Every finding on record at Gifted Touch Home Healthcare, LLC

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102 Survey Dates: 05/13/2025, 05/14/2025 and 05/15/2025 Active Census: 10 At this Emergency Preparedness survey, Gifted Touch Home Health Care was found to be in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 484.102. QR completed by Area 3 on 5/23/2025.

This visit was for an initial Federal Medicaid and State Licensure survey of a home health agency. On 05/15/2025 at 9:48 AM, the survey was announced fully extended. Survey dates: 05/13/2025, 05/14/2025, and 05/15/2025 Facility Number: 018111 Active Census: 10 During this Federal Initial Survey, Gifted Touch Home Health Care was found to be out of compliance with Conditions of Participation 484.50 Patient Rights; 484.55 Comprehensive Assessment of Patients; and 484.60 Care Planning, Coordination of services, and Quality of Care. Based on the Condition-level deficiencies during the 05/15/2025 survey, your HHA was subject to a partial or extended survey pursuant to section 1891(c)(2)(D) of the Social Security Act on 05/15/2025. Therefore, and pursuant to section 1891(a)(3)(D)(iii) of the Act, your agency is precluded from operating a home health aide training, skills competency and/or competency evaluation program for a period of two years beginning 05/15/2025 and continuing through 05/14/2027. Abbreviations used in report: POC – Plan of Care, SOC - Start of Care, HHA - Home Health Aide, RN - Registered Nurse, SN - Skilled Nurse. QR completed by Area 3 on 5/23/2025.

Condition of Participation: Patient rights. CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient's rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This CONDITION is not met as evidenced by: Based on record review and interview the agency failed to ensure patient rights were maintained; the agency failed to ensure it obtained signed consent for the care to be furnished, the cost of services, the disciplines required to furnish the care, and the frequency of visits (see G0434), and failed to ensure services were provided as ordered in the POC (see G436). The cumulative effect of these systemic problems resulted in the agency’s inability to ensure patients received appropriate care and services, which could result in the agency not providing quality care. These practices had the potential to impact 10 patients, in a total of 10 active home health patients serviced by the agency. *

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure it obtained signed consent for the care to be furnished, the cost of services, the disciplines needed to furnish the care, and the frequency of visits with 10 of 10 patients. (Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, and 10) Findings include: 1. A review of a policy titled 'Admission Documentation/Patient Education Policy Number : C:4' indicated, "… certain documentation will be provided … signed and dated by the patient and Agency … Services to be provided with frequencies, rates/charges for services …" 2. A clinical record review of Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, and 10 failed to evidence consent forms for services. 3. During a home visit conducted on 05/13/2025 at 3 PM, the review of Patient #3's Agency's home binder failed to evidence a consent form for services to be provided. When queried if Patient #3 recalled signing a consent form, they indicated all the forms they signed were in the binder, but did not remember. 6. On 05/14/2025 at 11:35 AM the Alternate Clinical Supervisor indicated they were aware consent forms for services were required and there were not consent forms in the clinical records for any Patients, it must have been an oversight of the agency. 4. During a home visit on 5/13/2025 at 2:00 PM, the review of Patient #2's agency home binder failed to evidence a consent form. 5. During a home visit on 05/14/2025 at 9:30 AM, the review of Patient #6's agency binder failed to evidence a consent form. The Alternate Clinical Manager, who was present, also reviewed the binder and confirmed there was not a consent for home health services present and should be. 410 IAC 17-12-3(b)(2)(D)(i)(AA) and (BB)

Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure services were provided as ordered in the POC with 8 of 10 active records reviewed. (Patients #1, 3, 4, 2, 5, 7, 9, and 10) Findings include: 1. A review of the clinical record for Patient #1 evidenced a POC dated 04/17/2025 for the certification period of 04/17/2025 through 06/15/2025 indicated SN services ordered for 1 time a week for 9 weeks for medication set-up. Further review of the Clinical Record evidenced SN visits were conducted on 04/25/2025 and on 05/06/2025, 10 days after the first SN visit. The record failed to evidence communication notes or physician orders as to why a late SN visit. 2. A review of the clinical record for Patient #3 evidenced a POC dated 04/21/2025 for the certification period of 04/21/2025 through 06/19/2025 indicated SN services ordered for 1 time a week for 9 weeks for medication set-up. Further review of the Clinical Record evidenced SN visits were conducted on 04/28/2025 and on 05/06/2025, 8 days after the first SN visit. The record failed to evidence communication notes or physician orders as to why a late SN visit. 3. A review of the clinical record for Patient #4 evidenced a POC dated 04/17/2025 for the certification period of 04/17/2025 through 06/15/2025 indicated SN services ordered for 1 time a week for 9 weeks for medication set-up. Further review of the Clinical Record evidenced SN visits were conducted on 04/24/2025 and on 05/02/2025, 8 days after the first SN visit. The record failed to evidence communication notes or physician orders as to why a late SN visit. 4. A review of the clinical record for Patient #7 evidenced a POC dated 04/15/2025 for the certification period of 04/15/2025 through 06/13/2025 indicated SN services ordered for 1 time a week for 9 weeks for medication set-up. Further review of the Clinical Record evidenced a SN visit conducted on 04/25/2025, 10 days after the initial assessment. The record failed to evidence communication notes or physician orders as to why a late SN visit. 