Every finding on record at Freedom Home Care, LLC

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR §484.102 Survey Dates: 03/26, 03/27, 03/30, 03/31, and 04/01/2026 Active Census: 301 At this Emergency Preparedness survey, Freedom Home Care, LLC was found out of compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR §484.102. QR completed by Area 3 on 4/13/2026.

Establishment of the Emergency Program (EP) CFR(s): 484.102 §403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.542, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must establish and maintain a [comprehensive] emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements: * (Unless otherwise indicated, the general use of the terms "facility" or "facilities" in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This CONDITION is not met as evidenced by: Based on record review and interview, the agency failed to ensure a facility based and community based risk assessment utilizing an all-hazards approach was updated every two years (E0006), attempts to contact local, regional, state, and federal officials to ensure collaboration in emergencies (E0009), ensure the patients' emergency plans were included in the comprehensive assessment (E0017), include volunteers (E0024), include contact information for staff, patients, entities providing services under arrangement, patient's physician's, and volunteers (E0030), include the name and contact information for Regional and state officials (E0031), participate in a community based full-scale exercise every two years with an analysis of the agency's response to the drill (E0039). The cumulative effect of these systematic problems resulted in the agency being out of compliance with the condition, Emergency Preparedness Requirements for Medicare Participating Providers and Suppliers for Home Health Agencies, at 42 CFR 484.102. Findings Include: 1. A review of an agency policy titled "Emergency Preparedness Policy" indicated but was not limited to, " … 4. A listing of all staff members and telephone numbers will be included in the agency's on-call book. …" 2. A review of the agency's emergency preparedness plan evidenced an untitled document indicating but not limited to, " … Freedom Home Care Emergency Preparedness Reviewed and Updated June 2025 …". The document was signed and undated by the DON, the line for the Administrator's signature was blank. The document failed to evidence what elements of the Emergency Preparedness was reviewed and updated. The agency's "Hazard Vulnerability Assessment" form was effective 03/2020. The document failed to evidence a recent review or update. A review of the Emergency Preparedness binder failed to evidence the agency contacted local, tribal, state, regional, and federal officials to ensure collaboration in emergencies. The active clinical records reviewed (Patients #1, #2, #3, #4, #5, #6, #7, and #8) failed to evidence the patient's emergency preparedness plan was included in the patients' comprehensive assessment. The Emergency Preparedness plan and policy failed to include the use of volunteers in their plan. The Emergency Preparedness plan and policy failed to include staff contact information, patient contact information, patient physicians, other entities providing services under arrangement, and volunteers information. Regional, state, and federal emergency officials were not included in the Emergency official contact list and information. Mock drills/tabletop discussions were conducted on 12/17/2024 and 10/28/2025. The mock drills failed to evidence all the employees involved in the discussion and an analysis of the results of the drills and discussion. The agency failed to evidence they conducted a full-scale emergency exercise every 2 years and performed an analysis of the results of the exercise. During an interview with the Administrator and DON on 03/27/2026 at 10:15 AM, the DON indicated they signed the review and update of Emergency Preparedness today for the June 2025 review. When queried regarding the staff, patient, patient's physicians, volunteers, and other entities contact information they indicated the patient information, with their physicians, was in the patient's individual charts. They confirmed they would not be easy to access in an emergency situation since they would need all the charts for the information. They indicated they had no volunteers at the time. They explained they had not documented their contact with local emergency officials and had not contacted state or federal officials. When asked regarding the date on the All-Hazards approach document, they indicated they would have reviewed it in June of 2025. They explained their documentation should be clear on what they reviewed and updated when they complete their annual review of their Emergency Preparedness plan. They indicated they performed the mock drills and indicated they should have included a sign-in sheet for all those involved and were unaware of a need to perform a full-scale. They confirmed they discussed the analysis of the drills and failed to document it.

This visit was for a Recertification and State Re-Licensure survey of a Home Health Provider. Survey Dates: 03/26, 03/27, 03/30, 03/31, and 04/01/2026 12-Month Unduplicated Skilled Admissions: 4 Fully-Extended survey announced on 03/27/2026 at 10:59 AM 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 DON Director of Nursing POC Plan of Care ADON Alternate Director of PT Physical Therapy Nursing SOC Start of Care ROC Resumption of Care RN Registered Nurse DC Discharge SN Skilled Nursing OASIS Outcome and Assessment Information Set ADL Activities of Daily Living QR completed by Area 3 on 4/13/2026.

Patient/payer will no longer pay for services CFR(s): 484.50(d)(2) The patient or payer will no longer pay for the services provided by the HHA; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure they discharged patients appropriately for 1 of 1 active clinical records (Patient #1) reviewed with a hold on HHA services going past the certification period and 1 of 1 closed clinical records (Patient #9) reviewed with a hold on HHA services going past the certification period. Findings Include: 3. Review of Patient # 9's inactive clinical record revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 07/17/2024, 08/16/2025 for the certification period of 12/14/2025 through 02/11/2026 and signed by RN 1. The POC indicated Patient #9 has but is not limited to, Fibromyalgia (chronic disorder characterized by widespread musculoskeletal pain, fatigue, sleep disturbances, and cognitive issues), Carpal Tunnel Syndrome (progressive condition caused by pressure on the median nerve as it passes through a narrow, rigid passageway in the wrist) since , and pain in thoracic spine (back pain). The POC indicated Patient #9 received SN services once every 60 days for recertification, and HHA services 14 hours weekly for assistance with ADL's, medication reminders, and meal prep. Review of Patient #9's inactive clinical record revealed a document titled "Addendum to: Plan of Treatment" with a SOC date of 07/17/2024, 08/16/2025 for the certification period of 12/14/2025 through 02/11/2026 and signed by the Alternate DON. The addendum stated, "Effective 01/01/2026, patient's insurance is ineffective. Patient does not wish to self-pay for services … Care on hold beginning 01/01/2026 …" On 03/31/2026 at 12:47 PM, the discharge order, discharge summary, and verification the discharge summary was sent to the physician was requested. During an interview on 03/31/2026 at 1:03 PM, the DON indicated there was no discharge information for Patient #9. 1. An agency policy titled "Services On Hold" indicated but was not limited to, " … 6. When it is anticipated that the client services will not resume within the anticipated time, the Director of Nursing will contact the appropriate staff members and initiate the discharge process. The physician will be notified of planned discharge. …" 2. A review of Patient #1's active clinical record evidenced a SOC comprehensive assessment dated 12/19/2025. Patient #1's POC with a SOC of 12/19/2025 and an initial certification period from 12/19/2025 to 02/16/2026. The POC revealed the patient received HHA services 5 hours a day, 7 days a week for 60 days. The POC was signed by the physician 01/22/2026. An addendum to the POC dated by the ADON on 12/21/2025 evidenced the patient was placed on hold by the agency until insurance approval. A POC with a SOC of 12/19/2025 and a recertification period from 02/17/2026 to 04/17/2026 evidenced an addendum and revealed the patient's HHA services started on 02/22/2026. The agency failed to ensure they discharged the patient after their certification period ended. 4. During an interview with the DON on 04/01/2026 at 11:15 AM, they explained when they had to wait on insurance they would send hold orders to the physician and keep the case open for when they received insurance approval, even when the certification period ended. 5. During an interview with the ADON on 04/01/2026 at 12:40 PM, when queried regarding their process for patients whose insurance was not approved and the certification period ended without the patient receiving services, they indicated they were unaware of the process.

Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient's eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This CONDITION is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessments included all necessary content and information of the patient (G0528), include the patients' goals, strengths, and care preferences (G0530), included the rehabilitation potential (G0534), and incorporate OASIS items for patients receiving skilled services (G0542). The cumulative effects of these systemic problems resulted in the home health agency's inability to ensure the provision of quality health care in a safe environment for the Condition of Participation of 42 CFR 484.55, Comprehensive Assessment of Patients. Findings Include: *

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the following information: (1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessments were complete and accurately reflected the patients' health status for 3 of 8 active clinical records reviewed. (Patients #1, #2, and #8) Findings Include: 3. During a home visit on 03/30/2026 at 5:00 PM, Patient #2 was observed independently playing a computer game. Review of Patient #2's active clinical record evidenced a recertification comprehensive assessment dated 02/28/2026 and signed by RN 5. The comprehensive assessment indicated Patient #2 has Bardet Biedl Syndrome (rare genetic disorder caused by dysfunctional cilia resulting in vision loss, obesity, polydactyl - presence of extra fingers or toes, renal problems, and learning disabilities), Obstructive Sleep Apnea requiring oxygen (sleep disorder where breathing repeatedly stops and starts because throat muscles relax too much resulting in the airway collapse during sleep), Hypertension (high blood pressure), and a heart murmur. The comprehensive assessment indicated Patient #2 wears glasses and is legally blind. The comprehensive assessment failed to assess Patient #2's allergies, prognosis, and hospitalization risk. 1. A policy titled "Client Assessment indicated but was not limited to, " … A thorough, well-organized, and accurate assessment … d. problem, needs, and strengths of clients e. Psychosocial Status … i. Family and/or support system capabilities/availability … 6. Discharge planning is initiated, goals are identified, and/or continuing care needs are recognized. …" 2. During a home visit at Patient #1's residence on 03/30/2026 at 4:03 PM, it was evidenced the patient spoke and understood English. A review of Patient #1's active clinical record evidenced a comprehensive assessment dated 02/14/2026. The assessment failed to evidence the section "Cardiopulmonary" was completed, included the patient was on a regular diet, the section "Skin Conditions/Wounds" was completed, indicated the patient needed an interpreter, and the risks for hospitalization or emergency room visit. Patient #1's active clinical record included a POC with a SOC of 12/19/2025 and a recertification period from 02/17/2026 to 04/17/2026. The patient's diagnoses included but were not limited to: Muscular Dystrophy (a condition where the muscles weaken and waste away, Scoliosis (an abnormal curvature of the spine in a "S" or "C" shape) status-post spinal fusion (a procedure done to connect vertebrae together to reduce pain and stabilize the spine) with infection, and Gastrostomy tube (G-tube, a device inserted in the abdomen to provide nutrients and medications in the body for individuals unable to consume enough calories by mouth) feeds long term. The POC evidenced the patient was on a regular diet with 1 to 2 cans of a nutritional shake. The POC included the patient's ability to verbally communicate and understand English. The comprehensive assessment failed to ensure it accurately reflected the patient, matched the POC, and was completed in its entirety. 4. A review of Patient #8's active clinical record evidenced a comprehensive assessment dated 01/31/2026 evidenced the section titled "EARS/NOSE/THROAT/MOUTH" was left blank. The subsections "Nasal Condition", "Pharyngeal Condition", and "Mouth Condition" were blank. The section titled "Psychosocial Status" evidenced the patient had a caregiver willing to assist the patient. The section failed to include the caregivers name and availability. The assessment revealed the patient had a pain level of a 4 out of 10, the assessment had not included what relieved the pain, pain description, and pain management. 5. During an interview with RN 7 on 04/01/2026 at 10:00 AM, they explained when they visited a patient, they completed a full comprehensive assessment and the comprehensive should match the POC. 6. During an interview with RN 5 on 04/01/2026 at 10:51 AM, they indicated the comprehensive assessment was to be fully completed for every patient and accurately reflect the patient. 7. During an interview with the DON on 04/01/2026 at 11:15 AM, they explained the comprehensive assessment was to be completed for all sections to reflect the patient's status. 8. During an interview with RN 2 on 04/01/2026 at 12:05 PM, they indicated the comprehensive should match the POC and include all the required elements. 9. During an interview with the ADON on 04/01/2026 at 12:40 PM, they explained everything pertaining to the patient should be completed and included on the comprehensive assessment with it matching the POC. 410 IAC 17-14-1(a)(1)(B)

