a patient is seen less often than weekly, wounds will be measured at each skilled visit … ” 3. A review of the clinical record for Patient #2, SOC date of 09/13/2025, contained a POC for the certification period of 09/13/2025 through 11/11/2025, electronically signed by the Administrator/CM. The POC indicated the following diagnoses: Type 2 Diabetes Mellitus (a condition caused by the body’s inability to control blood sugar), Obstructive Sleep Apnea (a condition in which breathing stops involuntarily for brief periods of time during sleep due to a blocked airway), Essential Hypertension (high blood pressure), and Low Back Pain. The POC had ordered services for SN 1 time a week for 8 for medication management and education for Obstructive Sleep Apnea, teaching on Continuous Positive Airway Pressure (CPAP) (a medical device used in treatment of sleep apnea delivering air through a mask to keep the airways open during sleep )use, weeks and HHA 2 times a week for 8 weeks to provide assistance with personal care and assistance with ADLs. A review of the HHA visit notes evidenced the following: During the week of 09/13/2024 through 09/20/2024, failed to evidence 2 HHA visits had been completed. During the week of 09/28/2024 through 10/04/2024, evidenced a HHA visit had been completed on 10/01/2025. The record failed to evidence two HHA services had been provided, per the POC. During the week of 10/26/2024 through 11/01/2024, evidenced a HHA visit had been completed on 10/30/2025. The record failed to evidence two HHA services had been provided, per the POC. During an interview on 11/12/2025 at 4:15 PM, when asked about the location of the missing HHA visit notes, the Administrator stated, “The patient refused visits on those days, and we should have moved the visit to a different day, and we did not.” The Administrator further confirmed Patient #2 had ordered services for HHA two times a week, and the agency had not provided HHA services two times a week. 4. A review of the clinical record for Patient #4, SOC date of 06/28/2025, contained a POC for the certification period of 10/26/2025 through 12/24/2025, electronically signed by the Administrator/CM. The POC indicated the following diagnoses: Lymphedema (a condition characterized by tissue swelling caused by an accumulation of fluid in lymphatic system), Type 1 Diabetes Mellitus with Diabetic Neuropathy (a condition caused by the body’s inability to control blood sugar which high blood sugars causing nerve damage), Essential Hypertension (high blood pressure), and Hyperlipidemia (a condition of high cholesterol). The POC had ordered services for SN 1 time a week for 8 weeks for medication management and education on diabetes, blood sugar monitoring, and pain assessments, and HHA 2 times a week for 8 weeks to provide assistance with personal care and assistance with ADLs. A review of the HHA visit notes evidenced during the week of 11/02/2025 through 11/08/2025, evidenced a HHA visit had been completed on 11/06/2025. The record failed to evidence two HHA services had been provided, per the POC. A review of the RN visit notes from the week of 11/02/2025 through 11/08/2025 revealed no RN services had been provided. During an interview on 11/12/2025 at 3:45 PM, when asked for the location of the missing HHA visit note and RN visit note for the week of 110/2/2025 through 11/08/2025, the Administrator stated, “The patient had a doctor’s appointment on 11/04/2025, the RN and HHA had missed visits, We should have moved the visit to a different day, and we did not.” The Administrator further confirmed that Patient #4 had ordered services for SN and HHA one time a week, and the agency had not provided or offered an alternative day for services to be completed within that week. 5. During the entrance conference on 11/10/2025 at 10:00 AM, when asked about the agency’s wound care policy and how often wounds are measured/assessed, the Administrator/CM communicated they measured and assessed wounds at every visit. 6. A review of the clinical record for Patient #6, SOC date of 08/28/2025, contained a POC for the certification period of 08/28/2025 through 10/26/2025, electronically signed by the Administrator/CM. The POC indicated the following diagnoses: Essential Hypertension (high blood pressure), Chronic Diastolic Heart Failure (a condition that affects the heart’s ability to pump blood to the rest of the body), Atherosclerosis native arteries of left leg with ulceration other part (a condition of plaque buildup in the arteries of the left leg leading to reduced blood flow and ulceration), Type 2 Diabetes with Diabetic Neuropathy (a condition caused by the body’s inability to control blood sugar causing nerve damage to the extremities), and Gastro-Esophageal Reflux (a condition in which stomach acid repeatedly flows back up into the throat and mouth). The POC had ordered services for SN 1 time a week