5. A review of the clinical record for Patient #9 evidenced a POC dated 04/17/2025 for the certification period of 04/17/2025 through 06/15/2025 indicated SN services ordered for 1 time a week for 9 weeks for medication set-up. Further review of the Clinical Record evidenced a SN visit was conducted on 04/25/2025, 8 days after the initial assessment visit. The record failed to evidence communication notes or physician orders as to why a late SN visit. 6. A review of the clinical record for Patient #10 evidenced a POC dated 04/17/2025 for the certification period of 04/17/2025 through 06/15/2025 indicated SN services ordered for 1 time a week for 9 weeks for medication set-up. Further review of the Clinical Record evidenced a SN visit conducted on 05/28/2025, 11 days after the initial assessment visit. The record failed to evidence communication notes or physician orders as to why a late SN visit. 9. On 05/15/2025 at 10 AM, during an interview with Administrator and the Alternate Clinical Supervisor, they indicated they do not communicate with the ordering physician after the initial assessment is completed. They develop the plan of care and fax over to the ordering physician for signature, wait for the POC to return before starting services. 7. A review of the clinical record for Patient #2 evidenced a POC dated 04/17/2025 for the certification period of 04/17/2025 through 06/15/2025 indicated SN services were ordered for 1 time a week for 9 weeks for "medication set-up". Further review of the Clinical Record evidenced the initial SN visit was conducted on 04/17/2025 and the subsequent visit occurred on 4/28/2025, 11 days after the first SN visit. The record failed to evidence communication notes or physician orders as to a missed weekly SN visit. 8. A review of the clinical record for Patient #5 evidenced a POC dated 04/15/2025 for the certification period of 04/15/2025 through 06/13/2025 indicated SN services were ordered for 1 time a week for 9 weeks for "medication management and or organization". Further review of the Clinical Record evidenced the initial SN visit was conducted on 04/15/2025 and the subsequent visit occurred on 04/25/2025, 10 days after the first SN visit. The record failed to evidence communication notes or physician orders as to why a late SN visit.

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 comprehensive assessments accurately reflected patients' health status (see G528), failed to ensure comprehensive assessments accurately reflected patients' goals (see G530), and failed to document the patient's need for home health services (see G532). The cumulative effect of these systemic problems resulted in the agency’s inability to ensure patients received appropriate care and services, which could result in the agency not providing quality care. These practices had the potential to impact 10 patients, in a total of 10 active home health patients serviced by the agency. *

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 comprehensive assessments accurately reflected patients' health status, including psychosocial status, in 8 of 10 active clinical records reviewed. (Patients #1, 2, 4, 5, 6, 7, 9, and 10) Findings include: 1. A review of an agency policy titled 'OASIS' (Outcome and Assessment Information Set, a data collection tool utilized by Centers for Medicare and Medicaid) stated, "… Comprehensive Assessment Requirements (OASIS) Each patient must receive a patient-specific comprehensive assessment (OASIS) that accurately reflects the patient status …" 2. A review of the clinical record for Patient #2 evidenced an OASIS SOC dated 04/17/2025, an initial certification period of 04/17/2025 to 06/15/2025, and diagnoses which included, but were not limited to: hypertension (high blood pressure) and cardiomyopathy (chronic disease of the heart muscle) which evidenced the following: Functional limitation was "ambulation", "No restrictions" for activities permitted, Musculoskeletal "within normal limits", and the patient was not homebound. The document failed to evidence date of last bowel movement and failed to evidence a fall assessment had been completed. The patient experienced "no shortness of breath", then later in the document the patient's goal was to be, "able to transfer [sic]with SOB (Shortness of breath), take medication on time and correctly". The cardiovascular assessment was "within normal limits", the patient had a pacemaker inserted in 2021, the patient's goal indicated they wanted, "more ejection fraction from heart valve, to be able to attend work", and the document failed to evidence information as to how the patient's current cardiac status affected activities of daily living. 3. A review of the clinical record for Patient #5 evidenced an OASIS SOC dated 04/15/2025, an initial certification period of 04/15/2025 to 06/13/2025, and exclusive diagnoses of: COPD (Chronic obstructive pulmonary disease, a term for certain types of irreversible lung and airway damage that block airways and make it hard to breathe), Essential Hypertension (high blood pressure not related to another medical cause) The record contained a comprehensive assessment which evidenced the following: Physician name was left blank, specific ordered start of care date was left blank, vital sign parameters were left blank. Ability to handle own finance was marked, "independent", the patient was alert and oriented, without cognitive deficits. The diagnosis list failed to evidence diabetes, a section titled 'Active Diagnosis' included, "… Diabetes …" which was marked "None of the above", a section titled 'Endocrine' queried, "Is client diabetic" was marked, "No" and the remainder of the endocrine section detailed evidence the patient and caregiver were independent in glucometer use, had a random reading of 136 mg/dl taken from the "left" and failed to identify the site, with a 'Comment' which stated, "check BS(blood sugar) before eating meals and snacks, with a goal of, "Client will be free from signs and symptoms of hypo/hyperglycemia during the care period", and failed to offer further explanation. Date of last bowel movement and a fall assessment were not completed. The record also contained a physician referral dated 04/15/2025 for home health skilled nursing services for medication management, and indicated the diagnoses for services were: Encephalopathy (refers to a change in brain function due to injury or disease), confusion (an altered mental status, in ability to think clearly, focus, or remember things, often leading to disorientation), and polypharmacy (the regular use of 5 or medications at the same time). The comprehensive failed to evidence the ordering physician's name, ordered start of care date, vital sign parameters, and additional diagnoses. 