Strengths, goals, and care preferences CFR(s): 484.55(c)(2) The patient's strengths, goals, and care preferences, including information that may be used to demonstrate the patient's progress toward achievement of the goals identified by the patient and the measurable outcomes identified by the HHA; This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure the comprehensive assessment included the patient's strengths, goals, and care preferences for 8 of 8 active clinical records reviewed (Patient # 1, 2, 3, 4, 5, 6, 7, and 8) Findings Include: 5. A review of Patient #1's comprehensive assessment dated 02/14/2026 evidenced the sections titled "Care Preferences/Patient's Personal Goals" and "Strengths/Limitations" were blank. The assessment failed to indicate the patient and caregiver's strengths, limitations, and caregiver identified goals. 6. A review of Patient #4's comprehensive assessment dated 03/03/2026 evidenced sections left blank titled "Goals Identified by Patient" and "Achievement of Goals Identified by Patient". The comprehensive assessment failed to ensure the patient's and caregiver's goals were identified in the assessment. 7. A review of Patient #5's comprehensive assessment dated 02/06/2026 evidenced the sections titled "Care Preferences/Patient's Personal Goals" and "Strengths/Limitations" were blank. The assessment failed to indicate the patient and caregiver's strengths, limitations, and caregiver identified goals. 8. A review of Patient #6's comprehensive assessment dated 02/14/2026 evidenced sections left blank titled "Goals Identified by Patient" and "Achievement of Goals Identified by Patient". The comprehensive assessment failed to ensure the patient's and caregiver's goals were identified in the assessment. 9. A review of Patient #8's active clinical record evidenced a comprehensive assessment dated 01/31/2026 evidenced sections left blank titled "Goals Identified by Patient" and "Achievement of Goals Identified by Patient". The comprehensive assessment failed to ensure the patient's and caregiver's goals were identified in the assessment. 10. During an interview with RN 7 on 04/01/2026 at 10:00 AM, they explained they included the patient's and caregiver's specified goals on the comprehensive assessment. 11. During an interview with RN 5 on 04/01/2026 at 10:51 AM, they indicated the section regarding the patient's specified goals should be written in the comprehensive assessment. 12. During an interview with the DON on 04/01/2026 at 11:15 AM, they indicated the section for the patient identified goals should be included for all patients in their comprehensive assessment. 13. During an interview with RN 2 on 04/01/2026 at 12:05 PM, they indicated they asked the patient and their caregiver their specified goals and should include them on the assessment. 14. During an interview with the ADON on 04/01/2026 at 12:40 PM, they explained the section for the patient's identified goals were to be completed on the comprehensive assessment. 1. Review of an agency policy dated 2017 and titled "Client Assessment" indicated but is not limited to, " … Evaluation and documentation is made regarding … problem, needs, and strengths of clients … Discharge planning is initiated, goals are identified …" 2. Review of Patient #2's active clinical record evidenced a recertification comprehensive assessment dated 02/28/2026 and signed by RN 5. The comprehensive assessment indicated Patient #2 has Bardet Biedl Syndrome (rare genetic disorder caused by dysfunctional cilia resulting in vision loss, obesity, polydactyl - presence of extra fingers or toes, renal problems, and learning disabilities), Obstructive Sleep Apnea requiring oxygen (sleep disorder where breathing repeatedly stops and starts because throat muscles relax too much resulting in the airway collapse during sleep), Hypertension (high blood pressure), and a heart murmur. The assessment failed to evidence patient or guardian identified strengths, goals, and care preferences. 3. Review of Patient # 3's active clinical record evidenced a recertification comprehensive assessment dated 02/17/2026. The POC indicated Patient #3 has but is not limited to, Guillian-Barre Syndrome (rare, serious autoimmune disorder where the immune system attack peripheral nerves), fall risk, muscle weakness, wheelchair bound, Hypertension (high blood pressure), and Chronic Obstructive Pulmonary Disease (COPD, progressive treatable lung disease that restricts airflow and makes breathing difficult). The assessment failed to evidence patient identified strengths or goals. 4. Review of Patient #7's active clinical record evidenced a recertification comprehensive assessment dated 02/09/2026. The assessment indicated Patient #7 has but is not limited to, Insulin dependent Diabetes Mellitus (chronic autoimmune disease where the pancreas produces little to no insulin), Asthma (chronic, non-curable lung disease that inflames and narrows the airways, making it difficult to breathe), and Hypertension (high blood pressure). The assessment failed to evidence patient identified strengths or goals.

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: Wednesday, April 1, 2026 3:58 PM Based on record review and interview the agency failed to ensure the comprehensive assessment included the patient's rehab potential and discharge planning needs for 8 of 8 active clinical records reviewed (Patient # 1, 2, 3, 4, 5, 6, 7, and 8) Findings Include: 4. A review of Patient #1's comprehensive assessment dated 02/14/2026 evidenced the sections titled "Discharge Plans" and "Rehab Potential" were blank. Patient #1's active clinical record included a POC with a SOC of 12/19/2025 and a recertification period from 02/17/2026 to 04/17/2026. The rehab potential was listed as "Guarded" and the patient's discharge plan was when the patient no longer needed assistance with ADLs. The comprehensive assessment failed to ensure the information matched the POC. 5. A review of Patient #4's comprehensive assessment dated 03/03/2026 evidenced the rehabilitation potential was blank and the discharge plan revealed there was no plan to discharge the patient. A review of Patient #4's active clinical record evidenced a POC with a SOC of 11/06/2026 and a recertification period from 03/06/2026 to 05/04/2026. The patient's prognosis was listed as "Guarded" and the discharge plan evidenced the patient would be discharged when the patient no longer needed assistance. The comprehensive assessment failed to ensure the information matched the POC. 6. A review of Patient #5's comprehensive assessment dated 02/06/2026 failed to evidence the patient's representative. The prognosis and rehabilitation potential were checked as "Good". The DC plan indicated but was not limited to, " … Family knowledgeable about when to notify physician … Patient … Family able to understand medication regimen and care related to diagnoses … Medical Condition stabilizes …" A review of Patient #5's active clinical record evidenced a POC with a SOC of 10/11/2025 and a recertification period from 02/08/2026 to 04/08/2026. The patient's prognosis and rehabilitation potential were marked as "Guarded". The DC plan for the patient indicated the patient would be discharged when they performed their ADLs independently. The comprehensive assessment failed to ensure the information matched the POC. 7. A review of Patient #6's comprehensive assessment dated 02/14/2026 evidenced the patient's prognosis was listed as "Fair", rehabilitation potential was blank, and the discharge plan revealed there was no plan to discharge the patient. Patient #6's active clinical record evidenced a POC with a ROC of 01/04/2023 and a recertification period from 02/17/2026 to 04/17/2026. The POC evidenced the patient's prognosis and rehabilitation potential were labeled as "Guarded". The discharge plan was to discharge the patient when they no longer needed assistance from the HHA. The comprehensive assessment failed to ensure the information matched the POC. 8. A review of Patient #8's active clinical record evidenced a comprehensive assessment dated 01/31/2026 evidenced the patient's prognosis was listed as "Fair", rehabilitation potential was blank, and the discharge plan revealed there was no plan to discharge the patient. Patient #8's active clinical record contained a POC with a SOC date of 03/31/2023 and a recertification period from 02/03/2026 to 04/03/2026. The POC evidenced the patient's prognosis and rehabilitation potential were labeled as "Guarded". The discharge plan was to discharge the patient when they no longer needed assistance from the HHA. The comprehensive assessment failed to ensure the information matched the POC. 9. During an interview with RN 7 on 04/01/2026 at 10:00 AM, they indicated they sometimes included the patient's rehabilitation potential on the comprehensive assessment. 10. During an interview with RN 5 on 04/01/2026 at 10:51 AM, they explained the rehabilitation potential was to be completed for each patient. 11. During an interview with the DON on 04/01/2026 at 11:15 AM, they indicated the prognosis, rehabilitation potential, and discharge plan sections should be completed and accurately reflect the POC and each patient. 12. During an interview with RN 2 on 04/01/2026 at 12:05 PM, they indicated the sections for the patient's prognosis, rehabilitation potential, and discharge planning should be completed and match the POC. 13. During an interview with the ADON on 04/01/2026 at 12:40 PM, they explained the rehabilitation potential, prognosis, and discharge plan was to be included on the comprehensive assessment. 410 IAC 17-14-1(a)(1)(B) 1. Review of Patient #2's active clinical record evidenced a recertification comprehensive assessment dated 02/28/2026 and signed by RN 5. The comprehensive assessment indicated Patient #2 has Bardet Biedl Syndrome (rare genetic disorder caused by dysfunctional cilia resulting in vision loss, obesity, polydactyl - presence of extra fingers or toes, renal problems, and learning disabilities), Obstructive Sleep Apnea requiring oxygen (sleep disorder where breathing repeatedly stops and starts because throat muscles relax too much resulting in the airway collapse during sleep), Hypertension (high blood pressure), and a heart murmur. The assessment failed to evidence Patient #2's rehab potential. 2. Review of Patient #3's active clinical record evidenced a recertification comprehensive assessment dated 02/17/2026. The POC indicated Patient #3 has but is not limited to, Guillain-Barre Syndrome (rare, serious autoimmune disorder where the immune system attack peripheral nerves), fall risk, muscle weakness, wheelchair bound, Hypertension (high blood pressure), and Chronic Obstructive Pulmonary Disease (COPD, progressive treatable lung disease that restricts airflow and makes breathing difficult). The assessment failed to evidence Patient #3's rehabilitation potential, and discharge planning. 3. Review of Patient #7's active clinical record evidenced a recertification comprehensive assessment dated 02/09/2026. The assessment indicated Patient #7 has but is not limited to, Insulin dependent Diabetes Mellitus (chronic autoimmune disease where the pancreas produces little to no insulin), Asthma (chronic, non-curable lung disease that inflames and narrows the airways, making it difficult to breathe), and Hypertension (high blood pressure). The assessment failed to indicate the patient's rehabilitation potential and discharge planning.

Incorporate OASIS items CFR(s): 484.55(c)(8) Incorporation of the current version of the Outcome and Assessment Information Set (OASIS) items, using the language and groupings of the OASIS items, as specified by the Secretary. The OASIS data items determined by the Secretary must include: clinical record items, demographics and patient history, living arrangements, supportive assistance, sensory status, integumentary status, respiratory status, elimination status, neuro/emotional/behavioral status, activities of daily living, medications, equipment management, emergent care, and data items collected at inpatient facility admission or discharge only. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure all OASIS sections in the comprehensive assessment were completed for 2 of 2 active clinical records reviewed with a patient previously receiving SN services (Patients #7 and #8) and 2 of 2 inactive clinical records reviewed with the patient receiving a skilled service (Patients #9 and #10). Findings Include: 4. Review of Patient #7's active clinical record evidenced a SOC OASIS dated 04/18/2025. The SOC OASIS indicated Patient #7 has but is not limited to, Insulin dependent Diabetes Mellitus (chronic autoimmune disease where the pancreas produces little to no insulin), Asthma (chronic, non-curable lung disease that inflames and narrows the airways, making it difficult to breathe), and Hypertension (high blood pressure). The SOC OASIS indicated Patient #7's primary caregiver is willing and able to assist with shopping, ADL's, and assist with medications. The SOC OASIS indicated Patient #7 uses a glucometer, oral hypoglycemic agents (medications used to lower blood sugar), has diabetes, and is insulin dependent. The SOC OASIS failed to provide the primary caregivers information, failed to document the patient's ability to draw up and administer their insulin, failed to identify endocrine interventions, failed to assess the patient or family knowledge and coping level regarding present diagnosis, failed to document the patient's prognosis, failed to evidence the patient is on a therapeutic diet, failed to document the rehabilitation potential, failed to document discharge planning, and failed to document goals identified by the patient. 5. Review of Patient #9's inactive clinical record evidenced a SOC OASIS dated 04/18/2025. The SOC OASIS indicated Patient #9 has but is not limited to, Fibromyalgia (chronic disorder characterized by widespread musculoskeletal pain, fatigue, sleep disturbances, and cognitive issues), Carpal Tunnel Syndrome (progressive condition caused by pressure on the median nerve as it passes through a narrow, rigid passageway in the wrist), and pain in thoracic spine (back pain). The SOC OASIS indicated Patient #9 never requires assistance with health information provided from a physician or pharmacy. The SOC OASIS indicated Patient #9's primary caregiver is willing and able to assist with shopping, ADL's, and assist with medications. The SOC OASIS failed to provide the primary caregivers information, to assess the patient or family knowledge and coping level regarding present diagnosis, to assess risk for hospitalization, failed to document the rehabilitation potential, to document discharge planning, and to document goals identified by the patient. 1. An agency policy titled "Client Assessment" indicated but was not limited to, " … A thorough, well-organized, and accurate assessment to determine the need for services will be completed by a qualified Nurse. … b. Pertinent physical findings … d. Problem, needs, and strengths of clients … f. Educational needs of the client/family/support team … h. Equipment and appropriate utilities management i. Family and/or support system capabilities/availability …" 2. A review of Patient #8's active clinical record evidenced a skilled comprehensive assessment dated 04/09/2025. The assessment failed to include the name and availability of the patient's caregiver, who provided the patient's interpreter, communication abilities and limitations for the patient or caregiver, and rehabilitation potential. The prognosis was listed as "Fair" for the patient and they had no plans to discharge the patient. Patient #8's clinical record evidenced a POC with a SOC date of 03/31/2023 and a recertification period from 08/07/2025 to 10/05/2025. The patient's prognosis and rehabilitation potential were listed as "Guarded" and they would discharge the patient when the patient was able to perform their ADLs without assistance. The comprehensive assessment failed to ensure it included all necessary information and matched the POC. 3. A review of Patient #10's inactive clinical record evidenced a SOC OASIS comprehensive assessment completed on 03/01/2026. The assessment failed to include the caregiver's availability, the patient and caregiver's communication preferences and knowledge, rehabilitation potential, patient's discharge goal, and goals identified by the patient. 4. Review of Patient #7's active clinical record evidenced a SOC OASIS dated 04/18/2025. The SOC OASIS indicated Patient #7 has but is not limited to, Insulin dependent Diabetes Mellitus (chronic autoimmune disease where the pancreas produces little to no insulin), Asthma (chronic, non-curable lung disease that inflames and narrows the airways, making it difficult to breathe), and Hypertension (high blood pressure). The SOC OASIS indicated Patient #7's primary caregiver is willing and able to assist with shopping, ADL's, and assist with medications. The SOC OASIS indicated Patient #7 uses a glucometer, oral hypoglycemic agents (medications used to lower blood sugar), has diabetes, and is insulin dependent. The SOC OASIS failed to provide the primary caregivers information, failed to document the patient's ability to draw up and administer their insulin, failed to identify endocrine interventions, failed to assess the patient or family knowledge and coping level regarding present diagnosis, failed to document the patient's prognosis, failed to evidence the patient is on a therapeutic diet, failed to document the rehabilitation potential, failed to document discharge planning, and failed to document goals identified by the patient. 5. Review of Patient #9's inactive clinical record evidenced a SOC OASIS dated 04/18/2025. The SOC OASIS indicated Patient #9 has but is not limited to, Fibromyalgia (chronic disorder characterized by widespread musculoskeletal pain, fatigue, sleep disturbances, and cognitive issues), Carpal Tunnel Syndrome (progressive condition caused by pressure on the median nerve as it passes through a narrow, rigid passageway in the wrist), and pain in thoracic spine (back pain). The SOC OASIS indicated Patient #9 never requires assistance with health information provided from a physician or pharmacy. The SOC OASIS indicated Patient #9's primary caregiver is willing and able to assist with shopping, ADL's, and assist with medications. The SOC OASIS failed to provide the primary caregivers information, to assess the patient or family knowledge and coping level regarding present diagnosis, to assess risk for hospitalization, failed to document the rehabilitation potential, to document discharge planning, and to document goals identified by the patient. 6. During an interview with RN 7 on 04/01/2026 at 10:00 AM, they explained when they visited a patient, they completed a full comprehensive assessment and the comprehensive should match the POC. 7. During an interview with RN 5 on 04/01/2026 at 10:51 AM, they indicated the comprehensive assessment was to be fully completed for every patient and accurately reflect the patient. 8. During an interview with the DON on 04/01/2026 at 11:15 AM, they explained the comprehensive assessment was to be completed for all sections to reflect the patient's status. 9. During an interview with RN 2 on 04/01/2026 at 12:05 PM, they indicated the comprehensive should match the POC and include all the required elements. 10. During an interview with the ADON on 04/01/2026 at 12:40 PM, they explained everything pertaining to the patient should be completed and included on the comprehensive assessment with it matching the POC.

