Every finding on record at Givingback 3 Inc

An Emergency Preparedness survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102, for a Medicaid participating non-deemed Home Health Agency. Date of survey: 02-21-2023, 02-22-2023, and 02-23-2023 Facility #: 014724 Census: 28 Unduplicated Skilled Admissions: 34 At this Emergency Preparedness survey, Givingback 3 Inc, was found to have been in compliance with the requirements of Emergency Preparedness for Medicare and Medicaid participating providers and suppliers, including staffing and implementation of staffing during a Pandemic, at 42 CFR 484.102. QR Completed 3/1/2023 A4

This visit was for a Federal Recertification and State Re-Licensure of a non-deemed Home Health Provider. A partially extended investigation was announced on 02-22-2023 at 02:40 PM to the Administrator. A fully extended investigation was announced on 02-23-2023 at 09:18 AM to the Administrator. Survey dates: 02-21-2023, 02-22-2023, and 02-23-2023 Census: 28 Unduplicated Skilled patients: 34 · These deficiencies reflect State Findings cited in accordance with 410 IAC 17. Refer to state form for additional state findings. Based on the Condition-level deficiencies during the 02-23-2023 survey, your HHA was subject to a partial or extended survey pursuant to section 1891(c)(2)(D) of the Social Security Act on 02-23-2023. Therefore, and pursuant to section 1891(a)(3)(D)(iii) of the Act, your agency is precluded from operating or being the site of a home health aide training, skills competency and/or competency evaluation programs for a period of two years beginning 02-23-2023 and continuing through 02-22-2025.

HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator's name, business address, and business phone number in order to receive complaints. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to provide the Administrator’s name to the patients for 3 of 3 home visit observations. (Patients #1, 2, and 4) Findings Include: 1. On 02-21-2023 at 09:55 AM, Administrator provided the admission folder titled, “Home Health Care”. The folder contained a document titled, “Fax’, and indicated the Alternate Administrator was the Administrator. The Alternate Administrator was listed as the Administrator under the subtitle titled, "Complaint Policy". 2. On 02-21-2023 at 04:05 PM, a home visit at Patient #4’s residence was conducted. Patient #4’s admission folder titled, “Home Health Care”, was reviewed and failed to provide the name of the Administrator. 3. On 02-22-2023 at 08:30 AM, a home visit at Patient #2’s residence was conducted. Patient #2’s admission folder titled, “Home Health Care”, was reviewed and failed to provide the name of Admin #1. 4. On 02-23-2023 at 10:30 AM, a home visit at Patient #1’s residence was conducted. Patient #1’s admission folder titled, “Home Health Care”, was reviewed and failed to provide the name of Admin #1. 5. On 02-21-2023 at 09:17 AM, during the entrance conference with Administrator, when queried who the Administrator of the agency was, the Administrator indicated that they were the Administrator.

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 patients received all services included in the plan of care 1 (Patient #5) of 4 active clinical records reviewed. Findings Include: 1. On 02-21-2023 at 09:55 AM, Administrator provided a Givingback 3 Inc admission folder with a document with a subtitle titled, “Decision Making.” The policy indicated but was not limited to, “… Establishing and revising the plan of care… the frequency of visits… any changes in the care to be furnished. The planning of care….” 2. On 02-22-2023 at 03:00 PM, a clinical record review for Patient #5 for the certification period 01-17-2023 through 03-17-2023 and a start of care (SOC) of 09-02-2021, was conducted. The plan of care (POC) included but was not limited to, Home Health Aide (HHA) visits 2 hours a visit, 2 days a week for 26 weeks. A review of the clinical record for Patient #5 failed to evidence HHA visit notes for the following weeks: 01-17-2023 through 01-21-2023 01-22-2023 through 01-28-2023 01-29-2023 through 02-04-2023 02-05-2023 through 02-11-2023 02-12-2023 through 02-18-2023 02-19-2023 through 02-25-2023 02-26-2023 through 02-27-2023. A review of Patient #5’s clinical record failed to evidence missed visit notes sent to the physician regarding the patient not receiving HHA services. A review of Patient #5's clinical record evidenced a document titled, "Nurse Supervision of Aide", dated 01-16-2023, and indicated, "no current aide". A review of Patient #5's clinical record evidenced a document titled, "Nurse Supervision of Aide", dated 02-06-2023, and indicated the patient had an aide, but the aide was not present at the time of the supervisory visit. 3. On 02-23-2023 at 04:08 PM, during an interview with Administrator regarding Patient #5’s services according to the plan of care, Administrator indicated the patient had been seen 1 visit a month and they notify the physician weekly. Missed visit notifications were not evidenced in the patient’s clinical record. On 02-23-2023 at 09:10 AM, during an interview with the Office Manager/Scheduler regarding HHA visits for Patient #5, they stated, “it has been difficult to staff the patient with an HHA because the patient has roaches.” Office Manager/Scheduler indicated the patient has not received HHA services since June of 2022. On 02-23-2023 at 02:29 PM, during a phone interview with Patient #5 indicated they were given a bath by another agency. Patient #5 did not provide further information regarding the care they are being provided.