4. A review of the clinical record for Patient #6 evidenced an OASIS SOC dated 04/22/2025, an initial certification period of 04/22/2025 to 06/20/2025, and diagnoses which included, but were not limited to: Unspecified atrial fibrillation (where the specific type or duration of the irregular heart rhythm is not detailed), chronic kidney disease stage 3 (kidneys have mild to moderate damage and are less able to filter waste and fluid out of your blood), Atherosclerotic heart disease (ASHD) of the native coronary artery without angina pectoris (the heart's coronary arteries are narrowed due to plaque buildup, but the patient is not experiencing angina [chest pain]). The document evidenced the following: Vital sign parameters were left blank, left-sided below the knee amputation (a surgical procedure where the leg is removed below the knee joint, involves removing the foot, ankle joint, and part of the tibia and fibula, along with related soft tissue structures) was noted but failed to be evidenced among listed diagnoses, failed to offer etiology, and indicated pedal pulses (pulses felt in the feet) were "1+ weak", "bilaterally (involving both left and right sides)", and failed to evidence a fall assessment had been completed. 5. A review of the Clinical Record for Patient #1 evidenced an OASIS SOC dated 04/17/2025 for the initial certification period of 04/17/2025 through 06/15/2025 indicated principal diagnosis as Hypertension (high blood pressure), other diagnoses included were but not limited to: Disorder of the autonomic nervous system (a condition where the nerves that regulate involuntary bodily functions [like heart rate, blood pressure, digestion] are not functioning correctly). Patient #1 had no functional limitations. Safety measures for Patient #1 were identified as Anticoagulant Precautions, keep pathway clear, Seizure Precautions, and Standard precautions, Support during Transfer and ambulation, Fall Precautions, safety in activities of daily living, slow position change, and use of assistive devices. Indicated Patient #1 did not have an IV site, but SN was to instruct on signs and symptoms of infection and infiltration. Indicated lung sounds were within normal limits, and Patient #1 was not short of breath, but had respiratory interventions and goals. Date of last bowel elimination was not assessed. Musculoskeletal indicated Patient #1 had joint pain and stiffness of back and left leg, was weak and had poor balance, indicated Patient #1 had partial weight bearing restrictions. Fall Assessment and vital signs parameters were left blank. The comprehensive assessment failed to accurately reflect the patient's health status, failed to identify what seizure and anticoagulant precautions were, failed to assessment bowel elimination, and failed to identify what the partial weight bearing restrictions were. 6. A review of the Clinical Record for Patient #4 evidenced an OASIS SOC dated 04/17/2025 for the initial certification period of 04/17/2025 through 06/15/2025 indicated principal diagnosis as Epilepsy (a neurological disorder that causes recurrent seizures), other diagnosis but not limited to was Irritable bowel syndrome (a chronic digestive disorder characterized by abdominal pain and changes in bowel habits, including diarrhea, constipation, or both) with constipation. Bowel Elimination was within normal limits, but failed to assess last bowel movement, Neuro/Behavioral Interventions were SN to instruct the Client/Caregiver on seizure precautions, Activities permitted were blank and Musculoskeletal was left blank. The comprehensive assessment failed to accurately reflect the patient's health status, failed to assess bowel elimination, and failed to identify seizure precautions. 7. A review of the Clinical Record for Patient #7 evidenced an OASIS SOC dated 04/15/2025 for the initial certification period of 04/15/2025 through 06/13/2025 which indicated principal diagnosis as Chronic combined systolic and diastolic heart failure (two types of left-sided heart failure, each impacting the heart's ability to pump and relax), other diagnosis was panlobular emphysema (a type of emphysema that affects all air sacs [alveoli] in a lobule [each lobe in a lung is further divided into lobules, which are the smallest divisible sections of the lung]. No vital sign parameters were identified and the fall assessment was blank. Safety measures included but not limited to: Oxygen precautions, Patient #7 had pacemaker implanted 10/17/2017, indicated bowel elimination was within normal limits, last Bowel movement was blank, indicated musculoskeletal was within normal limits, indicated Patient was able to get to and from the toilet and transfer independently and able to manage toileting hygiene and clothing management without assistance, fall assessment not completed, Self Care indicated Patient #7 required supervision or touching assistance with toileting hygiene and the ability to bathe self. On 05/14/2025 at 10:55AM when queried if Patient #7 had oxygen ordered, the Clinical Supervisor indicated they did not. The comprehensive assessment failed to accurately reflect the patient's health status, failed identify/include physician management of the pacemaker, and failed to assess bowel elimination. 