Every finding on record at Gant Family Home Health Care LLC

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 494.62. Survey Dates: 04/21/2025 and 04/22/2025 Active Census: 7 At this Emergency Preparedness survey, Gant Family Home Health Care LLC. was not found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 494.62. QR completed by Area 3/WL.

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to ensure the communication plan included the names and contact information for staff, entities providing services under arrangement, patients' physicians, and volunteers for one of one home health agencies. Findings Include: 1. Record review of an undated agency policy titled "Communication Plan for Emergency Preparedness" indicated but was not limited to, "POLICY As part of the agency's overall emergency disaster plan, the agency will establish and maintain a communication that complies with Federal, State, and local laws, and must be reviewed and updated at least every two years. 1. The communication plan must include all of the following: a. Names and contact information for the following: i. staff ii. Entities providing services under arrangement iii. Client's physicians iv. Volunteers 2. Record review of an undated agency document titled "Emergency Preparedness Communication Plan" failed to evidence contact information for staff, entities providing services under arrangement, patients' physicians, or volunteers. During an interview on 04/22/2025 at 2:53 PM, the DON indicated there was no contact information for staff, entities providing services under arrangement, patients' physicians, or volunteers within the communication plan.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to evidence who attended the exercise, who was contacted during the scenarios, who responded to the scenario, documentation of discussion of the scenarios, and documentation of discussion of an after action plan for one of one home health agency. Findings Include: 1. Record review of an undated agency policy titled "Emergency Disaster Plan Orientation and Training" indicated but was not limited to, " … Testing. The agency must conduct exercises to test the emergency plan at least annually. The agency must do the following: 1. Participate in a full-scale exercise that is community based; or a. When a community based exercise is not accessible, conduct an annual individual, agency based functional exercise every 2 years … 2. Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise is conducted … c. A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. 3. Analyze the agency's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the agency's emergency plan as needed …" 2. Record review of an undated agency document titled "Tabletop Exercise: Home Health Care Emergency Preparedness Plan" indicated but was not limited to, "Title: Winter Storm Emergency Response for Home Health Care Agencies … Date: 01/10/2025 … Scenario Overview It is January 10, 5:00 AM …" The tabletop exercise failed to evidence who attended the exercise, who was contacted during the scenario, who responded to the scenario, documentation of discussion of the scenario, or documentation of discussion of an after action plan. During an interview on 04/22/2025 at 2:53 PM, when queried about when testing was completed the DON indicated she thought the testing occurred on 01/10/2025. When queried about a roster to verify staff attendance, the DON indicated there was no roster. When queried if an after action plan was created following the table top exercise, the DON indicated no.

This visit was for an Initial Federal Certification for a Home Health provider. Survey Dates: 04/21/2025 and 04/22/2025 12 Month Unduplicated Admissions: 6 This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Refer to State Form for additional State Findings. Abbreviations: HHA Home Health Aide CNA Certified Nursing Assistant RN Registered Nurse DON Director of Nursing POC Plan of Care SOC Start of care ROC Resumption of Care SN Skilled Nursing DME Durable Medical Equipment HHA Home Health Aide OASIS Outcome and Assessment Information Set QR completed by Area 3/WL.