for 8 weeks to assess and cleanse the right great toe incision with sterile saline, pat dry with sterile gauze, apply betadine, cover with a non-adherent dressing, then a second layer of sterile gauze, and secure with tape. A review of the SN visit notes evidenced the following: During the week of 09/14/2025 through 09/20/2025, a RN visit had been completed on 09/18/2025, documented wound measurements of 1.20 centimeters (cm) x 1.00 cm x 0.10 cm. During the week of 09/21/2025 through 09/27/2025, a RN visit had been completed on 09/25/2025, but failed to evidence measurements had been completed per the POC. During the week of 09/28/2025 through 10/04/2025, a RN visit had been completed on 10/03/2025, documented wound measurements of 1.10 cm x 5.00 cm x 0.00 cm. During the week of 10/05/2025 through 10/11/2025, a RN visit had been completed on 10/09/2025, but failed to evidence measurements had been completed per the POC. During the week of 10/12/2025 through 10/18/2025, a RN visit had been completed on 10/15/2025, with wound measurements of 1.20 cm x 1.00 cm x 1.00 cm. During an interview on 11/12/2025 at 4:00 PM, when requested the location of Patient #6’s wound measurements for their visits on 09/25/2025 and 10/03/2025, the Administrator reviewed Patient #6’s chart and confirmed the wound measurements had not been completed during those visits, as per the POC. 7. A review of the clinical record for Patient #8, with a SOC date of 09/24/2025, contained a POC for the certification period from 09/24/2025 through 11/22/2025, electronically signed by the Administrator/CM. The POC indicated the following diagnoses: Type 2 Diabetes Mellitus with Diabetic Neuropathy (a condition caused by the body’s inability to control blood sugar which high blood sugars caused nerve damage), Dizziness and Giddiness (a condition feeling lightheaded, faintness, unsteady and imbalanced), Essential Hypertension (high blood pressure), Chronic Obstructive Pulmonary Disease (a condition of lack of airflow caused by inflammation caused by various lung diseases), Pruritus (itching), and Allergic Rhinitis (a condition of inflammation of the nasal passages). The POC had ordered services for SN 1 time a week for 8 weeks, including pain assessment, medication management, disease management, and safety for vertigo. Additionally, HHA services were ordered 3 times a week for 8 weeks to provide assistance with personal care and ADLs. A review of the HHA visit notes evidenced the following: During the week of 09/24/2024 through 09/27/2024, evidenced a HHA visit had been completed on 09/26/2025 and 09/27/2025. The record failed to evidence 3 HHA services had been provided, per the POC. During the week of 10/19/2024 through 10/25/2024, evidenced a HHA visit had been completed on 10/21/2025 and 10/22/2025. The record failed to evidence 3 HHA services had been provided, per the POC. During an interview on 11/12/2025 at 4:15 PM, when asked for the location of the missing HHA visit notes, the Administrator reviewed Patient #8’s record and indicated the patient had only been seen two times and could not provide the third visit note. The Administrator further confirmed Patient #8 had ordered services for HHA three times a week, but the agency had not provided HHA services at that frequency. 410 IAC 17-13-1(a)

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the physician had been notified of changes in a patient’s wound for 1 of 1 patients receiving wound care clinical records reviewed. (Patient: #6) Findings Include: 1. A review a an undated agency policy titled “ Physician’s Plan of Treatment and Order” indicated, but was not limited to, “Responsibility of Organization: 1. The organization will notify the physician either verbally, and/or in writing, or fax of the patient/client condition, including, but not limited to, the following: d. New clinical symptoms become evident. … g. Changes occur in the patient/client’s expected response to treatment … ” 2. A review of an undated agency policy titled “Wound Management” indicated, but was not limited to, “ … Wound Assessment … 2. Wounds are measured weekly, preferably at the first skilled home visit of the week. If a patient is seen less often than weekly, wounds will be measured at each skilled visit … c. Wound deterioration or lack of healing will be reported to the physician or allowed practitioner … ” 3. During the entrance conference on 11/10/2025 at 10:00 AM, when asked about the agency’s wound care policy and how often wounds are measured/assessed, the Administrator/CM communicated that they measure and assess wounds at every visit and notify the physician of any changes. 