8. A review of the Clinical Record for Patient #9 evidenced an OASIS SOC dated 04/17/2025 for the initial certification period of 04/17/2025 through 06/15/2025 which indicated principal diagnosis as Type 2 Diabetes Mellitus with hyperosmolarity (a serious condition that occurs when very high blood sugar levels, often exceeding 600 mg/dL, lead to severe dehydration and a high concentration of substances in the blood) with coma, other diagnoses included but not limited to were Chronic Obstructive Pulmonary Disease (a group of lung diseases that cause progressive airflow obstruction and breathing difficulties). Vital sign parameters were not identified. Special Treatments, Procedures, and programs was blank which included IV access, but included IV Interventions and goals, indicated Patient #9 did not have wounds, but indicated interventions and goals to assess wound and the wound would be free from signs and symptoms of infection, Assessment of last bowel elimination was blank, indicated Patient #9 had received and able to take injectable medications. On 05/14/2025 at 10:30 AM, Patient #9 indicated they did not have a wound or an IV access site, and did not take injectable medications. The comprehensive assessment failed to accurately reflect the patient's health status. 9. A review of the clinical record for Patient #10 evidenced an OASIS SOC dated 04/17/2025 for the initial certification period of 04/17/2025 through 06/15/2025 which indicated principal diagnosis as Sleep Apnea (a sleep disorder characterized by repeated pauses in breathing during sleep), other diagnoses included but not limited to were Borderline personality disorder (a mental health condition characterized by difficulties regulating emotions, instability in relationships, a distorted sense of self, and impulsivity), and Epilepsy (a neurological disorder that causes recurrent seizures). Safety Measure indicated were Standard Precautions and Fall Precautions, indicated Patient #10 had no pain, but included pain interventions, indicated Patient #10 had full mobility with no restrictions, indicated Patient #10 had a pacemaker implanted 01/01/1992, bowel elimination was left blank, mental status indicated Patient #10 was oriented, Cognitive functioning indicated Patient #10 becomes confused in new or complex situations, and is anxious all the time, Emotional status indicated Patient #10 was feeling down, depressed, or hopeless nearly every day, felt bad about themselves nearly every day, had trouble concentrating nearly every day, Cognitive behavioral, and psychiatric symptoms were demonstrated at least once a week, indicated no behaviors demonstrated, identified the frequency of disruptive behavior symptoms occurred several times a week. Fall assessment was left blank. The comprehensive assessment failed to accurately reflect the patient's health and cognitive status, failed to include seizure precautions, failed to identify/include physician management of the pacemaker, and failed to assess bowel elimination. 10. On 05/15/2025 at 10:50 AM, when discussing the lack of missing/conflicting information in the comprehensive assessments, the Alternate Clinical Manager indicated they should take an OASIS course, the assessments need to be complete and accurate. 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 comprehensive assessments accurately reflected patient-centered goals and/or care preferences, in 10 of 10 active records reviewed. (Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, and 10) Findings include: 6. A review of the clinical record for Patient #1 with a SOC of 04/17/2025 for the initial certification period of 04/17/2025 through 06/15/2025 which contained a comprehensive assessment dated 04/17/2025 which failed to evidence their care preferences and goals. 7. A review of the clinical record for Patient #3 with a SOC of 04/21/2025 for the initial certification period of 04/21/2025 through 06/19/2025 which contained a comprehensive assessment dated 04/21/2025 which failed to evidence their goals or care preferences. 8. A review of the clinical record for Patient #4 with a SOC of 04/17/2025 for the initial certification period of 04/17/2025 through 06/15/2025 which contained a comprehensive assessment dated 04/17/2025 which failed to evidence their care preferences and goals. 9. A review of the clinical record for Patient #7 with a SOC of 04/15/2025 for the initial certification period of 04/15/2025 through 06/13/2025 which contained a comprehensive assessment dated 04/15/2025 which failed to evidence their care preferences. 10. A review of the clinical record for Patient #9 with a SOC of 04/17/2025 for the initial certification period of 04/17/2025 through 06/15/2025 which contained a comprehensive assessment dated 04/17/2025 which failed to evidence their care preferences and goals. 11. A review of the clinical record for Patient #10 with a SOC of 04/17/2025 for the initial certification period of 04/17/2025 through 06/15/2025 which contained a comprehensive assessment dated 04/17/2025 which failed to evidence their care preferences and goals. 1. A review of an agency policy titled 'OASIS' (Outcome and Assessment Information Set, a data collection tool utilized by Centers for Medicare and Medicaid) stated, "… Comprehensive Assessment Requirements … The assessment will … Complete patient's … goals, and care preferences …" 2. A review of the clinical record for Patient #2 with a start of care date of 04/17/2025 and initial certification period of 04/17/2025 to 06/15/2025, contained a comprehensive assessment dated 04/17/2025 which failed to evidence the patient's care preferences. 3. A review of the clinical record for Patient #5 with a start of care date of 04/15/2025 and initial certification period of 04/15/2025 to 06/13/2025, contained a comprehensive assessment dated 04/17/2025 which failed to evidence patient's care preferences. 4. A review of the clinical record for Patient #6 with a start of care date of 04/22/2025 and initial certification period of 04/22/2025 to 06/20/2025, contained a comprehensive assessment dated 04/17/2025 which failed to evidence patient centered-goals and care preferences. 5. A review of the clinical record for Patient #8 with a start of care date of 04/17/2025 and initial certification period of 04/17/2025 to 06/15/2025, contained a comprehensive assessment dated 04/17/2025 which failed to evidence their care preferences. 12. On 05/15/2025 at 10:53 AM, when discussing lack of patient goals, and/or care preferences in each clinical record review, the Alternate Clinical Manager stated, "oh yeah" and indicated was aware, had forgotten these were required.