Within 48 hours of the patient's return CFR(s): 484.55(d)(2) Within 48 hours of the patient's return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure a resumption of care was performed within 48 hours of a patient's return home from a hospitalization for 1 of 1 patients hospitalized (Patient #7) Findings Include: During an interview with the DON on 04/01/2026 at 11:15 AM, they indicated a ROC was to be completed within 24 hours or if the patient was out of town, 2 days. They indicated they should document if the patient was unavailable within the appropriate time frame. During an interview with the ADON on 04/01/2026 at 12:40 PM, they explained a ROC was to be performed within 48 hours after the patient was released from the hospital. 1. Review of an agency policy dated 2017 and titled "Services On Hold" indicated but is not limited to, " … When client services are resumed following hospitalization … a reassessment visit will be performed within 24 hours of notification and earlier if client condition warrants …" 2. Review of Patient # 7's active clinical record evidenced a document titled "Addendum To: Plan of Treatment" dated 03/04/2025 and signed by the Alternate DON. The addendum stated "Received call from the family. Informed our office patient was hospitalized 03/04/2025 at … due to Pneumonia (infection that inflames the air sacs in one or both lungs, causing them to fill with fluid or pus)." Review of Patient #7's active clinical record evidenced a document titled "Addendum To: Plan of Treatment" dated 03/07/2025 and signed by the Alternate DON. The addendum indicated but is not limited to, " … Informed us patient discharged … 03/06/2025. All home care services resumed …" Review of Patient #7's active clinical record evidenced a SOC OASIS dated 04/18/2025. Patient #7's active clinical record failed to evidence a resumption of care was completed with 48 hours of return home. On 03/31/2026 at 12:47 PM, the transfer summary and resumption of care comprehensive assessment was requested from the DON. During an interview on 03/31/2026 at 1:03 PM, the DON indicated they did not see a resumption of care comprehensive assessment or transfer summary within Patient #7's active clinical record.