Discharge or Transfer Summary Content CFR(s): 484.58(b)(1) Standard: Discharge or transfer summary content. The HHA must send all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure a transfer summary was sent to the hospital when the patient was admitted for 1 of 1 active clinical records reviewed with a patient hospitalized. (Patient #1) Findings Include: 1. An undated policy titled "Client Transfer" indicated but was not limited to, " … 4. The original Transfer Summary form shall be sent to the new provider or facility …" 2. A review of Patient #1's clinical record evidenced a POC with a SOC date of 08/30/2024 and a certification from 02/13/2025 to 04/13/2025. The POC listed the following diagnoses: Congestive Heart Failure (a condition where the heart has difficulty pumping blood through the body), Right hip replacement, Type 2 Diabetes (a disease where the body was unable to appropriately regulate blood sugar), Diabetic Neuropathy (nerve damage caused by high blood sugar levels), Sleep Apnea (a sleep disorder where the person stops breathing at times during sleep), Chronic Obstructive Pulmonary Disease (a disease causing restricted airflow), and Gout (pain in the joints caused by acid buildup in the body). The POC indicated the patient received SN services weekly for medication set-up and subcutaneous (an injection given in the fat layer of tissue directly under the skin) injection of Ozempic (a medication used to assist the body in managing blood sugar levels) and HHA services weekly for assistance with bathing and dressing. A 60-day summary note dated 02/07/2025 indicated Patient #1 was a patient with the agency since 08/30/2024 and was admitted to the hospital on 01/22/2025. The document was signed by the physician on 02/14/2025. A review of the clinical record failed to evidence a transfer summary was sent to Entity 9, a hospital. During an interview with the DON on 04/22/2025 at 1:34 PM, they explained Patient #1 was admitted to the hospital according to the doctor's instruction and patient's physician office is associated with the hospital, Entity 9, the hospital would have all of the patient's information because they use the same system. They indicated they felt they had not needed to send the hospital a transfer summary since they had the patient's information from the physician's office. During an interview with the DON on 04/22/2025 at 3:48 PM, they indicated they were unaware a transfer summary was to be completed and sent to the hospital. 410 IAC 17-13-2(a)(b)(9)

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 observation, record review, and interview, the agency failed to ensure the agency followed their plan of correction in regards to plan of care elements ensuring ongoing compliance and the POC contained all necessary elements to including, all medications, DME, allergies, and diagnoses for 7 of 7 active clinical records (Patients #1, #2, #3, #4, #5, #6, and #7) reviewed. Findings Include: 5. Review of the clinical record for Patient #2 revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 04/01/2025 for the certification period of 04/01/2025 through 05/30/2025, dated 04/04/2025 and signed by the DON. The POC evidenced Patient #2 has, but is not limited to, Alzheimer's Disease (a progressive brain disorder that gradually destroys memory, thinking skills, and other cognitive functions). The POC subsection titled "Functional Limitations," indicated but is not limited to, bowel/bladder (incontinence) (the accidental loss of urine or stool or the inability to control the flow of urine or stool). The POC subsection titled "DME and Supplies," indicated none. The POC failed to evidence the correct SOC date and Patient #2 uses incontinent supplies. Review of the clinical record for Patient #2 revealed a document titled "Start of Care Comprehensive Adult Assessment OASIS E" dated 04/03/2025 and signed by the DON. The comprehensive assessment indicated but was not limited to a SOC date of 04/01/2025 for the certification period of 04/01/2025 through 05/30/2025, and Patient #2 is incontinent of urine. During an interview on 04/22/2025 at 3:00 PM, the DON indicated she thought the SOC date is the date the physician signs the order to start services. When queried if Patient #2 is incontinent and uses incontinent supplies, the DON indicated yes but thought only supplies provided by the agency should be included on the POC. 6. Review of the clinical record for Patient #3 revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 03/19/2025 for the certification period of 03/19/2025 through 05/17/2025, dated 03/28/2025 and signed by the DON. The POC failed to evidence the correct SOC date. Review of the clinical record for Patient #3 revealed a document titled "Start of Care Comprehensive Adult Assessment OASIS E" dated 03/26/2025 and signed by the DON. The comprehensive assessment indicated but was not limited to a SOC date of 03/19/2025 for the certification period of 03/19/2025 through 05/17/2025, and HHA once every two weeks for medication set up. 7. Review