Continuing need for home care CFR(s): 484.55(c)(3) The patient's continuing need for home care; This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to document the patient's need for home health services, in 2 of 10 active clinical records reviewed. (Patients #2, and #8) Findings include: 1. A review of an agency policy titled 'OASIS' (Outcome and Assessment Information Set, a data collection tool utilized by Centers for Medicare and Medicaid) stated, "… Comprehensive Assessment Requirements … The assessment will … Document the patient's continuing need for home care … Document the patient's medical, nursing … needs …" 2. A review of the clinical record for Patient #2 evidenced an OASIS SOC dated 04/17/2025 and initial certification period of 04/17/2025 to 06/15/2025, with diagnoses which included but were not limited to: hypertension (high blood pressure) and cardiomyopathy (chronic disease of the heart muscle), contained a comprehensive assessment dated 04/17/2025 which indicated the patient was alert and oriented, was without psychosocial issues, without cognitive impairment, wore eyeglasses, indicated their functional impairment was "ambulation", "no restriction" on activities permitted, and the patient was, "able to take medications at correct times if given reminders at the appropriate times". SN services were ordered for 1 time a week for 9 weeks for "medication set-up" and failed to evidence information as to how the patient's current status affected activities of daily living. The record failed to identify the patient's deficits or evidence needs which required home health skilled nursing services. 3. On 05/15/2025 at 10:13 AM, when queried as to what the skilled needs were for the agency's current patients, the Alternate Clinical Manager indicated the skilled need for nursing was medication set-up and, "they all should be skilled". 3. A review of the Clinical Record for Patient #7 evidenced an Oasis SOC dated 04/15/2025 for the initial certification period of 04/15/2025 through 06/13/2025 which indicated principal diagnosis as Chronic combined systolic and diastolic heart failure (two types of left-sided heart failure, each impacting the heart's ability to pump and relax), other diagnosis was panlobular emphysema (a type of emphysema that affects all air sacs [alveoli] in a lobule [each lobe in a lung is further divided into lobules, which are the smallest divisible sections of the lung], indicated Patient #7 never had someone help read instructions or other written material form doctor or pharmacy, wears glasses, and has cataracts, could see large print, had no cognitive, neurological, behavioral, or musculoskeletal issues. Assessment of Management of oral medications indicated the patient was able to take medications at the correct times if given reminders by another person. SN narrative stated, "Medication management and organization recommended." Further review evidenced a Plan of Care dated 04/15/2025 for the initial certification period of 04/15/2025 through 06/13/2025 indicated SN frequency 1 time a week for 9 weeks to assess patient filling medication box to determine if client is preparing correctly. The record failed to identify the patient's deficit(s) or need(s) requiring home health services and a skilled nurse. 4. On 05/15/2025 at 10:55 AM, when discussing lack of documentation for the need of continuing services in clinical record reviews, the Alternate Clinical Manager indicated they needed to be more specific in their documentation.