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 all necessary elements including medications listed in simple terms, patient specified goals, interventions within the scope of a HHA, and matched the comprehensive assessment for 9 of 10 clinical records reviewed (Patients # 1, 2, 3, 4, 5, 6, 7, 8, and 9) Findings Include: 6. Patient #1's active clinical record included a POC with a SOC of 12/19/2025 and a recertification period from 02/17/2026 to 04/17/2026. The patient's diagnoses included but were not limited to: Muscular Dystrophy (a condition where the muscles weaken and waste away, Scoliosis (an abnormal curvature of the spine in a "S" or "C" shape) status-post spinal fusion (a procedure done to connect vertebrae together to reduce pain and stabilize the spine) with infection, and Gastrostomy tube (G-tube, a device inserted in the abdomen to provide nutrients and medications in the body for individuals unable to consume enough calories by mouth) feeds long term. The POC evidenced the patient was on a regular diet with 1 to 2 cans of a nutritional shake. The patient's medications included but was not limited to, " … Miralax (stool softener) 8.5 gm (grams) mixed in 8 oz (sic ounces) liquid per G-tube Q (sic every) day, Norethindrone (oral contraception and pain during menstrual cycles) 5 mg (sic milligram) 1/2 tab crushed per G-tube Q day, Clindamycin HCL (antibiotic to treat infections) 150 mg 3 caps crushed Q 8 hours via G-tube, Rifampin (used to treat bacterial infections) 60 mg/ml (sic milliliter) susp (sic suspension) 5 ml PO (sic by mouth) 2x/day (sic two times per a day), Lovenox (a blood thinner to prevent clots) 40mg/0.4ml SQ (sic subcutaneous) Q 12 hours …". The HHA provided services 5 hours a day, 7 days a week for 60 days to assist the patient with showering, dressing, hair and nail care, meal preparation, and assisting the patient with feeding by mouth and G-tube feedings. The POC failed to evidence the patient's medications were written out in layman's terms, included the patient and caregiver stated goals, and only included care the HHA could provide the patient based on their training from the agency. During an interview with HHA 2 on 03/30/2026 at 4:03 PM, they indicated they were trained by nurses from Entity 1, a hospital (not associated with the agency). 7. A review of Patient #4's active clinical record evidenced a POC with a SOC of 11/06/2026 and a recertification period from 03/06/2026 to 05/04/20026. The POC included the patient's diagnosis of Type 2 Diabetes Mellitus (a disease where the body is unable to produce enough of use insulin effectively to lower blood sugar in the blood). The medications included in the POC indicated but was not limited to, " … Meloxicam (helps with pain and inflammation) 15 mg (sic milligrams) 1 tab po (sic by mouth) daily, Vitamin C (to assist with immune function) 1000 mg 1 tab po daily, Allopurinol (works to decrease the production of uric acid in the body) 100 mg 1 tab po 2 x daily, Metformin (lower blood sugar levels) 1000 mg 1 tab po daily, Atorvastatin (lowers bad cholesterol and increases good cholesterol) 10 mg 1 tab po daily, Amlodipine (treats high blood pressure) 5 mg 1 tab po daily, Glimeperide (makes the body produce more insulin to lower blood sugar) 1 mg 1 tab po daily, Loratadine (helps get rid of sneezing, runny nose, and hives) 10 mg 1 tab po daily, Lisinopril (treat high blood pressure) 20 mg 1 tab po daily, Docusate (stool softener) 100 mg 2 caps po daily …". The patient's prognosis was listed as "Guarded" and the discharge plan evidenced the patient would be discharged when the patient no longer needed assistance. The patient received HHA services 5 hours daily, 7 days a week for 60 days for assistance with nail care. Patient #4's comprehensive assessment dated 03/03/2026 revealed the patient's prognosis was not listed as "Fair" and they listed no plans to discharge the patient. The POC failed to evidence the patient's medications were written out in layman's terms, matched the comprehensive assessment, included the patient and caregiver stated goals, and only included care the HHA was allowed to provide patients with a Diabetic diagnosis. 8. A review of Patient #5's active clinical record evidenced a POC with a SOC of 10/11/2025 and a recertification period from 02/08/2026 to 04/08/2026. The POC included the patient's diagnosis of Supplemental oxygen and the supplies for the oxygen. The POC evidenced the patient stopped using oxygen on 01/19/2026 according to physician orders. The patients prognosis and rehabilitation potential were listed as "Guarded". The POC failed to evidence the patient's caregiver and their availability. Patient #5's comprehensive assessment dated 02/06/2026 evidenced the patient's prognosis and rehabilitation potential were listed as "Good". The POC failed to evidence the POC reflected the patient's current condition, patient and caregiver stated goals, the caregiver and their availability, and ensured the POC matched the data from the comprehensive assessment. 9. Patient #6's active clinical record evidenced a POC with a ROC of 01/04/2023 and a recertification period from 02/17/2026 to 04/17/2026. The POC evidenced a diagnosis of Type 2 Diabetes Mellitus. The medications listed evidenced but was not limited to, " … Aspirin (reduce pain and inflammation) 81 mg, 1 tab po daily, Atorvastatin (lowers bad cholesterol and increases good cholesterol) 40 mg 1 tab po daily PM, Mycophenolic acid (prevents organ rejection after a kidney transplant) 360 mg 1 tabs po 2 x daily, Gabapentin (treats nerve pain) 300 mg 1 cap po twice daily, Hydrocodone Acetaminophen (for pain) 5-325 1 tab po 2x/day prn (sic as needed) pain, Hydroxyzine 25 mg 1 tab po nightly prn allergies/itch, Januvia (increases insulin in the body and reduces sugar production) 25 mg po daily, Lantus solostar (controls high blood sugar) 24 units SQ (sic subcutaneous) twice daily, Fluticasone spray (treats nasal allergy symptoms) 50 mcg (sic micrograms) INH (sic inhalation) 2 spray to each nare daily prn … Tacrolimus (prevents organ rejection for transplant patients) 1 mg 1 cap po twice daily, Nitroglycerin 0.4 mg tab Sublingual every 5 minutes x 3 tabs for chest pain … Omeprazole DR (prevents excess stomach acid production) 20 mg 1 cap po daily, Trazodone 150 mg 1-2 tabs po daily at bedtime prn insomnia (sic difficulty falling asleep), Paroxetine HCL (treats depression and anxiety) 40 mg 1 tab po daily, Oxybutynin (prevents the frequent need to urinate) 5 mg 1/2 tab po 2x daily, Fenofibrate (lowers bad cholesterol and raises good cholesterol) 43 mg 1 tab po daily, Lisinopril (treats high blood pressure) 5 mg 1 tablet po daily, Metoclopramide solution (treats heartburn) 5 mg/ 5 ml (sic milliliter) take 5 ml po 15 mins (sic minutes) before meals 2 x day, Humalog (fast acting insulin used to lower high blood sugar) Kwikpen 100 units/1 ml SQ 16 unites before breakfast, 16 unites before dinner … Insulin NPH (intermediate-acting insulin to manage blood sugar levels), 5 units SQ once daily …". The POC evidenced the patient's prognosis and rehabilitation potential were labeled as "Guarded". The discharge plan was to discharge the patient when they no longer needed assistance from the HHA. The patient received HHA services 2 hours daily Tuesday through Saturday and 48 hours through waiver services for 60 days. The HHA was to perform nail care for the patient. A review of Patient #6's comprehensive assessment dated 02/14/2026 evidenced the patient's prognosis was listed as "Fair", rehabilitation potential was blank, and the discharge plan revealed there was no plan to discharge the patient. The POC failed to list the medication information in layman's terms, accurately reflect the information in the comprehensive assessment, include the patient identified goals, and only include tasks a HHA can perform on a Diabetic patient. 10. A review of Patient #8's active clinical record evidenced a POC with a SOC of 03/31/2023 with a recertification period from 02/03/2026 to 04/03/2026. The POC revealed the patient had Noninsulin-Dependent Diabetes Mellitus (high blood sugar and the body's resistance to insulin, managed through oral medications, diet, and exercise). The patient's medications included but were not limited to, " … Tizanidine 4 mg 1 tab po daily PRN for muscle spasms, Sumatriptan 100 mg 1 tab po every 2 hrs (sic hours) prn Migraine HA (sic headache), Lisinopril (treats high blood pressure) 10 mg 1 tab po daily, Pantoprazole (treats acid reflux) 40 mg 1 tab po daily AM, Atorvastatin (lowers bad cholesterol and raises good cholesterol) 40 mg 1 tab po daily PM, Lantus (long-acting insulin to control blood sugar levels) 22 units SQ nightly, Metformin (used to lower blood sugar levels) 500 mg 2 tabs po twice daily, Tradjenta (improves blood sugar levels) 5 mg 1 tab po daily, Meclizine 25 mg 1 tab po daily prn dizziness, Albuterol 90 mcg INH 1-2 puffs every 4 hours prn SOB (sic shortness of breath) … Benzonatate 100 mg 1 tab po every 4 hours prn cough, Triamcinolone acetonide (used to treat skin redness and inflammation) ointment PRN …". The patient received HHA services 5 hours a day, Monday through Saturday for 60 days and attendant care services 42 hours a week. The HHA provided assistance with shower, ADLs, dressing, hair, foot, nail, oral care, and meal preparation. The POC evidenced the patient's prognosis and rehabilitation potential were labeled as "Guarded". The discharge plan was to discharge the patient when they no longer needed assistance from the HHA. A review of Patient #8's active clinical record evidenced a comprehensive assessment dated 01/31/2026 evidenced the patient's prognosis was listed as "Fair", rehabilitation potential was blank, and the discharge plan revealed there was no plan to discharge the patient. The POC failed to ensure the diagnoses actively reflected the medications the patient was taking, included medical information in layman's terms, included the reason for all PRN medications, included only tasks a HHA was able to perform, included the patient specified goals, and matched the comprehensive assessment. 11. During an interview with RN 7 on 04/01/2026 at 10:00 AM, when queried regarding the elements needed on the POC, they indicated the POC focused on safety of the patient, many patients had the same goals to improve their quality of life, included the patient's representatives, include medication information in layman's terms, and the POC and comprehensive assessment should have matching information. They explained the agency had not trained their HHAs to manage G-tubes. 12. During an interview with RN 5 on 04/01/2026 at 10:51 AM, they indicated the goals depended on the patient and the possibility of their improvement in a time frame. They indicated they asked patient's their specific goals. They explained they would include use abbreviations for the medications and how the patient was to take them. They indicated a HHA was not to perform nail care on a Diabetic patient and no trained by the agency to manage G-tubes. 13. During an interview with the DON on 04/01/2026 at 11:15 AM, they explained the goals included on the POC were based on the patient's needs. The patient's goals should be asked and included on the POC. The DON explained they should ensure the medications were written in a way the patient and caregiver would understand. They explained the G-tubes were managed by the patient's relatives and the HHAs were not trained by the agency to feed patients through their G-tube. 14. During an interview with RN 2 on 04/01/2026 at 12:05 PM, they indicated the POC was dependent on the specifics of each patient and should match the comprehensive assessment. They indicated nail care was not to be performed by the HHA on Diabetic patients. They indicated the medications should be written in a way the patient's and their caregivers would understand. 15. During an interview with the ADON on 04/01/2026 at 12:40 PM they explained the POC should match the information input on the comprehensive assessment and use layman's terms when describing how the patient took their medications. 410 IAC 17-13-1(a)(1)(D)(iii, iv, v, xiii) 1. Review of an agency policy dated December 2019 and titled "Plan of Care / 485 / Orders" indicated but is not limited to, " … The plan of care developed will include: … medications … Patient specific interventions … measurable outcomes and goals …" 2. Review of Patient #2's active clinical record revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 09/09/2024 for the certification period of 03/03/2026 through 05/01/2026 and signed by RN 5. The POC indicated Patient #2 has but is not limited to, Bardet Biedl Syndrome (rare genetic disorder caused by dysfunctional cilia resulting in vision loss, obesity, polydactyl - presence of extra fingers or toes, renal problems, and learning disabilities), Obstructive Sleep Apnea requiring oxygen (sleep disorder where breathing repeatedly stops and starts because throat muscles relax too much resulting in the airway collapse during sleep), Hypertension (high blood pressure), and a heart murmur. The POC subsection titled "10. Medications" indicated Patient #2 takes but is not limited to, "Metoprolol (blood pressure medication) 10 mg/1 ml suspension take 2 mL (milliliter) PO 2x/day (take 2 mL by mouth twice a day), Aspirin (medication used for to help prevent clotting or for pain) 81 mg 1 tab PO once daily (take 1 tablet by mouth daily), Oxygen 2L (liters) NC via CPAP at night (use 2 L of oxygen through a nasal cannula through a CPAP at night), Albuterol (inhaler used to improve airflow to lungs) 0.083% 2.5 mg/3 mL INH 1 vial every 6 hours prn SOB (take 1 vial every 6 hours as needed for shortness of breath)." The POC indicated the activities permitted were up as tolerated with a wheelchair. The POC failed to evidence medications listed in simple terms, and accurate activities permitted. 3. Review of Patient #3's active clinical record revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 10/23/2025 for the certification period of 02/20/2026 through 04/20/2026 and signed by RN 5. The POC indicated Patient #3 has but is not limited to, Guillian-Barre Syndrome (rare, serious autoimmune disorder where the immune system attack peripheral nerves), fall risk, muscle weakness, wheelchair bound, Hypertension (high blood pressure), and Chronic Obstructive Pulmonary Disease (COPD, progressive treatable lung disease that restricts airflow and makes breathing difficult). The POC subsection titled "10. Medications" indicated Patient #3 takes "Propranolol (blood pressure medication) 20 mg (milligrams) 1 tab PO TID (1 tablet by mouth three times a day), Azelastin HCL (eye drop used to treat itchy eyes) 0.05% 1 drop opth into eye Q day (1 drop into eye every day), Omeprazole DR (medication used to treat excess stomach acid) 40 mg 1 cap PO Q Day (1 capsule by mouth every day), and Multivitamin." The POC failed to evidence medications listed in simple terms. 4. Review of Patient #7's active clinical record revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 11/02/2024, 08/16/2025 for the certification period of 02/12/2026 through 04/12/2026 and signed by RN 1. The POC indicated Patient #7 has but is not limited to, Insulin dependent Diabetes Mellitus (chronic autoimmune disease where the pancreas produces little to no insulin), Asthma (chronic, non-curable lung disease that inflames and narrows the airways, making it difficult to breathe), and Hypertension (high blood pressure). The POC subsection titled "10. Medications" indicated Patient #7 takes "Albuterol HFA 90 mcg (micrograms, inhaler used to relax muscles in the airway to increase airflow to the lungs) INH (inhaled) 1-2 puff Q4-6 hours PRN SOB (1-2 puffs every 4-6 hours as needed for shortness of breath), Anoro Ellipta (inhaler used to relax airway muscles to improve breathing) 62.5-25 mcg INH 1 puff Q Day (1 puff every day), Lantus Solostar (long acting insulin) 100 units / 1 mL (milliliter) 10 units SQ Q day for BS 200 (take 12-14 units for a blood sugar above 200), 14-16 units for BS > 300 (take 14-16 units for a blood sugar above 300), Metformin HCL (anti-diabetic medication used to manage elevated blood sugars) 500 mg (milligrams) 1 tab PO 2x day (1 tablet by mouth twice a day), Atorvastatin (medication used to decrease cholesterol) 40 mg 1 tab PO Q day (1 tablet by mouth daily), Trazadone (medication used as a sleep aide) 50 mg 1 tab PO Q PM PRN insomnia (1 tablet by mouth as needed at night for difficulty falling asleep, staying asleep, or waking too early), Losartan Potassium (medication used to treat high blood pressure) 25 mg 1 tab PO Q day, Jardiance (medication used to help treat elevated blood sugar related to Diabetes) 25 mg 1 tab PO Q day, and Omeprazole DR (medication used to treat excess stomach acid) 40 mg 1 cap PO daily, Iprat-albut. (inhaler used to relax airway muscles to improve airflow to the lungs) 0.5-3(2.5) mg/3mL INH 2 puffs daily prn wheezing /SOB (2 puffs daily as needed for wheezing/shortness of breath), Ozempic (medication used to improve blood sugar levels in patients with diabetes) 0.25 - 0.5 mg/dose pen 0.5 mg SQ 1x week (subcutaneous once a week), Triamcinolone Acetonide ointment (steroid used to treat inflammation) 0.1% topical BID prn itching (twice a day as needed for itching), Flonase (steroid used to prevent the release of substances in the body that cause inflammation) 50 mg inh 1 spray per nostril 1 x day (1 spray per nare once a day), Lidocaine Patch (patch used to treat pain or discomfort) 5% 1 patch daily remove after 12 hrs." The orders section indicated the HHA interventions include assist with shower, skin and hair care/shampoo, dressing, foot care, and nail care. The POC failed to evidence medications listed in simple terms and included nailcare as a task for a HHA caring for a diabetic patient. 5. Review of Patient #9's inactive clinical record revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 07/17/2024, 08/16/2025 for the certification period of 12/14/2025 through 02/11/2026 and signed by RN 1. The POC indicated Patient #9 has but is not limited to, Fibromyalgia (chronic disorder characterized by widespread musculoskeletal pain, fatigue, sleep disturbances, and cognitive issues), Carpal Tunnel Syndrome (progressive condition caused by pressure on the median nerve as it passes through a narrow, rigid passageway in the wrist), and pain in thoracic spine (back pain). The POC subsection titled "10. Medications" indicated Patient #9 takes "Pregabalin (medication used to treat pain associated with Fibromyalgia) 150 mg 1 cap po 2x day (1 capsule by mouth twice a day), Duloxetine HCL (medication used to treat mood disorders) 60 mg 1 cap po daily (1 capsule by mouth daily), Diclofenac sodium (medication used to treat pain) 75 mg 1 tab po every 12 hrs prn pain (1 tablet by mouth every 12 hours as needed for pain), Meloxicam (medication used to treat pain) 7.5 mg 1 tab PO Q day with food (1 tablet by mouth every day with food), Loratadine (allergy medication) 10 mg 1 tab po q day (1 tablet by mouth every day), Triamcinolone Acetonide (steroid cream) 0.1% TOP to affected areas 2x day prn (topical to affected area as needed twice a day), Buspirone HCL (medication used to treat anxiety) 10 mg 1 tab PO daily (1 tablet by mouth daily), Hydroxyzine (medication used to treat anxiety) 25 mg 1 tab PO 2x daily (1 tablet by mouth twice a day), Pravastatin Sodium 40 mg 1 tab po daily (1 tablet by mouth daily). The POC failed to evidence medications listed in simple terms.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the agency received timely orders to hold services for 1 of 1 active clinical records reviewed with HHA services placed on hold (Patient #1) and 1 of 2 inactive records reviewed with no order to the physician to DC services (Patient #10) Findings Include: 1. An agency policy titled "Services On Hold" indicated but was not limited to, " … 6. When it is anticipated that the client services will not resume within the anticipated time, the Director of Nursing will contact the appropriate staff members and initiate the discharge process. The physician will be notified of planned discharge. …" 2. A review of Patient #1's active clinical record evidenced a SOC comprehensive assessment dated 12/19/2025. Patient #1's POC with a SOC of 12/19/2025 and an initial certification period from 12/19/2025 to 02/16/2026. The POC revealed the patient received HHA services 5 hours a day, 7 days a week for 60 days. The POC was signed by the physician 01/22/2026. An addendum to the POC dated by the ADON on 12/21/2025 evidenced the patient was placed on hold by the agency until insurance approval. The addendum was signed by the physician 03/31/2026. A POC with a SOC of 12/19/2025 and a recertification period from 02/17/2026 to 04/17/2026 evidenced an addendum and revealed the patient's HHA services started on 02/22/2026. Patient #1's active clinical record failed to ensure they received hold orders from the physician within a reasonable time frame. 3. A review of Patient #10's inactive clinical record evidenced a POC with a SOC of 03/01/2026 and an initial certification period from 03/01/2026 to 04/29/2026. The POC evidenced the patient received physical therapy for evaluation and treatment. A Physical Therapy POC with a certification period of 03/05/2026 to 04/29/2026 evidenced Patient #10 received PT services 1 to 2 times a week for 2 weeks. A discharge OASIS was completed on 03/11/2026 and evidenced Patient #10 was discharged from the agency on 03/09/2026 for the patient being unable to advance more in PT. The clinical record failed to evidence a discharge order was sent to the physician, Person 2. 4. During an interview with the ADON on 04/01/2026 at 12:40 PM, they explained for DC orders, they would have submitted an addendum to the POC explaining the need to discharge for services. They indicated they sometimes would send the DC order and summary to the physician. 410 IAC 17-13-1(a)