of the clinical record for Patient #5 revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 03/04/2025 for the certification period of 03/04/2025 through 05/02/2025, dated 03/07/2025 and signed by the DON. The POC evidenced Patient #5 has, but is not limited to, Type 2 Diabetes Mellitus with Chronic Kidney Disease Stage 3 (Type 2 Diabetes Mellitus - a chronic condition where the body either does not produce enough insulin or cannot effectively use the insulin the body does produce, CKD - kidneys functioning at a moderate level), Hypertension (high blood pressure), GERD (Gastroesophageal Reflux Disease - a condition where acidic gastric fluid flows backward into the esophagus), and Hypoventilation with Obstructive Sleep Apnea (a breathing disorder where breathing is too slow or shallow, specifically during sleep, leading to a buildup of carbon dioxide and a potential decrease in oxygen levels). The POC subsection titled "DME and Supplies," indicated but is not limited to, cane and rollator walker. The POC subsection titled "Medications," indicated but is not limited to, Amlodipine (prescribed for high blood pressure), Losartan (prescribed for high blood pressure), Protonix (prescribed for GERD), Farxiga (prescribed for Type 2 Diabetes Mellitus and also reduces the risk of worsening kidney disease), and Famotidine (prescribed for GERD to reduce the acid in the stomach). The POC failed to evidence the correct SOC date, DME: CPAP (Continuous Positive Airway Pressure machine - used to treat sleep apnea and other sleep disorders), and Tylenol as an as needed medication to treat pain. Review of the clinical record for Patient #5 revealed a document titled "Start of Care Comprehensive Adult Assessment OASIS E" dated 03/05/2025 and signed by the DON. The comprehensive assessment indicated but was not limited to a SOC date of 03/04/2025 for the certification period of 03/04/2025 through 05/02/2025. The SOC assessment indicated, but is not limited to, Patient #5 has a CPAP, and uses over the counter Tylenol as needed for pain management. During an interview on 04/22/2025 at 3:28 PM, the DON indicated the CPAP machine should be included on the POC. When queried if over the counter medications such as Tylenol should be included on the POC, the DON indicated yes she would want to include all over the counter medications on the POC. 8. Review of the clinical record for Patient #6 revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 03/27/2025 for the certification period of 03/27/2025 through 05/25/2025, dated 03/30/2025 and signed by the DON. The POC evidenced Patient #6 has, but is not limited to, Dementia (a group of brain disorders that cause a decline in cognitive abilities, such as memory thinking, problem-solving, and language). The POC subsection titled "DME and Supplies," indicated but is not limited to, walker. The POC subsection titled "Allergies," is blank. The POC subsection titled "Functional Limitations," indicated but is not limited to, bowel/bladder (incontinence). The POC failed to evidence the correct SOC date, allergies, DME: incontinent supplies. Review of the clinical record for Patient #6 revealed a document titled "Start of Care Comprehensive Adult Assessment OASIS E" dated 03/29/2025 and signed by the DON. The comprehensive assessment indicated but was not limited to a SOC date of 03/27/2025 for the certification period of 03/27/2025 through 05/25/2025, Patient #6 is incontinent, and has no known allergies. During an interview on 04/22/2025 at 3:10 PM, the DON indicated Patient #6 is incontinent and incontinent supplies should be listed on the POC. When queried if Patient #6 has any allergies, the DON indicated she was not sure, but there should be something filled within the box. 9. During an interview on 04/22/2025 at 4:13 PM, the DON indicated they had a misunderstanding of when the SOC date was. They indicated they understood the SOC date was the first time the patient was seen by the agency. They explained they had the wrong SOC date for all active and inactive patients. 410 IAC 17-13-1(a)(1)(D)(ii, iii, viii, ix, and xiii) 1. A review of an undated policy "Plan of Care" indicated but was not limited to, " … 2. The Plan of Care shall be completed in full to include: a. All pertinent diagnosis(es) … e. Need for/presence of home medical equipment and assistive devices …" 2. A review of Patient #1's clinical record evidenced a POC with a SOC date of 08/30/2024 and a certification from 02/13/2025 to 04/13/2025 and a certification period from 04/14/25 and 06/12/2025. The POC listed the following diagnoses: Congestive Heart Failure (a condition where the heart has difficulty pumping blood through the body), Right hip replacement, Type 2 Diabetes (a disease where the body was unable to appropriately regulate blood sugar), Diabetic Neuropathy (nerve damage caused by high blood sugar levels), Sleep Apnea (a sleep disorder where the person stops breathing at times during sleep), Chronic Obstructive Pulmonary Disease (a disease causing restricted airflow), and