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on record review and interview the agency failed to include all elements required in the Plans of Care (see G574), failed to ensure orders were incorporated into the Patient's Plan of Care (see G576), and failed to ensure communication occurred with the ordering provider for the development and implementation of a coordinated plan of care (see G602). The cumulative effect of these systemic problems resulted in the agency’s inability to ensure patients received appropriate care and services, which could result in the agency not providing quality care. These practices had the potential to impact 10 patients, in a total of 10 active home health patients serviced by the agency. *

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 include all elements in patients' Plans of Care, in 8 of 10 active clinical records reviewed. (Patients #1, 2, 4, 5, 6, 7, 9, and 10) Findings include: 5. A review of the Clinical Record for Patient #1 evidenced an Oasis SOC dated 04/17/2025 for the initial certification period of 04/17/2025 through 06/15/2025 indicated principal diagnosis as Hypertension (high blood pressure), other diagnoses included were but not limited to: Disorder of the autonomic nervous system (a condition where the nerves that regulate involuntary bodily functions [like heart rate, blood pressure, digestion] are not functioning correctly). Safety measures for Patient #1 were identified as Anticoagulant Precautions, Seizure Precautions, and standard precautions. Musculoskeletal assessment indicated Patient #1 had joint pain and stiffness of back and left leg, was weak and had poor balance, indicated Patient #1 had partial weight bearing restrictions. Further review evidenced a Plan of Care dated 04/17/2025 for the initial certification period of 04/17/2025 through 06/15/2025 failed to evidence ambulation as a functional limitation, failed to evidence intervention for seizure and anticoagulant precautions, failed to identify partial weight bearing restrictions and failed to identify patient goals. 6. A review of the Clinical Record for Patient #4 evidenced an Oasis SOC dated 04/17/2025 for the initial certification period of 04/17/2025 through 06/15/2025 indicated principal diagnosis as Epilepsy (a neurological disorder that causes recurrent seizures), other diagnosis but not limited to was Irritable bowel syndrome (a chronic digestive disorder characterized by abdominal pain and changes in bowel habits, including diarrhea, constipation, or both) with constipation. Bowel Elimination was within normal limits, but failed to assess last bowel movement, Neuro/Behavioral Interventions were SN to instruct the Client/Caregiver on seizure precautions, did not identify what precautions, Activities permitted were blank and Musculoskeletal was left blank. Further review evidenced a Plan of Care dated 04/17/2025 for the initial certification period of 04/17/2025 through 06/15/2025 failed to evidence endurance as a functional limitation, failed to evidence seizure interventions and failed to identify patient goals. 7. A review of the Clinical Record for Patient #7 evidenced an Oasis SOC dated 04/15/2025 for the initial certification period of 04/15/2025 through 06/13/2025 which indicated principal diagnosis as Chronic combined systolic and diastolic heart failure (two types of left-sided heart failure, each impacting the heart's ability to pump and relax), other diagnosis was panlobular emphysema (a type of emphysema that affects all air sacs [alveoli] in a lobule [each lobe in a lung is further divided into lobules, which are the smallest divisible sections of the lung]. Safety measures included but not limited to: anticoagulant precautions, Patient #7 had pacemaker implanted 10/17/2017. Further review evidenced a Plan of Care dated 04/15/2025 for the initial certification period of 04/15/2025 through 06/13/2025 indicated activities permitted which failed to evidence use of a walker, failed to include interventions for anticoagulant precautions, failed to identify/include physician management of the pacemaker, and failed to identify patient goals. 8. A review of the Clinical Record for Patient #9 evidenced an Oasis SOC dated 04/17/2025 for the initial certification period of 04/17/2025 through 06/15/2025 which indicated principal diagnosis as Type 2 Diabetes Mellitus with hyperosmolarity (a serious condition that occurs when very high blood sugar levels, often exceeding 600 mg/dL, lead to severe dehydration and a high concentration of substances in the blood) with coma, other diagnoses included but not limited to were Chronic Obstructive Pulmonary Disease (a group of lung diseases that cause progressive airflow obstruction and breathing difficulties). Special treatments, procedures, and programs indicated Patient #9 did not have an intravenous ( an IV line is a small tube inserted into a vein that allows for the delivery of these substances into the bloodstream) site, Integumentary status failed to evidence wounds, Assessment of last bowel elimination was blank, indicated Patient #9 had received and able to take injectable medications. Further review evidenced a Plan of Care dated 04/17/2025 for the initial certification period of 04/17/2025 through 06/15/2025 failed to evidence ambulation as a functional limitation, Orders for Discipline and Treatments indicated SN was to observe for signs and symptoms of infection, healing status, wound deterioration and complications. Medications failed to evidence injectable medications. Agency goals indicated IV will remain patent and free from signs and symptoms of infection, Wound(s) will be free from signs and symptoms of infection, and failed to evidence patient stated goals. 9. A review of the Clinical Record for Patient #10 evidenced an Oasis SOC dated 04/17/2025 for the initial certification period of 04/17/2025 through 06/15/2025 which indicated principal diagnosis as Sleep Apnea (a sleep disorder characterized by repeated pauses in breathing during sleep), other diagnoses included but not limited to were Borderline personality disorder (a mental health condition characterized by difficulties regulating emotions, instability in relationships, a distorted sense of self, and impulsivity), and Epilepsy (a neurological disorder that causes recurrent seizures). Pain assessment indicated Patient #10 had no pain, but included pain interventions, indicated Patient #10 had full mobility with no restrictions, bladder and bowel assessment was within normal limits, indicated Patient #10 had a pacemaker implanted 01/01/1992, mental status indicated Patient #10 was oriented, Cognitive functioning indicated Patient #10 becomes confused in new or complex situations, and is anxious all the time, Emotional status indicated Patient #10 was feeling down, depressed, or hopeless nearly every day, felt bad about themselves nearly every day, had trouble concentrating nearly every day, Cognitive behavioral, and psychiatric symptoms were demonstrated at least once a week, then indicated no behaviors demonstrated, and identified the frequency of disruptive behavior symptoms occurred several times a week. Fall assessment was left blank. Further review evidenced a Plan of Care dated 04/17/2025 for the initial certification period of 04/17/2025 through 06/15/2025 failed to evidence seizure precautions and interventions, Mental status indicated patient was oriented only, failed to identify/include physician management of the pacemaker, pain management when the assessment indicated the patient experienced no pain, bladder and bowel management when the assessment indicated no issues, and failed to include patient stated goals. 