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 coordinate care with other entities providing services for 2 of 2 active clinical records reviewed with patients currently receiving or previously received outside services (Patient #2 and #3) Findings Include: 5. A review of Patient #5's active clinical record evidenced a POC with a SOC of 10/11/2025 and a recertification period from 02/08/2026 to 04/08/2026. The POC revealed the patient received PT services once a week. Patient #5's clinical record failed to evidence from whom they received PT services and coordination notes with the other agency. 6. During an interview with RN 7 on 04/01/2026 at 10:00 AM, they indicated they had not directly communicated with outside entities, they relayed the messages they need to the patient's physicians and the physician's offices would coordinate for them. 410 IAC 17-14-1(a)(1)(F) 1. Review of an agency policy dated 2017 and titled "Coordination of Client Services" indicated but is not limited to, " … Coordination with other agencies and institutions, if the need arises …" 2. Review of Patient #2's active clinical record revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 09/09/2024 for the certification period of 03/03/2026 through 05/01/2026 and signed by RN 5. The POC indicated Patient #2 has but is not limited to, Bardet Biedl Syndrome (rare genetic disorder caused by dysfunctional cilia resulting in vision loss, obesity, polydactyl - presence of extra fingers or toes, renal problems, and learning disabilities), Obstructive Sleep Apnea requiring oxygen (sleep disorder where breathing repeatedly stops and starts because throat muscles relax too much resulting in the airway collapse during sleep), Hypertension (high blood pressure), and a heart murmur. The POC indicated Patient #2 received PT at Entity #, a children's hospital, once every two weeks. Review of Patient #2's active clinical record evidenced a recertification comprehensive assessment dated 02/28/2026. The assessment indicated Patient #2 currently received PT and OT. 3. Review of Patient #3's active clinical record revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 10/23/2025 for the certification period of 02/20/2026 through 04/20/2026 and signed by RN 5. The POC indicated Patient #7 has but is not limited to, Guillain-Barre Syndrome (rare, serious autoimmune disorder where the immune system attack peripheral nerves), fall risk, muscle weakness, wheelchair bound, Hypertension (high blood pressure), and Chronic Obstructive Pulmonary Disease (COPD, progressive treatable lung disease that restricts airflow and makes breathing difficult). The POC indicated Patient #3 has OT for an hour twice a week and PT for an hour twice a week. Review of Patient #3's active clinical record revealed a document titled "60-Day Summary," and provided a summary of care from 12/22/2025 to 02/19/2026. The summary indicated Patient #3 works with PT and OT 1 hour each two times a week. 4. On 03/31/2026 at 12:47 PM, coordination of care notes were requested for Patient #2 and Patient #3. During an interview on 03/31/2026 at 1:03 PM, the DON indicated the agency does not coordinate care.

Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA's governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This STANDARD is not met as evidenced by: Based on record review and interview, the Governing Body failed to ensure their Quality Assurance Performance Improvement (QAPI) program identified and developed a plan to obtain skilled patient referrals for 1 of 1 agency QAPI program. Findings Include: 1. A meeting note dated 07/12/2024 evidenced the hiring of new employees was slow due to competing with larger cooperations able to offer higher compensation. A review of a document titled "Professional Advisory Group Meeting/Recommendations" dated 12/13/2024 revealed the agency had difficulty hiring RNs and HHA staff due to online retailers and fast food restaurants. The document evidenced they received referrals and were unable to accept them with their staffing shortage. A meeting note dated 07/10/2025 evidenced the hiring of new employees was slow due to competing with larger industries' ablity to offer higher compensation. A review of a document titled "Professional Advisory Group Meeting/Recommendations" dated 10/28/2025 indicated but was not limited to, " … Services offered … Inability to take on new cases with lack of staffing. … Admission Criteria … Skilled Patient census remains low; can only handle a few patients at a time. Unable to provide care to patients that require care more than twice a week. … Referrals are sent daily for patients needing services … unfortunately unable to accept due to staffing shortages." The QAPI program failed to evidence how the governing body was attempting to draw in more full-time nurses and how they were working to solve the staffing concerns. 2. A review of the employee list evidenced the agency had 11 RNs. 3. During an interview with RN 5 on 04/01/2026 at 10:51 AM, they indicated they were willing to take a wound patient if the agency had a wound. 4. During an interview on 03/27/2026 at 10:15 AM, the Administrator and DON indicated the agency did not have any active skilled nursing patients at the time of survey. When queried about the last time the agency provided skilled nursing services, the Administrator and DON indicated 2025. 5. During an interview with the Administrator, Alternate Administrator, and ADON on 04/01/2026 at 1:29 PM, the Alternate Administrator indicated they had received SN referrals, but no full time nursing staff to take on cases requiring SN visits 2 to 3 times a week. They indicated they had not kept a log of the referrals they were not proceeding to admit. They explained when they hired more full time nurses to cover the demand, they would proceed to call back the referrals requesting SN services.

Duties of a HH aide CFR(s): 484.80(g)(3) The duties of a home health aide include: (i) The provision of hands-on personal care; (ii) The performance of simple procedures as an extension of therapy or nursing services; (iii) Assistance in ambulation or exercises; and (iv) Assistance in administering medications ordinarily self-administered. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure HHAs were trained to perform Gastrostomy tube (G-tube, a tube inserted through the abdomen to bring nutrition and medications to individuals unable to eat orally) tasks by an accredited agency for 1 of 2 active clinical records reviewed with a patient having a G-tube. (Patient #5) Findings Include: 1. An agency policy titled "Home Health Aide Services" indicated but was not limited to, " … Home health aide services will be provided to appropriate clients … under the direct supervision of an agency Registered Nurse … Home Health Aide services may include: a. Assisting with bathing, dressing, feeding, weighing, back rubs, and shampoos …" 2. A review of Patient #5's active clinical record evidenced a POC with a SOC of 10/11/2025 and a recertification period from 02/08/2026 to 04/08/2026. The POC included the patient received HHA services 5 hours a day, 7 days a week for 60 days. The POC revealed the patient had a G-tube placement and was fed through the G-tube with 40 milliliters (ml) of Enfamil baby formula every 3 hours with a water flush of 4 to 5 mls of water after every second and third feed. The document titled "Home Care Aide Care Plan" evidenced the HHA was to assist Patient #5 with feeding every visit. A review of the HHA visit notes dated from 02/02/2026 to 03/31/2026 by HHA 1 evidenced, but was not limited to, " … Assist with Feeding … Special Notes: Gtube … Each Visit … Completed …". During an interview with HHA 1, through a translator (Administrative Staff 5) on 03/31/2026 at 1:26 PM, when queried regarding who was responsible for Patient #5's G-tube, they indicated HHA 1 took care of the tube. They indicated they were trained by nurses at the hospital, Entity 1, where the patient received the G-tube. HHA 1 confirmed the patient received formula only through the G-tube every 3 hours. During an interview with the DON on 04/01/2026 at 11:15 AM, they indicated the agency had not trained HHAs to maintain G-tubes and needed to take them off of the POC. They explained they will have their staff clock in and out if the patient's HHA is a relative. 410 IAC 17-14-1 (h)(9)(14)

HH aide supervision elements CFR(s): 484.80(h)(4)(i-vi) Home health aide supervision must ensure that aides furnish care in a safe and effective manner, including, but not limited to, the following elements: (i) Following the patient's plan of care for completion of tasks assigned to a home health aide by the registered nurse or other appropriate skilled professional; (ii) Maintaining an open communication process with the patient, representative (if any), caregivers, and family; (iii) Demonstrating competency with assigned tasks; (iv) Complying with infection prevention and control policies and procedures; (v) Reporting changes in the patient's condition; and (vi) Honoring patient rights. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the HHAs were supervised and included all the necessary elements for 3 of 3 pediatric active records reviewed (Patients #1, #2, and #5) and 2 of 3 records reviewed who previously receiving SN services. (Patients #7 and #9) Findings Include: 4. Review of Patient #2's active clinical record revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 09/09/2024 for the certification period of 03/03/2026 through 05/01/2026 and signed by RN 5. The POC indicated Patient #2 received SN services once every 60 days for recertification, and HHA services 35 hours weekly for assistance with ADL's. Review of Patient #2's active clinical record evidenced SN visit notes. The visit notes dated 06/03/2025, 08/02/2025, 10//01/2025, 11/30/2025, and 01/29/2026 indicated a supervisory visit was performed. The supervisory visit notes failed to evidence if the HHA was following the plan of care, maintaining open communication, demonstrated competency with assigned task, complied with infection prevention procedures, or honored patient rights. 5. Review of Patient #7's active clinical record revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 11/02/2024, 08/16/2025 for the certification period of 02/12/2026 through 04/12/2026 and signed by RN 1. The POC indicated Patient #7 received SN services every 60 days for recertification of care, and HHA services 35 hours weekly for assistance with ADL's, medication reminders, and meal preparation. Review of Patient #7's active clinical record evidenced SN visit notes. The visit notes dated 08/01/2025, 09/15/2025, 11/11/2025, 01/01/2026, and 03/11/2026 indicated a supervisory visit was performed. The supervisory visit notes failed to evidence if the HHA was following the plan of care, maintaining open communication, demonstrated competency with assigned task, complied with infection prevention procedures, or honored patient rights. 6. Review of Patient #9's inactive clinical record revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 07/17/2024, 08/16/2025 for the certification period of 12/14/2025 through 02/11/2026 and signed by RN 1. The POC indicated Patient #9 received SN services every 60 days for recertification of care, and HHA services 14 hours weekly for assistance with ADL's, medication reminders, and meal preparation. Review of Patient #9's inactive clinical record evidenced SN visit notes. The visit notes dated 04/24/2025, 05/07/2025, 05/22/2025, 06/05/2025, 09/15/2025, and 11/12/2025 indicated a supervisory visit was performed. The supervisory visit notes failed to evidence if the HHA was following the plan of care, maintaining open communication, demonstrated competency with assigned task, complied with infection prevention procedures, or honored patient rights. 7. During an interview on 03/31/2026 at 1:03 PM, the DON indicated the RNs typically alternate where the supervisory visit is documented. The DON indicated the supervisory visit notes completed on the SN visit notes were generic. 410 IAC 17-14-1(n) 1. An agency policy titled "Home Health Aide Supervision" indicated but was not limited to, " … b. Home health aide services only: … a registered nurse must make a supervisory visit to the client's residence at least once every 30 days. …" 2. Patient #1's active clinical record included a POC with a SOC of 12/19/2025 and a recertification period from 02/17/2026 to 04/17/2026. The HHA provided services 5 hours a day, 7 days a week for 60 days to assist the patient with showering, dressing, hair and nail care, meal preparation, and assisting the patient with feeding by mouth and G-tube feedings. A supervisory visit note was dated 03/14/2026. The note failed to evidence the RN verified the HHA maintains an open communication with the patient and their family, complied with infection control practices, reported any patient conditions, and honored patient rights. 3. A review of Patient #5's active clinical record evidenced a POC with a SOC of 10/11/2025 and a recertification period from 02/08/2026 to 04/08/2026. The POC included the patient received HHA services 5 hours a day, 7 days a week for 60 days. A supervisory visit note was dated 03/08/2026. The note failed to evidence the RN verified the HHA maintains an open communication with the patient and their family, complied with infection control practices, reported any patient conditions, and honored patient rights. 8. During an interview with the DON on 04/01/2026 at 11:15 AM, they indicated the supervisory visits for the HHA were to ensure the aide followed the POC, washed their hands, performed tasks appropriately, and respected the patient's rights. 9. During an interview with the ADON on 04/01/2026 at 12:40 PM, they indicated when they performed a supervisory visit, they ensured the HHA followed the POC and gave medication and blood sugar check reminders.