4. A review of the clinical record for Patient #6, SOC date of 08/28/2025, contained a POC for the certification period of 08/28/2025 through 10/26/2025, electronically signed by the Administrator/CM. The POC indicated the following diagnoses: Essential Hypertension (high blood pressure), Chronic Diastolic Heart Failure (a condition that affects the heart’s ability to pump blood to the rest of the body), Atherosclerosis native arteries of left leg with ulceration other part (a condition of plaque buildup in the arteries of the left leg leading to reduced blood flow and ulceration), Type 2 Diabetes with Diabetic Neuropathy (a condition caused by the body’s inability to control blood sugar cases nerve damage to the extremities), and Gastro-Esophageal Reflux (a condition in which stomach acid repeatedly flows back up into the throat and mouth). The POC had ordered services for SN 1 time a week for 8 weeks to assess and cleanse the right great toe incision with sterile saline, pat dry with sterile gauze, apply betadine, cover with a non-adherent dressing, then a second layer of sterile gauze, and secure with tape. A review of the SN visit notes evidenced the following: During the week of 09/14/2025 through 09/20/2025, a RN visit had been completed on 09/18/2025, documented wound measurements of 1.20 centimeters,(cm) x 1.00 cm x 0.10 cm. During the week of 09/21/2025 through 09/27/2025, a RN visit had been completed on 09/25/2025, but failed to evidence measurements had been completed per the POC. During the week of 09/28/2025 through 10/04/2025, a RN visit had been completed on 10/03/2025, documented wound measurements of 1.10 cm x 5.00 cm x 0.00 cm. The RN visit note failed to evidence that the physician had been notified of a change in the wound's increased size. During the week of 10/05/2025 through 10/11/2025, a RN visit had been completed on 10/09/2025, but failed to evidence measurements had been completed per the POC. During the week of 10/12/2025 through 10/18/2025, a RN visit had been completed on 10/15/2025, with wound measurements of 1.20 cm x 1.00 cm x 1.00 cm. The RN visit note failed to evidence the physician had been notified of a change in the increased size of the wound. A review of the communication notes dated 08/28/2025 through 11/12/2025 failed to evidence the physician had been notified of the changes in Patient #6’s wound size measurements. During an interview on 11/12/2025 at 4:00 PM, when asked the regarding the process for reporting to the physician changes in the wounds and the documentation for Patient #6’s physician for the increased size in the wound documented 10/03/2025 and 10/15/2025, the Administrator communicated they had not notified the physician of changes in the wound, there had to be a mistake in the documentation they had completed. 410 IAC 17-13-1(a)(2)

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 HHAs provided services per the POC in 1 of 2 active clinical records reviewed of HHA home visit observations. (Patients: # 8) Findings Include: 1. A review of an undated agency policy titled “Home Health Aide Duties” indicated, but was not limited to, “ … Definition of Home Health Aide Services (Aide Services): 1. A Home health aide provides services that are: a. Ordered by the physician … b. Included in the plan of care … c. The written instructions provided to the home health aide must specify the task to be provided and how frequently to provide it … d. Revisions to the aide plan of care must be discussed, approved, and documented by the RN … The home health aide should document the discussion with the RN … if a revision is made to the plan of care … ” 2. During a home visit at the residence of Patient #8 on 11/12/2025 at 8:00 AM, observed HHA 1 completing hand hygiene, donning gloves, and obtaining a temperature, pulse, and oxygen saturation for Patient #8. HHA 1 asked Patient #8 if they could take their blood pressure. Patient #8 stated, “You know I don’t like you taking my blood pressure. I only want the nurse doing that.” HHA 1 reported Patient #8 had always refused to have their blood pressure taken and would only allow the nurse to do it during their visits. A review of the clinical record for Patient #8, with a SOC date of 09/24/2025, contained a POC for the certification period from 09/24/2025 through 11/22/2025, electronically signed by the Administrator/CM. The POC indicated the following diagnoses: Type 2 Diabetes Mellitus with Diabetic Neuropathy (a condition caused by the body’s inability to control blood sugar which high blood sugars caused nerve damage), Dizziness and Giddiness (a condition feeling lightheaded, faintness, unsteady and imbalanced), Essential Hypertension (high blood pressure), Chronic Obstructive Pulmonary Disease (a condition of lack of airflow caused by inflammation caused by various lung diseases), Pruritus (itching), and Allergic Rhinitis (a condition of inflammation of the nasal passages). The POC had ordered services for SN 1 time a week for 8 weeks, including pain assessment, medication management, disease management, and safety for vertigo. Additionally, HHA services were ordered 3 times a week for 