Freedom from discrimination or reprisal CFR(s): 484.50(c)(11) Be free from any discrimination or reprisal for exercising his or her rights or for voicing grievances to the HHA or an outside entity. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to provide services for 1 (Patient #5) of 4 active patients because of the condition of the patient's residence. Findings Include: 1. On 02-21-2023 at 09:55 AM, the Administrator provided a Givingback 3 Inc admission folder with a document titled, “Patient Rights and Responsibilities,” with a subtitle titled, “Dignity and Respect.” The policy indicated but was not limited to, “… The patient has the right have his or her property treated with respect, consideration and recognition of client/patient dignity and individuality… Patients will not be discriminated against based on social status… handicap….” 2. On 02-22-2023 at 03:00 PM, a clinical record review for Patient #5 for the certification period 01-17-2023 through 03-17-2023 and a start of care (SOC) of 09-02-2021, was conducted. The plan of care (POC) included, but was not limited to, Home Health Aide (HHA) visits 2 hours a visit, 2 days a week for 26 weeks. A review of the clinical record for Patient #5 failed to evidence HHA visit notes for the following weeks: 01-17-2023 through 01-21-2023 01-22-2023 through 01-28-2023 01-29-2023 through 02-04-2023 02-05-2023 through 02-11-2023 02-12-2023 through 02-18-2023 02-19-2023 through 02-25-2023 02-26-2023 through 02-27-2023 3. On 02-23-2023 at 04:08 PM, during an interview with the Administrator regarding Patient #5’s services according to the plan of care, Admin #1 indicated the patient was seen 1 visit a month and they notify the physician weekly. Missed visits were not evidenced in the patient’s clinical record. 4. On 02-23-2023 at 09:10 AM, during an interview with the Office Manager/Scheduler regarding HHA visits for Patient #5, Office Manager/Scheduler stated, “it has been difficult to staff the patient with an HHA because the patient has roaches.” The Office Manager/Scheduler indicated the patient has not received HHA services since June of 2022. 410 IAC 17-12-3 (b) (2) (B)