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 home health agency failed to ensure the Administrator notified the Indiana Department of Health the home health agency added PT services and documented all referrals received (G0948) and failed to ensure the home health agency provided skilled nursing services (G0982). These deficiencies had a potential cumulative effect on all 301 active patients. The cumulative effect of these systemic problems resulted in the home health agency's inability to ensure the provision of quality health care in a safe environment for the Condition of Participation of 42 CFR 484.105, Organization and Administration of Services. Findings Include: 410 IAC 17-12-1(a)(1)

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on record review and interview, the Administrator failed to notify the Indiana Department of Health the home health agency added physical therapy as a service the agency provided before providing PT services and tracked referrals for SN services for 1 of 1 home health agency. Findings Include: 1. During the entrance conference on 03/26/2026 at 12:45 PM, the Alternate Administrator and DON indicated the agency added physical therapy. The DON indicated the agency was servicing one PT patient. On 03/26/2026 a letter notifying the Indiana Department of Health the agency added PT was requested. During an interview on 03/27/2026 at 10:15 AM, the Administrator and DON indicated the agency began providing PT on 03/05/2026. The Administrator and DON indicated the Indiana Department of Health was not notified yet, and the agency was waiting to notify the Indiana Department of Health once the agency was servicing more PT patients. 2. A meeting note dated 07/12/2024 evidenced the hiring of new employees was slow due to competing with larger cooperations able to offer higher compensation. A review of a document titled "Professional Advisory Group Meeting/Recommendations" dated 12/13/2024 revealed the agency had difficulty hiring RNs and HHA staff due to online retailers and fast food restaurants. The document evidenced they received referrals and were unable to accept them with their staffing shortage. A meeting note dated 07/10/2025 evidenced the hiring of new employees was slow due to competing with larger cooperations able to offer higher compensation. A review of a document titled "Professional Advisory Group Meeting/Recommendations" dated 10/28/2025 indicated but was not limited to, " … Services offered … Inability to take on new cases with lack of staffing. … Admission Criteria … Skilled Patient census remains low; can only handle a few patients at a time. Unable to provide care to patients that require care more than twice a week. … Referrals are sent daily for patients needing services … unfortunately unable to accept due to staffing shortages." The agency failed to evidence how they were attempting to draw in more full-time nurses and how they were working to solve the staffing concerns. A review of the employee list evidenced the agency had 11 RNs. During an interview with the Administrator, Alternate Administrator, and ADON on 04/01/2026, the Alternate Administrator indicated they had received SN referrals, but no full time nursing staff to take on cases requiring SN visits 2 to 3 times a week. They indicated they had not kept a log of the referrals they were not proceeding to admit. They explained when they hired more full time nurses to cover the demand, they would proceed to call back the referrals requesting SN services. 410 IAC 17-12-1 (c)(1)

Skilled services furnished CFR(s): 484.105(f) Standard: Services furnished. Skilled nursing services and at least one other therapeutic service (physical therapy, speech-language pathology, or occupational therapy; medical social services; or home health aide services) are made available on a visiting basis, in a place of residence used as a patient's home. An HHA must provide at least one of the services described in this subsection directly, but may provide the second service and additional services under arrangement with another agency or organization. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure skilled nursing services were provided for 1 of 1 home health agency. Findings Include: 4. Patient #8's clinical record evidenced a POC with a SOC date of 03/31/2023 and a recertification period from 08/07/2025 to 10/05/2025. The following diagnoses were listed on the POC: Assistance with ADLs, pain, shortness of breath, Hypertension (high blood pressure), muscle weakness, and Noninsulin-Dependent Diabetes Mellitus (high blood sugar and the body's resistance to insulin, managed through oral medications, diet, and exercise). The patient received SN services every other week for assessment, medication set-up, manage blood sugar log, educate patient and family on proper diet and hydration. A review of Patient #8's Discharge OASIS comprehensive assessment dated 10/03/2025 evidenced the patient was discharge from SN services for stabilizing blood sugar levels improving and understanding how to correctly manage their medication. A review of the clinical record evidenced Patient #8 was the last patient they provided SN services. 5. During an interview on 03/26/2026 at 3:09 PM, the Alternate DON indicated the agency was servicing one skilled PT patient (Patient #10). The Alternate DON indicated the agency previously had several skilled nursing patients; however, the skilled nursing patients discharged due to meeting their goals. 6. During an interview on 03/27/2026 at 10:15 AM, the Administrator and DON indicated the agency did not have any active skilled nursing patients at the time of survey. When queried about the when was the last time the agency provided skilled nursing services, the Administrator and DON indicated 2025. 1. Review of an agency policy dated 2017 and titled "Services Provided" indicated but is not limited to, " … Freedom Home Care, LLC. Will provide intermittent, part-time, or extended hours of skilled nursing … 2. Review of Patient #7's active clinical record evidenced a document titled "Addendum to: Plan of Treatment" with a SOC date of 11/02/2024 for the certification period of 03/02/2025 through 04/30/2025 signed by the Alternate DON. The addendum indicated the agency was requesting an order to provide skilled nursing. The addendum indicated the SN would perform a multi system assessment including vital signs, weight, and blood sugar. The SN would provide education regarding the importance of checking, logging blood sugar results daily, maintain adequate hydration, encourage medication compliance and proper diet, monitor pain level and discuss pain management, assess feet and skin for skin breakdown, and maintain communication with the physician for any abnormal findings. Review of Patient #7's active clinical record evidenced a document titled "Home Health Certification and Plan of Care" with a SOC date of 11/02/2024, 04/18/2025 skilled for the certification period of 04/18/2025 through 06/16/2025 and signed by the Alternate DON. The POC indicated Patient #7 has but is not limited to, Insulin dependent Diabetes Mellitus (chronic autoimmune disease where the pancreas produces little to no insulin) since 01/01/2022, Asthma (chronic, non-curable lung disease that inflames and narrows the airways, making it difficult to breathe) since 03/01/2021, and Hypertension (high blood pressure) since 03/01/2021. The POC indicated Patient #7 received SN services once every other week for nine weeks. The POC indicated but was not limited to, the SN would provide education regarding the importance of checking, logging blood sugar results daily, maintain adequate hydration, encourage medication compliance and proper diet, monitor pain level and discuss pain management, assess feet and skin for skin breakdown, and maintain communication with the physician for any abnormal findings. The POC indicated the patient goals were but not limited to, "By the end of week 2, patient will check/log blood sugar as ordered …" Review of Patient #7's active clinical record evidenced a SOC OASIS dated 04/18/2025. The SOC OASIS indicated Patient #7 always requires help with their health literacy, and is alert and oriented. The SOC OASIS indicated the patient lives with another person around the clock. The SOC OASIS indicated the patient was able to take their medications as prescribed if reminded by another person. The SOC OASIS indicated the measurable goals were no fall or hospitalizations, no clutter, and the patient's hygiene and personal care will be met within 60 days. The SOC OASIS indicated the patient would benefit from SN due to a knowledge deficit and non-med compliance. The SOC OASIS failed to assess the patient or family's knowledge and coping level regarding present diagnosis. Review of Patient #7's active clinical record evidenced SN visit notes. The SN visit note dated 08/01/2025 indicated the RN performed a skilled observation and assessment, evaluated diet and fluid intake, provided education regarding diet, safety factors, and diabetes. The note indicated the RN educated the patient regarding activity, when to take rest, and to use breathing treatments as needed. The note indicated no further plan for SN visits, and discussion of discharge planning was not applicable. Review of Patient #7's active clinical record evidenced a discharge OASIS dated 08/15/2025. The discharge OASIS indicated the patient always required help with their health literacy, the patient was alert and oriented, and the patient is able to take medications if another person provides a medication reminder at the appropriate times. The discharge OASIS indicated diet, activity, and medication were discussed. The discharge OASIS stated "Pt [patient] is agreeable to discharging from skilled care; will now receive HHA only." The discharge OASIS evidenced an OASIS Discharge Summary. The summary indicated the patient was admitted 04/18/2025 and discharged 08/15/2025. The summary indicated the outcomes were goals met, condition improved, stabilized, and improved knowledge of self-care. The summary indicated no discharge instructions were given. 3. Review of Patient #9's inactive clinical record revealed a document titled "Addendum to: Plan of Treatment" with a SOC date of 07/17/2024 for the certification period of 03/14/2025 through 05/12/2025 and signed by the Alternate DON. The addendum indicated the agency was requesting permission to provided skilled nursing services. The addendum indicated the SN would perform an assessment, check vitals, weight, and perform a medication set up bi-weekly. The addendum indicated the SN would provide education regarding medication compliance, proper diet, maintain adequate hydration, promotion of home safety, monitor pain levels and discuss pain management options, and main communication with the physician for any abnormal findings. Review of Patient #9's inactive clinical record revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 07/17/2024, 04/18/2025-skilled for the certification period of 04/18/2025 through 06/16/2025 and signed by the Alternate DON. The POC indicated Patient #9 has but is not limited to, Fibromyalgia (chronic disorder characterized by widespread musculoskeletal pain, fatigue, sleep disturbances, and cognitive issues) since 01/01/2010, Carpal Tunnel Syndrome (progressive condition caused by pressure on the median nerve as it passes through a narrow, rigid passageway in the wrist) since 01/01/2010, and pain in thoracic spine (back pain) since 01/01/2010. The POC indicated Patient #9 received SN services bi-weekly for an assessment, medication set-up, and provide education, and HHA services 14 hours weekly for assistance with ADL's, medication reminders, and meal preparation. Review of Patient #9's inactive clinical record evidenced a SOC OASIS dated 04/18/2025. The SOC OASIS indicated Patient #9 never requires help with their health literacy, and is alert and oriented. The SOC OASIS indicated the patient lives with another person around the clock. The SOC OASIS indicated the patient was able to take their medications as prescribed if reminded by another person. The SOC OASIS indicated the measurable goals were no fall or hospitalizations, no clutter, and the patient's hygiene and personal care will be met within 60 days. The SOC OASIS indicated the patient would benefit from SN due to a knowledge deficit. The SOC OASIS failed to assess the patient or family's knowledge and coping level regarding present diagnosis. Review of Patient #9's inactive clinical record evidenced SN visit notes. The SN visit note dated 08/01/2025 indicated the RN performed a skilled observation and assessment, evaluated diet and fluid intake, provided education regarding diet, safety factors, and pain management. The note indicated the RN educated the patient regarding when to take pain medication, and encouraged the patient to ambulate, and stretch extremities three times a day. The note indicated no further plan for SN visits, and discussion of discharge planning was not applicable. Review of Patient #9's inactive clinical record evidenced a discharge OASIS dated 08/15/2025. The discharge OASIS indicated the patient sometimes required help with their health literacy, the patient was alert and oriented, and the patient is able to take medications if another person provides a medication reminder at the appropriate times. The discharge OASIS indicated the patient has stabilized and needs unskilled care. The discharge OASIS evidenced an OASIS Discharge Summary. The summary indicated the patient was admitted 04/18/2025 and discharged 08/15/2025. The summary indicated the reason for discharge was due to patient refusing care. The summary indicated the outcomes were goals met, condition improved, stabilized, and improved knowledge of self-care. The summary indicated no discharge instructions were given.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure all HHA visit notes were completed for every day worked for 5 of 8 active clinical records reviewed. (Patients #1, #4, #5, #6, and #8) Findings Include: 1. An agency policy titled "Clinical Records/Documentation Standards" indicated but was not limited to, " … Standards for documentation are listed as follows, but not limited to: … 2. Care/services will be documented at the time of care/services. …" 2. An agency policy titled "Home Health Aide: Documentation" indicated but was not limited to, " … 4. The original documentation shall be filed in the clinical record within seven (7) days of the end of the recording period. …" 3. Patient #1's active clinical record included a POC with a SOC of 12/19/2025 and a recertification period from 02/17/2026 to 04/17/2026. The HHA provided services 5 hours a day, 7 days a week for 60 days to assist the patient with showering, dressing, hair and nail care, meal preparation, and assisting the patient with feeding by mouth and G-tube feedings. An addendum to the POC revealed the patient's HHA services started on 02/22/2026. Patient #1's active clinical record evidenced on the timesheet calendar, HHA 2 had provided HHA services to Patient #1 on 02/22, 02/23, 02/24, 02/25, 02/26, 02/27, 02/28, 03/01, 03/02, 03/03, 03/04, 03/05, 03/06, 03/07, and 03/08/2026. The clinical record failed to evidence HHA visit notes for the dates listed. 3. A review of Patient #4 active clinical record evidenced a POC with a SOC of 11/06/2025 and a recertification period from 03/06/2026 to 05/04/2026. The POC evidenced the patient received HHA services 7 days a week, 5 hours a day for 60 days for assistance with ADLs, dressing, showering, oral care, foot care, and nail care. Patient #4's active clinical record evidenced on the timesheet calendar, HHA 7 had provided HHA services to Patient #4 on 02/05, 03/01, and 03/02/2026. The clinical record failed to evidence HHA visit notes for the dates listed. 4. A review of Patient #5's active clinical record evidenced a POC with a SOC of 10/11/2025 and a recertification period from 02/08/2026 to 04/08/2026. The POC included the patient received HHA services 5 hours a day, 7 days a week for 60 days for assistance with ADLs, dressing, showering, oral care, foot care, and nail care. Patient #5's active clinical record evidenced on the timesheet calendar HHA 1 had provided HHA services to Patient #5 on 02/04, 02/05, 02/06, 02/07, 02/22, and 02/27/2026. The clinical record failed to evidenced HHA visit notes for the dates listed. 5. Patient #6's active clinical record evidenced a POC with a ROC of 01/04/2023 and a recertification period from 02/17/2026 to 04/17/2026. The patient received HHA services 2 hours daily Tuesday through Saturday and 48 hours through waiver services for 60 days for assistance with ADLs, showering, nail, hair, and foot care, and meal preparation. Patient #6's active clinical record evidenced on the timesheet calendar, HHA 8 had provided HHA services on 02/05, 02/12, and 03/10/2026. The clinical record failed to evidence HHA visit notes for the dates listed. 7. During an interview with the DON on 03/31/2026 at 3:17 PM, they indicated visit notes were to be completed within 48 hours of the visit. 8. During an interview with the Alternate Administrator on 04/01/2026 at 1:15 PM, they indicated they were unable to find the visit notes requested for Patients #1, #4, #5, #6, and #8. They evidenced the schedule revealed the HHAs clocked in and out for the visits and had no visit notes for the dates requested.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure a discharge/transfer summary contained all the necessary elements and was sent to the physician for a patient transferred or discharged from the agency for 2 of 2 active clinical records reviewed (Patients #7 and #8) and 2 of 2 inactive clinical records reviewed (Patient # 9 and 10). Findings Include: 4. Patient #8's clinical record evidenced a POC with a SOC date of 03/31/2023 and a recertification period from 08/07/2025 to 10/05/2025. The following diagnoses were listed on the POC: Assistance with ADLs, pain, shortness of breath, Hypertension (high blood pressure), muscle weakness, and Noninsulin-Dependent Diabetes Mellitus (high blood sugar and the body's resistance to insulin, managed through oral medications, diet, and exercise). The patient received SN services every other week for assessment, medication set-up, manage blood sugar log, educate patient and family on proper diet and hydration. A review of Patient #8's active clinical record evidenced a document titled "Discharge Summary" with a SOC date of 04/09/2025 and a discharge date of 10/05/2025. The discharge summary failed to include the reason for admission for SN services, the types of services provided and their frequency, patient's condition at discharge, summary of the care the patient received, medications on at the time of discharge, and the patient's post-discharge instructions. The record failed to evidence the discharge summary was sent to the physician. 5. A review of Patient #10's inactive clinical record evidenced a document titled "Discharge Summary" dated by the ADON on 03/11/2026. The document evidenced the patient was admitted to the agency on 03/01/2026 for PT services and discharged on 03/09/2026. The discharge summary failed to evidence the physician responsible for the POC, reason for admission, frequency of the services, and the patient's condition at discharge. 6. During an interview with the DON on 04/01/2026 at 11:15 AM, they indicated a discharge summary was completed when the patient went from a skilled service to only an unskilled service and when a patient left the agency. They indicated the DC summary should include the services received and goals met. The DON failed to mention the other required elements necessary on a DC summary. 7. During an interview with the ADON on 04/01/2026 at 12:40 PM, they explained a DC summary would include why the patient was discharged, name, diagnosis, and the hospital they prefer. They indicated they sometimes sent the discharge summary to the physician. 410 IAC 17-15-1(a)(7) 1. Review of an agency policy dated December 2019 and titled "Discharge Summary" indicated but is not limited to, " … The discharge summary shall include: Admission date, Discharge date, Physician responsible for care, Reason for admission to home health, Type and Frequency of services provided, Labs, Current medications, Discharge condition, Patient outcomes in meeting goals in plan of care, Patient and family post discharge instructions … If the client is being referred to another agency or facility, a Transfer Summary form shall also be completed. The original Discharge Summary shall be filed in the clinical record …" Review of an agency policy dated December 2019 and titled "Client Transfer" indicated but is not limited to, " … A Transfer Summary shall be completed by the Registered Nurse and sent to the physician within 2 (two) business days of the transfer. The transfer summary shall include: Admission Date, Transfer date, Physician Responsible for care, Reason for admission to home health, Type and Frequency of services provided, Labs (if applicable), Current Medications, Transfer condition, Patient outcomes in meeting goals in plan of care, Patient and family post discharge or transfer instructions … The Transfer Summary form shall be sent to the new provider or facility and a copy shall be retained for the client's chart …" 2. Review of Patient #7's active clinical record evidenced a document titled "Addendum To: Plan of Treatment" dated 03/04/2025 and signed by the Alternate DON. The addendum stated "Received call from the family. Informed our office patient was hospitalized 03/04/2025 at … due to Pneumonia (infection that inflames the air sacs in one or both lungs, causing them to fill with fluid or pus)." On 03/31/2026 at 12:47 PM, the transfer summary and verification the transfer summary was sent to the physician was requested from the DON. During an interview on 03/31/2026 at 1:03 PM, the DON indicated they did not see a transfer summary within Patient #7's active clinical record. The clinical record failed to evidence a transfer summary was completed and sent to the physician. Review of Patient #7's active clinical record evidenced a document titled Discharge Summary. The summary indicated the patient was admitted 04/18/2025 and discharged 08/15/2025. The summary indicated the outcomes were goals met, condition improved, stabilized, and improved knowledge of self-care. The summary indicated no discharge instructions were given. The discharge summary failed to include the reason for home health, type of services provided, condition at discharge, current status, specific discharge instruction, the physician responsible for discharge, current medications, and confirmation the summary was sent to the physician. 3. Review of Patient #9's inactive clinical record evidenced a discharge OASIS dated 08/15/2025. The discharge OASIS indicated the patient sometimes required help with their health literacy, the patient was alert and oriented, and the patient is able to take medications if another person provides a medication reminder at the appropriate times. The discharge OASIS indicated the patient has stabilized and needs unskilled care. The discharge OASIS evidenced an OASIS Discharge Summary. The summary indicated the patient was admitted 04/18/2025 and discharged 08/15/2025. The summary indicated the reason for discharge was due to patient refusing care. The summary indicated the outcomes were goals met, condition improved, stabilized, and improved knowledge of self-care. The summary indicated no discharge instructions were given. The discharge summary failed to evidence the reason for home health, type of services provided, condition at discharge, current status, specific discharge instruction, the physician responsible for discharge, current medications, and confirmation the summary was sent to the physician.