Gout (pain in the joints caused by acid buildup in the body). The section titled "DME and Supplies" included cane, electric scooter, a continuous positive airway pressure machine, and oxygen. The POC failed to list the patient's oxygen as a medication. A review of Patient #1's SOC comprehensive assessment evidenced the assessment was completed on 09/02/2024 by the DON. A review of Patient #1's clinical record evidenced a comprehensive assessment dated 02/12/2025 by the DON. The document evidenced the patient had a cane, wheelchair, alcohol pads, diabetic supplies, and exam gloves. The POC failed to evidence the correct SOC date, all the patients supplies, and medications. During an interview with the DON on 04/22/2025 at 3:48 PM, they indicated oxygen was a medication and the supplies listed in the comprehensive assessment were supposed to be included on the POC. 3. A review of Patient #4's clinical record evidenced a POC with a SOC date of 02/24/2025 and a certification period from 04/15/2025 to 06/13/2025. The POC listed the following diagnoses: Hypertension (high blood pressure), Type 2 Diabetes, Hypothyroidism (when the thyroid gland was unable to produce enough of the thyroid hormone causing fatigue, weight gain, and constipation), and Diabetic Neuropathy. The POC included a cane and a rollator walker as the patient's DME. During a home visit at Patient #4's residence on 04/21/2025 at 2:40 PM, HHA 1 was observed assisting the patient with a shower. It was evidenced the patient had a glucometer, lancets, and chemstrips to check their blood sugars. The POC failed to evidence all the patient's Diabetic supplies. During an interview with the DON on 04/22/2025 at 3:58 PM, they indicated Patient #4 had diabetic supplies in the home and indicated they should have been listed on the POC. 4. A review of Patient #7's clinical record evidenced a POC with a SOC date of 03/25/2025 and a certification period from 03/25/2025 to 05/23/2025. The POC listed the following diagnoses: Type 2 Diabetes, Right knee replacement, Hypertension, Chronic Kidney Disease (condition where the kidneys lose their ability to properly filter and remove excess fluid and waste from the blood), and Hyperlipidemia (high levels of fat in the blood). The POC indicated the patient had a Rollator and wheelchair for their DME. A review of Patient #7's SOC comprehensive assessment dated 03/27/2025 by the DON evidenced a section titled "DME and Supplies" and indicated the patient had a wheelchair, walker, alcohol pads, and Diabetic supplies. The assessment evidenced in a subsection titled "Functional Limitations" indicated the patient had bladder incontinence. The POC failed to include the patient Diabetic and bladder incontinence supplies. The POC failed to list the correct SOC date of 03/27/2025. During an interview with the DON on 04/22/2025 at 2:42 PM, they indicated the POC should have included the diabetic supplies and incontinence supplies of the patient.

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 ensure the RN coordinated care to meet the patient's needs for 6 of 7 (Patients: #2, 3, 4, 5, 6, and 7) active records reviewed of patients receiving outside services. Findings Include: 6. A review of Patient #4's clinical record evidenced a document titled "Intake Referral Form" dated by the Administrator on 02/07/2025. The document indicated the referral source came from Entity 1, a personal service agency. A review of Patient #4's clinical record failed to evidence communication notes to Entity 1. During an interview with HHA 1 and Patient #4 on 04/22/2025 at 2:40 PM, they indicated the patient received services from Entity 1 on the days the HHA did not provide home health care services. 7. A review of Patient #7's SOC comprehensive assessment dated 03/27/2025 by the Administrator evidenced a section titled "Psychosocial Status" indicated the patient received services from Entity 1. A review of Patient #7's clinical record failed to evidence communication notes to Entity 1. 8. During an interview with the DON on 04/22/2025 at 1:59 PM, upon the DON's review of Patients #2, #3, #4, #5, #6, and #7 they indicated nothing had really happened to the newer patients and so they had not documented communication with Entity 1. 410 IAC 17-14-1(a)(1)(F) 1. A review of an undated policy titled "Coordination of Client Services" indicated but was not limited to, " … 7. Clients, their representatives, and other caregivers will be included in the coordination activities and will receive direct communication related to planning and in the plan 8. Documentation must address the coordination activities … 12. Coordination will include providers of care who are not part of the agency …" 2. Review of the clinical record for Patient #2 revealed a document titled "Comprehensive Adult Assessment OASIS E" dated 04/03/2025 and signed by the DON. The comprehensive assessment indicated but was not limited to a SOC date of 04/01/2025 for the certification period of 04/01/2025 through 05/30/2025, and Patient #2 receives attendant care services through Entity 1, a homecare agency. Review of the communication notes dated 04/03/2025 through 04/22/2025 failed to evidence coordination of care with Entity 1, a homecare agency. The clinical record failed to evidence coordination of care with Entity 1. 