8 weeks to provide assistance with personal care and ADLs. A review of the Aide POC dated 09/25/2025 and signed by the Administrator/CM, contained orders for HHA 3 times a week for 8 weeks. The Aide POC assignments included each visit obtaining temperature, respirations, blood pressure, pulse rate, hair care, nail care, dressing, light housekeeping, light laundry, make bed, sweep, vacuum, take out trash encourage conversation, and weekly bed linen changes, light housekeeping, take out trash, feed and take care of pets, water plants. A review of the HHA visit notes dated 09/24/2025 through 11/12/2025 evidenced the following: During the week of 09/24/2025 through 09/27/2025, the HHA visit notes dated 09/26/2025 and 09/27/2025, evidenced blanks for temperature, respirations, blood pressure, and pulse rate. During the week of 09/28/2025 through 10/04/2025, the HHA visit notes dated 09/30/2025, 10/01/2025, and 10/03/2025, evidenced blanks for temperature, respirations, blood pressure, and pulse rate. During the week of 10/05/2025 through 10/11/2025, the HHA visit notes dated 10/07/2025, 10/08/2025, and 10/09/2025, evidenced blanks for temperature, respirations, blood pressure, and pulse rate. During the week of 10/12/2025 through 10/18/2025, the HHA visit notes dated 10/14/2025, 10/15/2025, and 10/17/2025, evidenced blanks for temperature, respirations, blood pressure, and pulse rate. During the week of 10/19/2025 through 10/25/2025, the HHA visit notes dated 10/21/2025 and 10/22/2025, evidenced blanks for temperature, respirations, blood pressure, pulse rate. During the week of 10/26/2025 through 11/01/2025, the HHA visit notes dated 10/28/2025, 10/29/2025, and 10/30/2025, evidenced documentation Patient #8 refused HHA to had obtained blood pressure. During the week of 11/02/2025 through 11/08/2025, the HHA visit notes dated 11/04/2025, 11/05/2025, and 11/07/2025, evidenced documentation Patient #8 refused HHA to had obtained blood pressure. During an interview on 11/12/2025 at 2:55 PM, when asked regarding the HHA POC assignment and process for the HHAs to follow if the patient refuses tasks, the Administrator/CM communicated vital signs were to be taken every visit; if not, the HHA is to report to the RN, and the HHA POC needs to be updated.

Aides are members of interdisciplinary team CFR(s): 484.80(g)(4) Home health aides must be members of the interdisciplinary team, must report changes in the patient's condition to a registered nurse or other appropriate skilled professional, and must complete appropriate records in compliance with the HHA's policies and procedures. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure the HHA notified the RN of changes in the patient’s condition in 1 of 2 (Patient: # 8) HHA home visit observations conducted. Findings Include: 1. A review of an undated agency policy “Coordination of Services” indicated, but was not limited to, “1. The organization coordinates care by: … d. Integrating services, whether services are provided directly, or under arrangement, to ensure the identification of patient needs, factors that could affect patient safety, treatment effectiveness, and the coordination of care by all disciplines … ” 2. A review of an undated agency policy “Home Health Aide Service” indicated, but was not limited to, “ … Duties of a Home Health Aide: … m. Observe any deviations from the usual physical or mental status of the patient/client, and immediately report the fact to the coordinating nurse … ” 3. During a home visit at the residence of Patient #8 on 11/12/2025 at 8:00 AM, observed HHA 1 completing hand hygiene, donning gloves, and obtaining a temperature, pulse, and oxygen saturation for Patient #8. Patient #8 refused their shower, complaining of nausea and stomach discomfort. During an interview on 11/12/2025 at 8:40 AM, when questioned regarding the process when a patient has a change in condition, HHA 1 stated, “I notify the [Administrator/CM], or [Alternate Administrator/Alternate CM]. They are always available.” A review of the Clinical record for Patient #8, SOC 09/24/2025, contained a HHA visit note dated 11/12/2025, which failed to evidence the RN had been notified of Patient #8’s change in condition. A review of the communication notes dated 09/24/2025 to 11/12/2025 failed to evidence HHA 1 had communicated Patient #8’s change in condition. During an interview on 11/12/2025 at 2:55 PM, when questioned, the Administrator/CM regarding the process of the HHA when a patient has a change in condition, the Administrator/CM stated, “HHAs are to notify the RN for following up if they have noted a change in condition, or if their vital signs are outside the call parameters.” When asked for the notification from HHA 1 to the Administrator/CM regarding Patient #8’s complaints of nausea and stomach issues during the home visit this morning, the Administrator/CM stated, “No. I did not know.”