An Emergency Preparedness survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102 for a Home Health Provider and Supplier. Survey Dates: 08-14, 08-15, and 08-16-2023 Active Census: 102 Unduplicated Skilled Census: 1 At this Emergency Preparedness Survey, Freedom Home Care LLC was found to be in compliance with Conditions of Participation 42 CFR 484.102 Emergency Preparedness requirements for Medicare Participating Providers and Suppliers. QR completed by A3 on 08/21/2023

This visit was for a Federal Recertification and State Re-Licensure survey of a Home Health Provider. Survey Dates: 08-14, 08-15, and 08-16-2023 Active Census: 102 12-Month Unduplicated Skilled Admissions: 1 This deficiency report reflects State Findings cited in accordance with 410 IAC 17. During this Federal Recertification and State Re-Licensure survey, a partially extended survey was announced on 08-15-2023 at 11:30 AM. No Conditions were cited. QR completed by A3 on 08/21/2023.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment was completed and accurately reflected the patient’s condition and information for 1 of 3 active clinical records reviewed without a home visit. (Patient #1) Findings Include: 1. On 08-16-2023 at 3:00 PM, the Director of Nursing (DON) provided a 2017 Freedom Home Care LLC policy titled “Client Assessment”. The policy indicated but was not limited to, “ … Purpose … ensure an accurate projection of client needs. … 1. Evaluation and documentation … a. Medical History … 8. Registered Nurses will complete assessments. …” 2. On 08-14-2023 at 2:45 PM, Patient #1’s clinical record was reviewed. The clinical record evidenced a document titled “Start of Care Version” with a start of care (SOC) date of 01-04-2023 and an assessment completed date of 01-04-2023. The document indicated but was not limited to, “ … (M1000) From which of the following Inpatient Facilities was the patient discharged within the past 14 days? … NA (sic not applicable) – Patient was not discharged from an inpatient facility. …” The comment section indicated the patient had been hospitalized from 12-14-2022 to 01-03-2023 for a kidney transplant (a surgery to replace a nonfunctional kidney with a healthy kidney). The comprehensive assessment indicated Patient #1’s primary diagnosis was ESRD (End Stage Renal Disease) with dialysis (a treatment where a machine cleans the blood in a person’s body when the kidneys are no longer functioning). The assessment evidenced a section titled “Elimination Status”, it indicated the patient’s urinary elimination was within normal limits. The start of care comprehensive assessment failed to accurately depict the patient’s current health status and condition. The comprehensive assessment failed to include an accurate assessment of a post-surgery kidney transplant patient. On 08-15-2023 at 1:25 PM, the DON provided a document dated and signed by the DON on 08-15-2023. The document indicated Patient #1 no longer had an ESRD with dialysis diagnosis and were to be on a fluid restriction because the patient’s “urination stream remains slow and weak.” The clinical record failed to ensure Patient #1’s comprehensive assessment accurately reflected the patient’s health status. 3. On 08-14-2023 at 2:45 PM, Patient #1’s clinical record was reviewed. The clinical record evidenced a document titled “Adult Re-Assessment 485 P.O.C Recertification Worksheet and OASIS follow-up”. The document indicated the comprehensive assessment was completed on 06-30-2023. The document indicated the patient’s primary diagnosis was ESRD with dialysis. The document failed to accurately reflect the patient’s health status. 4. During an interview with Person G, a patient representative at Person C’s, Patient #1’s physician, office, Entity A, on 08-15-2023 at 9:28 AM, indicated they would contact the nurse and inform them a return call was requested. The call was never returned from Entity A. 5. During an interview with Person D, a social worker, from Entity B, a dialysis center, on 08-15-2023 at 9:35 AM, they confirmed Patient #1 had a kidney transplant and was no longer on dialysis. 6. During an interview with the DON on 08-16-2023 at 10:10 AM, they confirmed Patient #1 no longer had a diagnosis of ESRD with Dialysis. 7. During an interview with the DON on 08-15-2023 at 10:10 AM, they indicated the comprehensive assessments were to be complete and accurate according to the patient’s current condition. 410 IAC 17-14-1(a)(1)(B)

Strengths, goals, and care preferences CFR(s): 484.55(c)(2) The patient's strengths, goals, and care preferences, including information that may be used to demonstrate the patient's progress toward achievement of the goals identified by the patient and the measurable outcomes identified by the HHA; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessments contained patient identified goals and preferences for 4 of 5 active clinical records reviewed. (Patients # 1, 2, 4, and 5) Findings Include: 4. A review of the clinical record for Patient #2 evidenced a document titled “Comprehensive Adult Assessment 484 P.O.C. Start of Care Version” completed on 05-19-2023. The sections titled “Goals identified by Patient” and “Achievement of Goals Identified by the Patient” were left blank. 5. A review of the clinical record for Patient #4 evidenced a document titled. The clinical record evidenced a document titled “Adult Re-Assessment 485 P.O.C Recertification Worksheet and OASIS follow-up”. The document indicated the comprehensive assessment was completed on 06-14-2023. The sections titled “Goals identified by Patient” and “Achievement of Goals Identified by the Patient” were left blank. 1. On 08-16-2023 at 3:00 PM, the Director of Nursing (DON) provided a 2017 Freedom Home Care LLC policy titled “Client Assessment”. The policy indicated but was not limited to, “ … Purpose … ensure an accurate projection of client needs. … 1. Evaluation and documentation … d. Problems, needs, and strengths of clients …” 2. On 08-14-2023 at 2:45 PM, Patient #1’s clinical record was reviewed. The clinical record evidenced a document titled “Start of Care Version” with a start of care (SOC) date of 01-04-2023 and an assessment completed date of 01-04-2023. The document contained a section titled “Patient Care Preferences Communicated by Patient”, the section was not filled out with the patient’s care preferences. The sections titled “Goals Identified by Patient” and “Achievement of Goals Identified by the Patient” were left blank and did not identify the patient-identified goals. On 08-14-2023 at 2:45 PM, Patient #1’s clinical record was reviewed. The clinical record evidenced a document titled “Adult Re-Assessment 485 P.O.C Recertification Worksheet and OASIS follow-up”. The document indicated the comprehensive assessment was completed on 06-30-2023. The sections titled “Goals Identified by Patient” and “Achievement of Goals Identified by the Patient” were left blank and did not identify the patient-identified goals. 3. On 08-15-2023 at 2:00 PM, Patient #5’s clinical record was reviewed. The clinical record evidenced a document titled “Adult Re-Assessment 485 P.O.C Recertification Worksheet and OASIS follow-up”. The document indicated the comprehensive assessment was completed on 06-30-2023. The sections titled “Goals Identified by Patient” and “Achievement of Goals Identified by the Patient” were left blank and did not identify the patient-identified goals.