3. Review of the clinical record for Patient #3 revealed a document titled "Start of Care Comprehensive Adult Assessment OASIS E" dated 03/26/2025 and signed by the DON. The comprehensive assessment indicated but was not limited to a SOC date of 03/19/2025 for the certification period of 03/19/2025 through 05/17/2025, and Patient #3 receives services from Entity 1, a homecare agency. Review of the communication notes dated 03/26/2025 through 04/22/2025 failed to evidence coordination of care with Entity 1, a homecare agency. The clinical record failed to evidence coordination of care with Entity 1. 4. Review of the clinical record for Patient #5 revealed a document titled "Start of Care Comprehensive Adult Assessment OASIS E" dated 03/05/2025 and signed by the DON. The comprehensive assessment indicated but was not limited to a SOC date of 03/04/2025 for the certification period of 03/04/2025 through 05/02/2025, Patient #5 receives services from Entity 1, a homecare agency. Review of the communication notes dated 03/05/2025 through 04/22/2025 failed to evidence coordination of care with Entity 1, a homecare agency. The clinical record failed to evidence coordination of care with Entity 1. 5. Review of the clinical record for Patient #6 revealed a document titled "Start of Care Comprehensive Adult Assessment OASIS E" dated 03/29/2025 and signed by the DON. The comprehensive assessment indicated but was not limited to a SOC date of 03/27/2025 for the certification period of 03/27/2025 through 05/25/2025, and Patient #6 receives services from Entity 1, a homecare agency. Review of the communication notes dated 03/27/2025 through 05/25/2025 failed to evidence coordination of care with Entity 1, a homecare agency. The clinical record failed to evidence coordination of care with Entity 1.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation and interview, the agency failed to ensure infection control practices were followed for 2 of 3 home visits. (Employees: DON and HHA 1) Findings Include: 1. A review of an undated policy titled "OSHA Infection Control/Exposure Control Plan" indicated but was not limited to, " … a. Wearing and changing gloves as necessary during the delivery of client care … f. Frequent handwashing by home health care employees: Before and after the provision of direct client care … after removing gloves … g. Keeping clean and dirty items separate …" 2. During a home visit at Patient #1's residence on 04/21/2025 at 1:30 PM, the DON was observed performing an assessment and filling the medication planner. The DON touched and assessed the patient's feet and legs with gloves, and using the same gloves, reached into their nursing bag and retrieved the scale. The DON was later observed placing the patient's medications in the medication planner. The DON put the medications, Allopurinol (for inflammation and joint pain), Apixaban (for a blood clot blocking the artery), Famotidine (for heartburn), Potassium Chloride (for low potassium levels), Docusate (for constipation), Spironolactone (for reducing swelling), and Torsemide (for reducing excess fluid in the body) into the bottle's cap and picked them up with their gloved finger which had touched the outside of the bottles. The DON failed to ensure their gloves were discarded, performed hand hygiene, and donned new gloves prior to reaching into the bag or touching the patient's feet. During an interview with the DON on 04/21/2025 at 3:10 PM, they indicated after touching the patient's feet they should change gloves. They explained some of the medications were very small and they had not wanted any of them to drop on the floor. They indicated the preferred method for adding medication into the medication planner was to use the cap to place the medications in the planner. 3. During a home visit at Patient #4's residence on 04/21/2025 at 2:40 PM, HHA 1 was observed assisting the patient with a shower. HHA 1 grabbed the gait belt, set the gait belt back down, and donned gloves without performing hand hygiene. HHA 1 wiped the patient's back and legs, doffed gloves, washed their hands, and turned the sink off with their hands. During an interview with HHA 1 on 04/21/2025 at 3:10 PM, they indicated hand hygiene was supposed to be performed before donning gloves. They explained a paper towel was supposed to be used to turn off the faucet. 410 IAC 17-12-1(m)