10. On 05/15/2025 at 10:27AM, when discussing all concerns, the Alternate Clinical Supervisor indicated they needed to ensure all precautions with interventions were included in the POC, pertinent diagnosis, safety measures to protect against injury, patient specific interventions, and goals identified by the patient. 410 IAC 17-13-1(a)(1)(D)(i-xiii) 1. A review of an agency policy titled 'PLAN OF CARE (POC)' stated, "… The POC … includes: a. All pertinent diagnosis, b. Patients mental, Psychosocial, and cognitive status … g. Functional Limitations, h. Activities permitted … k. Safety measures to protect against injury … o. Patient specific interventions & education, p. … goals identified by the patient & Agency …" 2. A review of the clinical record for Patient #2 with a start of care date of 04/17/2025, an initial certification period of 04/17/2025 to 06/15/2025, and diagnoses which included but were not limited to: hypertension (high blood pressure) and cardiomyopathy (chronic disease of the heart muscle). The document evidenced the patient experienced "no shortness of breath". The cardiovascular assessment was "within normal limits", the patient had a pacemaker inserted in 2021, the patient's goal indicated they wanted, "more ejection fraction from heart valve, to be able to attend work", and the document failed to evidence information as to how the patient's current cardiac status affected activities of daily living. Further review evidenced a Plan of Care dated 04/17/2025 for the initial certification period of 04/17/2025 through 06/15/2025 evidenced the patient's goal with home health services was to "transfer [sic]with SOB (shortness of breath)". 3. A review of the clinical record for Patient #5 with a start of care date of 04/15/2025, an initial certification period of 04/15/2025 to 06/13/2025, and diagnoses were: COPD (Chronic obstructive pulmonary disease, a term for certain types of irreversible lung and airway damage that block airways and make it hard to breathe), Essential Hypertension (high blood pressure not related to another medical cause). The record contained a comprehensive assessment which evidenced the following: A section titled 'Active Diagnosis' included, "… Diabetes …" which was marked "None of the above", a section titled 'Endocrine' queried, "Is client diabetic" was marked, "No" and the remainder of the endocrine section detailed evidence the patient and caregiver were independent in glucometer use, had a random reading of 136 mg/dl taken from the "left" and failed to identify the site, with a 'Comment' which stated, "check BS(blood sugar) before eating meals and snacks, with a goal of, "Client will be free from signs and symptoms of hypo/hyperglycemia during the care period", and failed to offer further explanation. The diagnosis list failed to evidence Diabetes. The record also contained a physician referral dated 04/15/2025 for home health skilled nursing services for medication management, and indicated the diagnoses for services were: Encephalopathy (refers to a change in brain function due to injury or disease), confusion (an altered mental status, in ability to think clearly, focus, or remember things, often leading to disorientation), and polypharmacy (the regular use of 5 or medications at the same time). Further review evidenced a Plan of Care dated 04/15/2025 for the initial certification period of 04/15/2025 to 06/13/2025 evidenced the patient's exclusive diagnoses were: COPD (Chronic obstructive pulmonary disease, a term for certain types of irreversible lung and airway damage that block airways and make it hard to breathe), Essential Hypertension (high blood pressure not related to another medical cause) and failed to evidence additional diagnoses. 4. A review of the clinical record for Patient #6 with a start of care date of 04/22/2025, an initial certification period of 04/22/2025 to 06/20/2025, and diagnoses which included but were not limited to: The record contained a Plan of Care dated 4/22/2025 which evidenced the following: Orders for skilled nursing to "assess client and fill medication box". The Plan of Care failed to evidence goals for medication management. 10. On 05/15/2025 at 10:22 AM, in an interview with the Administrator and Alternate Clinical Manager discrepancies and inaccuracies found during chart review were reviewed and discussed the Clinical Manager indicated there should have been appropriate documentation in the records, agreed should have been complete and accurately reflected each patients status, and added if it was not documented, then it did not happen.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure all orders were incorporated into the Patient's record in 1 of 1 patient receiving home health aide services. (Patient #3) Findings include: Based on record review and interview, the agency failed to ensure all orders were incorporated into the Patient's record in 1 of 1 patient receiving home health aide services. (Patient #3) Findings include: 1. A review of a policy titled 'Plan of Care (POC) Policy Number : C:48' indicated, "… 4. POC Includes: all orders, from all medical providers involved with the patient's care will be integrated into the POC. … All patient care orders, including verbal orders, must be recorded in the plan of care …" 2. A review of the clinical record for Patient #3 evidenced a Plan of Care dated 04/21/2025 for the certification period of 04/21/2025 through 06/19/2025 signed by the Clinical Supervisor, indicated Patient #3 was to receive Home Health Aide (HHA) services 1 time a week for 9 weeks. Further review of the clinical record evidenced a Physician Order dated 04/22/2025 signed by the Alternate Clinical Supervisor, discontinuing HHA services due to Patient #3's request, a 2nd Physician Order dated 05/06/2025 signed by the Clinical Supervisor, to add HHA services. The Clinical Supervisor failed to ensure all orders were incorporated into the POC. 3. On 05/15/2025 at 10:45 AM, the Alternate Clinical Supervisor indicated they hadn't realized after the POC is developed, new orders should be added into the POC.