Primary caregiver(s), if any CFR(s): 484.55(c)(6)(i,ii) The patient's primary caregiver(s), if any, and other available supports, including their: (i) Willingness and ability to provide care, and (ii) Availability and schedules; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the primary caregiver and their availability was listed in the comprehensive assessment for 4 of 5 active clinical records reviewed. (Patients #1, 2, 4, and 5) Findings Include: 5 .A review of the clinical record for Patient #2 evidenced a document titled “Comprehensive Adult Assessment 484 P.O.C. Start of Care Version” completed on 05-19-2023. The document contained but was not limited to a section titled “Psychosocial Status” and evidenced the question, “ Is caregiver willing and able to assist? the document indicated "yes". The sections titled "Name of Primary caregiver, Relationship, and Availability/Schedule ” were left blank. 6. A review of the clinical record for Patient #4 evidenced a document titled “Adult Re-Assessment 485 P.O.C Recertification Worksheet and OASIS follow-up completed on 06-14-2023. The document contained but was not limited to a section titled “Psychosocial Status” and evidenced the question “ Is caregiver willing and able to assist? the document indicated "yes". The sections titled "Name of Primary caregiver, Relationship, and Availability/Schedule ” were left blank. 1. On 08-16-2023 at 3:00 PM, the Director of Nursing (DON) provided a 2017 Freedom Home Care LLC policy titled “Client Assessment”. The policy indicated but was not limited to, “ … Purpose … ensure an accurate projection of client needs. … 1. Evaluation and documentation … i. Family and/or support system capabilities/availability …” 2. On 08-14-2023 at 2:45 PM, Patient #1’s clinical record was reviewed. The clinical record evidenced a document titled “Adult Re-Assessment 485 P.O.C Recertification Worksheet and OASIS follow-up”. The document indicated the comprehensive assessment was completed on 06-30-2023. The assessment contained a section titled “Psychosocial Status” and indicated but was not limited to, “ … is caregiver willing and able to assist? … Yes … Name of primary caregiver: (sic blank) … Relationship: (blank) … Availability/Schedule: (sic blank) …” The document failed include the name and availability of the patient's primary caregiver. 3. On 08-15-2023 at 2:00 PM, Patient #5’s clinical record was reviewed. The clinical record evidenced a document titled “Adult Re-Assessment 485 P.O.C Recertification Worksheet and OASIS follow-up”. The document indicated the comprehensive assessment was completed on 06-30-2023. The document contained a section titled “Psychosocial Status” and indicated but was not limited to, “ … Is caregiver willing and able to assist? … Yes … Name of primary caregiver: (sic blank) … Relationship: (sic blank) … Availability/Schedule: (sic blank) …” The assessment failed to indicate the name and availability of the patient’s primary caregiver. 4. During an interview with the Director of Nursing on 08-15-2023 at 10:10 AM, they indicated the comprehensive assessments were to be complete and accurate according to the patient’s current condition.

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 was up-to-date and reflected an accurate diagnosis for 1 of 3 active records reviewed without a home visit. (Patient #1) Findings Include: 1. On 08-15-2023 at 3:36 PM, the Director of Nursing (DON) provided a 2019 Freedom Home Care, LLC policy titled “Plan of Care / 485 / Orders”. The policy indicated but was not limited to, “ … Procedure … 1. Plan of Care … will include … all pertinent diagnosis …” 2. On 08-14-2023 at 2:45 PM, Patient #1’s clinical record was reviewed. The clinical record evidenced a plan of care with a start of care (S0C) date of 01-04-2023 and a certification period of 01-04-2023 to 03-04-2023. The plan of care evidenced a primary diagnosis of End stage renal disease (ESRD) with dialysis (a treatment where a machine cleans the blood in a person’s body when the kidneys are no longer functioning) and indicated the patient went to dialysis Mondays, Wednesdays, and Fridays. The plan of care evidenced a note indicating the patient was in the hospital from 12-14-2022 to 01-03-2023 for a kidney transplant (a surgery to replace a nonfunctional kidney with a healthy kidney). On 08-14-2023 at 2:45 PM, Patient #1’s clinical record was reviewed. The clinical record evidenced a plan of care with a start of care (S0C) date of 01-04-2023 and a certification period of 07-03-2023 to 08-31-2023. The plan of care evidenced a primary diagnosis of ESRD with dialysis. On 08-15-2023 at 1:25 PM, the DON provided a document dated and signed by the DON on 08-15-2023. The document indicated Patient #1 no longer had an ESRD with dialysis diagnosis as of 01-04-2023. The plans of care with the certification periods of 01-04-2023 to 03-04-2023 and 07-03-2023 to 08-31-2023 failed to reflect an accurate diagnosis for Patient #1. 3. During an interview with Person D, a social worker, from Entity B, a dialysis center, on 08-15-2023 at 9:35 AM, they confirmed Patient #1 had a kidney transplant and was no longer on dialysis. 4. During an interview with the DON on 08-15-2023 at 1:25 PM, they indicated the plan of care was to reflect the patient's current condition and should have been revised. 5. During an interview with the DON on 08-16-2023 at 10:10 AM, they confirmed Patient #1 no longer had a diagnosis of ESRD with Dialysis. 410 IAC 17-13-1 (a)(1)(C)

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 inform the physician the patient was hospitalized and send hold orders for 1 of 1 active clinical record reviewed with a recent hospitalization. (Patient #1) Findings Include: 1. On 08-16-2023 at 3:00 PM, the Director of Nursing (DON) provided a 2017 Freedom Home Care, LLC policy titled “Medical Supervision”. The policy indicated but was not limited to, “ … 4. Physician will be contacted when … a. Condition changes …” 2. On 08-14-2023 at 2:45 PM, Patient #1’s clinical record was reviewed. The clinical record evidenced a plan of care with a start of care (S0C) date of 01-04-2023 and a certification period of 01-04-2023 to 03-04-2023. The plan of care evidenced a primary diagnosis of End stage renal disease (ESRD) with dialysis (a treatment where a machine cleans the blood in a person’s body when the kidneys are no longer functioning) and indicated the patient went to dialysis Mondays, Wednesdays, and Fridays. The plan of care evidenced a note indicating the patient was in the hospital from 12-14-2022 to 01-03-2023 for a kidney transplant (a surgery to replace a nonfunctional kidney with a healthy kidney). On 08-15-2023 at 1:25 PM, the DON provided a document dated and signed by the DON on 08-15-2023. The document indicated but was not limited to, “ … error on previous careplan: Patient care on hold 12-14-2022-01-03-2023 …” The document indicated Patient #1 no longer had an ESRD with dialysis diagnosis as of 01-04-2023. The clinical record for Patient #1 failed to evidence a hold order sent to the physician for when the patient was hospitalized for the kidney transplant in a timely manner. The clinical record failed to evidence a discharge summary from the hospital, Entity H, were Patient #1 was discharged. 3. During an interview with the DON on 08-15-2023 at 10:10 AM, they indicated they were unable to find a order for a hold on the services for Patient #1 and they did not receive the patient’s discharge summary from Entity H. The DON indicated Home Health Aide (HHA) 2 failed to inform the agency the patient was admitted to the hospital. The DON clarified the agency discovered Patient #1 was hospitalized when Registered Nurse (RN) 1 attempted to schedule a recertification visit. The DON indicated a hold order should have been sent to the physician, Person C, when the RN discovered Patient #1 was in the hospital. 410 IAC 17-13-1(a)(2)

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 accurate information was provided to a patient’s case manager for 1 of 3 active clinical records reviewed with no home visits. (Patient #1) Findings Include: 1. On 08-15-2023 at 4:03 PM, the Director of Nursing (DON) provided a 2017 Freedom Home Care, LLC policy titled “Coordination of Client Services”. the policy indicated but was not limited to, “ … Purpose … 10. To ensure continuity of care … 1. Care Conferences will be held to establish interchange, reporting, and coordinated evaluation between all disciplines involved in the client’s care. …” 2. On 08-14-2023 at 2:45 PM, Patient #1’s clinical record was reviewed. The clinical record evidenced a plan of care with a start of care (S0C) date of 01-04-2023 and a certification period of 01-04-2023 to 03-04-2023. The plan of care evidenced a primary diagnosis of End stage renal disease (ESRD) with dialysis (a treatment where a machine cleans the blood in a person’s body when the kidneys are no longer functioning). The plan of care evidenced a note indicating the patient was in the hospital from 12-14-2022 to 01-03-2023 for a kidney transplant (a surgery to replace a nonfunctional kidney with a healthy kidney). During clinical record review for Patient #1, an email, dated 01-30-2023, from the agency to Person F, the patient’s case manager from Entity E (an agency that helps the aging population remain safe in their homes), indicating Patient #1 was in the hospital Entity H for a lung transplant. The agency failed to provide accurate information about Patient #1 to Patient #1 case manager, Person F from Entity E. The clinical record failed to evidence further communication to the case manger regarding the inaccurate information. 3. During an interview with the DON on 08-15-2023 at 1:25 PM, they indicated the email sent to Person F from Entity E was supposed to indicate kidney transplant and not a lung transplant. 410 IAC 17-14-1(a)(1)(F)

Duties of a HH aide CFR(s): 484.80(g)(3) The duties of a home health aide include: (i) The provision of hands-on personal care; (ii) The performance of simple procedures as an extension of therapy or nursing services; (iii) Assistance in ambulation or exercises; and (iv) Assistance in administering medications ordinarily self-administered. This ELEMENT is not met as evidenced by: Based on record review and interview the Agency failed to ensure the Home Health Aide duties where within their scope of practice in 2 of 2 active clinical records reviewed with home observations. (Patient's #4 and 5) 5. On 08-15-2023 at 2:00 PM, Patient #5’s clinical record was reviewed. The clinical record evidenced a Home Health Aide Plan of Care dated 07-03-2023. The aide plan of care indicated the aide would perform the tasks grocery shopping weekly and assistance to appointments weekly or as needed. The aide plan of care failed to only include tasks a Home Health Aide (HHA) could perform. The clinical record of Patient #5 evidenced documents titled “Home Health Care Activity Report” signed by HHA 9. On 07-02-2023 from 8:00 PM to 10:00 PM, HHA 9 went shopping and brought Patient #5 to an appointment. On 07-09-2023 from 8:00 PM to 10:00 PM, HHA 9 went shopping and brought Patient #5 to an appointment. On 07-16-2023 from 8:00 PM to 10:00 PM, HHA 9 went shopping and brought Patient #5 to an appointment. On 07-23-2023 from 8:00 PM to 10:00 PM, HHA 9 went shopping and brought Patient #5 to an appointment. On 07-30-2023 from 8:00 PM to 10:00 PM, HHA 9 went shopping and brought Patient #5 to an appointment. The clinical record evidenced HHA 9 performed tasks outside of their scope of practice. 410 IAC 17-14-1(h)(2)(14) 1. A review of a policy received from the Director of Nursing (DON) on 08-15-2023 at 3 PM titled “Home Health Aide Services” indicated but was not limited to “Purpose: To abide by state/federal guidelines." 2. A review of a policy received from the DON on 08-15-2023 at 3 PM titled “Home Health Aide Care Plan” indicated but was not limited to “ A Registered Nurse shall develop a complete and appropriate care plan identifying duties to be performed by the home health aide…The home health aide tasks must be related to the physical care needs of the client; he/she should not be assigned to solely homemaker tasks.” 3. A review of the clinical record for Patient #4 and an Aide Plan of Care for the Certification Period of 06-17-2023 to 08-15-2023 signed by the Alternate DON indicated but not limited to "...aide to pick up prescriptions..." 4. During an interview with the DON on 08-15-2023 at 4:16 PM when queried as to what duties a home health aide could perform she indicated personal care such as bathing, dressing, skin care, and vital signs (blood pressure, pulse, respirations). When asked if they could pick up prescriptions or other non personal care, she said "no" and explained some aides are also personal service attendants and that is for the times they work those hours.

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure the after-hours on-call process was operating and available to the public, clients, and employees as noted after 2 of 2 unsuccessful attempts to reach the after-hours phone number. Findings Include: 1. On 08-16-2023 at 3:00 PM, the Director of Nursing (DON) provided a 2017 Freedom Home Care LLC policy titled “Services Provided”. The policy indicated but was not limited to, “ … Telephone answering services will be supplied seven (7) days a week, 24 hours per day. …” 2. On 08-15-2023 at 7:38 PM, an attempt was made to reach the on-call number. The on-call number was listed in the admission packet as the office phone number. The agency failed to answer the on-call phone, and a technology- operated voice indicated the memory box was full and ended the call. A message was unable to be left. 3. On 08-16-2023 at 7:50 AM, a second attempt was made to reach the on-call number. The agency failed to answer the on-call phone, and a technology-operated voice indicated the memory box was full and ended the call. A message was unable to be left. 4. During an interview with the Administrator on 08-16-2023 at 10:48 AM, they indicated the number the patients were to call after-hours was provided in the office phone number included in the admission packet, and the message would direct the patient to call 911 in the event of an emergency or leave a message. 5. During an interview with the Administrator on 08-16-2023 at 10:52 AM, they indicated if the patients were to call the office after-hours, they were directed to call the DON’s number. 6. During an interview with the DON on 08-16-2023 at 2:30 PM, when queried about the on-call number memory box being full, they indicated the number was to include their direct number and indicated they would investigate the issue. 410 IAC 17-12-1(c)(1)