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the HHA was supervised every 14 days for 1 of 1 active clinical record reviewed (Patient #1) and 2 of 2 inactive clinical records reviewed (Patients #8 and #10) with patients who received SN and HHA services. Findings Include: 3. Review of the clinical record for Patient #8 revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 07/05/2024 for the certification period of 07/05/2024 through 09/05/2024 and signed by the DON. The document evidenced, but was not limited to, Patient #8 received HHA services weekly for assistance with ADLs and SN services for medication set up. Review of the clinical record for Patient #8 revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 07/05/2024 for the certification period of 09/05/2024 through 11/05/2024 and signed by the DON. The document evidenced, but was not limited to, Patient #8 received HHA services weekly for assistance with ADLs and SN services for medication set up. Review of the clinical record for Patient #8 revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 07/05/2024 for the certification period of 11/05/2024 through 01/05/2025 and signed by the DON. The document evidenced, but was not limited to, Patient #8 received HHA services weekly for assistance with ADLs and SN services for medication set up. Review of the clinical record for Patient #8 revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 12/18/2024 for the certification period of 12/18/2024 through 02/15/2025 and signed by the DON. The document evidenced, but was not limited to, Patient #8 received HHA services weekly for assistance with ADLs and SN services for medication set up. Review of the clinical record for Patient #8 revealed documents titled "Supervisory Visit" dated 09/11/2024, 10/16/2024, and 11/13/2024 and signed by the DON. The clinical record failed to evidence a supervisory visit was performed every 14 days. 4. Review of the clinical record for Patient #10 revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 09/04/2024 for the certification period of 09/04/2024 through 11/04/2024 and signed by the DON. The document evidenced, but was not limited to, Patient #10 received HHA and SN services. Review of the clinical record for Patient #10 revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 09/04/2024 for the certification period of 11/04/2024 through 01/04/2025 and signed by the DON. The document evidenced, but was not limited to, Patient #10 received HHA services weekly for assistance with ADLs and SN services for medication set up. Review of the clinical record for Patient #10 revealed a document titled "Home Health Certification and Plan of Care" with a SOC date of 12/17/2024 for the certification period of 12/17/2024 through 02/14/2025 and signed by the DON. The document evidenced, but was not limited to, Patient #10 received HHA services weekly for assistance with ADLs and SN services for medication set up. Review of the clinical record for Patient #10 revealed a document titled "Supervisory Visit" dated 10/16/2024 and signed by the DON. The clinical record failed to evidence a supervisory visit was performed every 14 days. 5. During an interview on 04/22/2025 at 3:18 PM, the DON indicated she thought the agency policy was for supervisory visits to be completed every 30 days for patients receiving skilled services and HHA services. When queried if she knew what the regulation requirement was, she indicated she did not know. The DON failed to indicate supervisory visits should be completed every 14 days for patients receiving both HHA and SN services. 1. An undated policy titled "Home Health Aide Supervision" indicated but was not limited to, " … When skilled services are being provided to a client, a Registered Nurse/Therapist must make a supervisory visit to the client's residence no less frequently than every 14 days …" 2. A review of Patient #1's clinical record evidenced a POC with a SOC date of 08/30/2024 and a certification from 02/13/2025 to 04/13/2025 and a certification period from 04/14/25 and 06/12/2025. The POC listed the following diagnoses: Congestive Heart Failure (a condition where the heart has difficulty pumping blood through the body), Right hip replacement, Type 2 Diabetes (a disease where the body was unable to appropriately regulate blood sugar), Diabetic Neuropathy (nerve damage caused by high blood sugar levels), Sleep Apnea (a sleep disorder where the person stops breathing at times during sleep), Chronic Obstructive Pulmonary Disease (a disease causing restricted airflow), and Gout (pain in the joints caused by acid buildup in the body). The POC indicated the patient received SN services weekly for medication set-up and subcutaneous (an injection given in the fat layer of tissue directly under the skin) injection of Ozempic (a medication used to assist the body in managing blood sugar levels) and HHA services weekly for assistance with bathing and dressing. A review of the supervisory visit notes evidenced the DON completed supervisory visits on HHA 1 on 01/15/2025, 02/19/2025, 03/07/2025, and 04/04/2025. The DON failed to ensure the a supervisory visit was completed every 14 days on HHA 1. During an interview with the DON on 04/22/2025 at 3:18 PM, they indicated if a patient received both HHA and SN services, a supervisory visit was completed every 30 days. They explained they were unaware the supervisory visits were supposed to be completed every 14 days.