Communication with all physicians CFR(s): 484.60(d)(1) Standard: Coordination of Care. The HHA must: (1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure communication occurred with the ordering provider for the development and implementation of a coordinated plan of care with 10 of 10 active records reviewed. (Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, and 10) Findings include: 1. A review of a policy titled 'Plan of Care (POC) Policy Number : C:48' indicated, "… 4. POC Includes: … The POC is developed in consultation with … medical provider …" 2. A review of the clinical record for Patient #1 evidenced an Oasis Start of Care (SOC) dated 04/17/2025 signed by RN 1, failed to evidence coordination of care with the ordering physician for the development of the plan of care. 3. A review of the clinical record for Patient #3 evidenced an Oasis SOC dated 04/21/2025, signed by Admin #2, evidenced coordination of care with a physician, but failed to identify who they spoke with. 4. A review of the clinical record for Patient #4 evidenced an Oasis SOC dated 04/17/2025 signed by Admin #2, evidenced coordination of care with a physician, but failed to identify who they spoke with. 5. A review of the clinical record for Patient #7 evidenced an Oasis SOC dated 04/15/2025 signed by RN 1, failed to evidence coordination of care with the ordering physician for the development of the plan of care. 6. A review of the clinical record for Patient #9 evidenced an Oasis SOC date 04/17/2025 signed by RN1, failed to evidence coordination of care with the ordering physician for the development of the plan of care. 7. A review of the clinical record for Patient #10 evidenced an Oasis SOC dated 04/17/2025 signed by RN1, failed to evidence coordination of care with the ordering physician for the development of the plan of care. 12. On 05/15/2025 at 10 AM, during an interview with Administrator and the Alternate Clinical Supervisor, they indicated they do not communicate with the ordering physician after the initial assessment is completed. They develop the plan of care and fax over to the ordering physician for signature. 8. A review of the clinical record for Patient #2 evidenced an Oasis SOC dated 04/17/2025 signed by RN 1, failed to evidence coordination of care with the ordering physician for the development of the plan of care. 9. A review of the clinical record for Patient #5 evidenced an Oasis SOC dated 04/15/2025 signed by RN 1, failed to evidenced coordination of care with the ordering physician, for the development of the plan of care. 10. A review of the clinical record for Patient #6 evidenced an Oasis SOC dated 04/22/2025 signed by RN 1, evidenced coordination of care with the ordering physician, but failed to identify who they spoke with. 11. A review of the clinical record for Patient #8 evidenced an Oasis SOC dated 04/17/2025 signed by RN 1, evidenced coordination of care with the ordering physician, but failed to identify who they spoke with. 410 IAC 17-14-1(a)(1)(G)

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure an accurate HHA POC was provided to the HHA in 1 of 1 patient receiving HHA services. (Patient #3) Findings include: 1. A review of the HHA POC dated 04/21/2025 for Patient #3, indicated the patient had an amputation, used a wheelchair, and received a partial bed bath. 2. On 05/13/2025 at 3PM, during a home visit with Patient #3 to observe HHA 1 provide care. Patient #3 met this writer and HHA 1 downstairs at the locked entrance. Patient #3 escorted this writer and HHA to the 2nd level via the stairway. HHA1 proceeded to assist Patient #3 for their shower. 3. On 05/13/2025 at 3:25 PM, Patient #3 indicated they were grateful for the services they received, indicated they prefer showers instead of baths, and indicated they had not had a wheelchair and it was obvious there was no amputation. The Clinical Supervisor failed to ensure the HHA POC accurately reflected Patient #3 health status and their care preference. On 05/14/2025 at 11:10 AM, after addressing concerns with the HHA POC, the Alternate Clinical Supervisor indicated they needed to correct the POC. 410 IAC 17-13-2(a)