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 agency failed to ensure they provided skilled services to a total of 10 patients and were currently providing skilled services to at least seven active patients for their initial Medicaid certification survey for 1 of 1 home health agency. Findings Include: 1. A review of an agency policy dated 10/2024 titled "Regulatory Compliance: State/Local Level" indicated but was not limited to, " … will operate and furnish services in compliance with all applicable federal, state, and local laws and regulations related to the health & safety of patients. …" 2. A review of the active and inactive patient clinical records evidenced one active patient (Patient #1) received SN and HHA services, two active patients received SN services only (Patients #3 and #5), four active patients received HHA services only (Patients #2, #4, #6, and #7), two inactive patients (Patients #8 and #10) received SN and HHA services, and one inactive patient (Patient #9) received SN services only. 3. During the entrance conference on 04/21/2025 at 9:55 AM, the DON indicated they had two active patients receiving SN services only, four active patients receiving HHA services only, and one active patient receiving SN and HHA services. They indicated one inactive patient received SN services only and two inactive patients received SN and HHA services. 4. During an interview with the DON on 04/22/2025 at 4:13 PM, they explained they were unaware they had to have seven active patients receiving SN services at the time of the survey. 410 IAC 17-12-1(c)(1)

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 the discharge summary contained all the necessary elements for 3 of 3 inactive clinical records reviewed. (Patients: #8, 9, 10) Findings Include: 4. A review of Patient #9's clinical record evidenced a POC with a SOC date of 03/06/2025 and a certification period from 03/06/2025 to 03/27/2025. The POC evidenced the following diagnoses: Type 2 Diabetes (a disease where the body is unable to properly regulate blood sugar levels), Hypertension (high blood pressure), Muscle Spasms, and Chronic pain. The POC listed the following medications the patient took: Atenolol (for Hypertension) 50 milligrams (mg) by mouth one time a day, Amlodipine (for Hypertension) 5mg by mouth once a day, Metformin (for Diabetes) 750mg by mouth two times a day, Cyclobenzaprine 10mg by mouth every eight hours as needed for muscle spasms, Hydroxyzine 50mg by mouth four times a day as needed for itching, and Oxycodone two 10/325mg tablets by mouth every 4 hours as needed for pain. Patient #9's inactive clinical record evidenced a Discharge Summary dated and signed by the DON on 03/24/2025. The document failed to include the patient's diagnoses and current medications the patient was taking at discharge. 5. During an interview with the DON on 04/22/2025 at 3:18 PM, they indicated the discharge summary was supposed to include the care they provided the patients, diagnoses, medications, physician information, reason for discharge, discharge disposition, allergies, code status, and outcome toward meeting goals. The DON failed to indicate admission and discharge date, reason for admission for home health, laboratory data, patient discharge condition and patient or caregiver post-discharge instructions should be included on the discharge summary. 410 IAC 17-15-1(a)(7) 1. A review of an undated policy titled "Discharge Summary" indicated but was not limited to, " … 2. The Discharge Summary will incorporate findings from the discharge OASIS assessment and shall include, but not be limited, to: … b. Reason for admission to home health c. Type of services provided and frequency of services … e. A current and accurate reconciled list of all Medication the client is on at the time of discharge. … h. Reason for discharge … j. Transfer information, as applicable …" 2. Review of the inactive clinical record for Patient #8 revealed a document titled "Discharge/Transfer Summary" dated 12/30/2024 and signed by the DON. The document evidenced but is not limited to, the admission and discharge date, patient's discharge condition, and patient outcomes in meeting goals in the plan of care. The discharge summary failed to evidence who the physician responsible for home health is, reason for admission to home health, services provided and frequency, current medication list, and patient or caregiver post-discharge instructions. 3. Review of the inactive clinical record for Patient #10 revealed a document titled "Discharge/Transfer Summary" dated 01/24/2025 and signed by the DON. The document evidenced but is not limited to, the admission and discharge dates, physician responsible for home health, reason for admission to home health, type of services provided, patient discharge condition, patient outcome in meeting goals in the plan of care, and patient or caregiver post-discharge instructions. The discharge summary failed to evidence the frequency of services provided and a current medication list.