Make efforts to resolve the problem(s) CFR(s): 484.50(d)(5)(ii) (ii) Make efforts to resolve the problem(s) presented by the patient's behavior, the behavior of other persons in the patient's home, or situation; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to make efforts to resolve problems in 1 (Patient #5) of 1 active clinical record reviewed with Home Health Aide services (HHA) and Skilled Nursing (SN) services. Findings Include: 1. On 02-21-2023 at 09:55 AM, Administrator (Admin #1) provided a Givingback 3 Inc admission folder with a document with a subtitle titled, “Decision Making.” The policy indicated but was not limited to, “… Establishing and revising the plan of care… the frequency of visits… any changes in the care to be furnished. The planning of care….” 2. On 02-22-2023 at 03:00 PM, a clinical record review for Patient #5 for the certification period 01-17-2023 through 03-17-2023 and a start of care (SOC) of 09-02-2021, was conducted. The plan of care (POC) included Skilled Nurse (SN) visits 1 visit a day, 1 day a week for 26 weeks and Home Health Aide (HHA) visits 2 hours a visit, 2 days a week for 26 weeks. A review of the clinical record for Patient #5 failed to evidence HHA visit notes for the following weeks: 01-17-2023 through 01-21-2023 01-22-2023 through 01-28-2023 01-29-2023 through 02-04-2023 02-05-2023 through 02-11-2023 02-12-2023 through 02-18-2023 02-19-2023 through 02-25-2023 02-26-2023 through 02-27-2023 The clinical record review of Patient #5’s chart failed to evidence communication notes to the physician regarding the patient not receiving HHA services as listed on the plan of care. A review of Patient #5’s clinical record failed to evidence missed visit notes sent to the physician regarding the patient not receiving HHA services. A review of Patient #5's clinical record failed to evidence communication notes notifying the physician of the patient's living situation. On 02-23-2023 at 04:08 PM, during an interview with the Administrator regarding Patient #5’s services according to the plan of care, the Administrator indicated the patient was seen 1 visit a month and they notify the physician weekly. Missed visits were not evidenced in the patient’s clinical record. On 02-23-2023 at 04:08 PM, during an interview with the Administrator, when queried about whether the patient is to receive all services as ordered by the plan of care, the Administrator indicated they are to follow the plan of care and notify the physician of any missed visits. On 02-23-2023 at 09:10 AM, during an interview with the Office Manager/ Scheduler regarding HHA visits for Patient #5, Office Manager/Scheduler stated, “it has been difficult to staff the patient with an HHA because the patient has roaches.” The Office Manager/Scheduler indicated the patient has not received HHA services since June of 2022. On 02-23-2023 at 11:27 AM, during a phone interview with Patient #5's physician's office, Entity A, Person C indicated there were no communication notes of missed visits for the patient's HHA services from the agency. On 02-23-2023 at 02:29 PM, during a phone interview with Patient #5, they confirmed a nurse comes out to set up their medications. The patient indicated they were given a bath by the agency. Patient #5 did not provide further information regarding the care they are being provided.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to follow physician orders on the plan of care for 1 (Patient #5) of 4 active clinical records reviewed. 1. On 02-21-2023 at 09:55 AM, Administrator (Admin #1) provided a Givingback 3 Inc admission folder with a document with a subtitle titled, “Decision Making.” The policy indicated but was not limited to, “… Establishing and revising the plan of care… the frequency of visits… any changes in the care to be furnished. The planning of care….” 2. On 02-22-2023 at 03:00 PM, a clinical record review for Patient #5 for the certification period 01-17-2023 through 03-17-2023 and a start of care (SOC) of 09-02-2021, was conducted. The plan of care (POC) included Skilled Nurse (SN) visits 1 visit a day, 1 day a week for 26 weeks and Home Health Aide (HHA) visits 2 hours a visit, 2 days a week for 26 weeks. A review of the clinical record for Patient #5 failed to evidence HHA visit notes for the following weeks: 01-17-2023 through 01-21-2023 01-22-2023 through 01-28-2023 01-29-2023 through 02-04-2023 02-05-2023 through 02-11-2023 02-12-2023 through 02-18-2023 02-19-2023 through 02-25-2023 02-26-2023 through 02-27-2023 The clinical record review of Patient #5’s chart failed to evidence communication notes to Person B, the physician, regarding the patient not receiving HHA services as listed on the plan of care. A review of Patient #5’s clinical record failed to evidence missed visit notes sent to the physician regarding the patient not receiving HHA services. On 02-23-2023 at 04:08 PM, during an interview with Admin #1 regarding Patient #5’s services according to the plan of care, Admin #1 indicated the patient was seen 1 visit a month and they notify the physician weekly. Missed visits were not evidenced in the patient’s clinical record. On 02-23-2023 at 09:10 AM, during an interview with the Office Manager/Scheduler regarding HHA visits for Patient #5, Office Manager/Scheduler stated, “it has been difficult to staff the patient with an HHA because the patient has roaches.” The Office Manager/Scheduler indicated the patient has hygienic issues, which make it difficult to keep an HHA in the patient's residence. Office Manager/Scheduler indicated the patient has not received HHA services since June 2022. On 02-23-2023 at 11:27 AM, during a phone interview with Patient #5's physician's office, Entity A, Person C indicated there were no communication notes of missed visits for the patient's HHA services from the agency. On 02-23-2023 at 02:29 PM, during a phone interview with Patient #5, they confirmed a nurse comes out to set up their medications. The patient indicated they were given a bath by the agency. Patient #5 did not provide further information regarding the care they are being provided.

Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA's governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA's performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This CONDITION is not met as evidenced by: Based on record review and interview the agency failed to provide a Quality Assurance Performance Improvement (QAPI) program as documented over 3 of 3 survey days. The cumulative effect of these systematic problems resulted in the agency’s inability to ensure the provision of quality of care in a safe environment for Condition of Participation of Part of 42 CFR 484.65, Quality Assessment and Performance improvement. Findings include: 1. A policy received from the Administrator on 2-21-23 at 9:54 AM, titled “QUALITY ASSESSMENT PERFORMANCE AND PERFORMANCE IMPROVEMENT (QAPI) POLICY,” with a revision and reviewed date of 3-07-2020, contained but not limited to, “Giving Back 3 Home Healthcare will develop, implement, evaluate, and maintain an effective ongoing agency wide, data driven QAPI program…The agency will maintain and document evidence of its QAPI program and be able to demonstrate its operations…the frequency and detail of the data collection must be approved by the governing body and noted in meeting minutes…must conduct performance improvement projects…an ongoing program for quality improvement and patient safety is defined, implemented and maintained. 2. A review of documents in binder received from the Administrator on 2-22-23 at 10:10 AM failed to evidence collection of data, performance improvement projects, and an indication that QAPI program information was reviewed or approved by the governing body. 3. On 2-22-23 at 10:10 AM the Administrator provided the following documents not found in the binder: A. “Meeting Minutes 3/17/20” which contained but was not limited to, "Governing body is responsible for all actions and activities of the QAPI program. This will be reflected in meeting minutes." The document indicated attendees included the Board President, Former Director of Nursing, and Secretary. B. “Quarter: 1st…Governing Body Board Report…” no date to indicate when the report was transcribed and the document contained only the signature of the former administrator. C. “Quarter: 2nd April-June 2022…Governing Body Board Report…” The report contained data collection, a performance improvement plan, and changes and updates. The report contained no evidence of attendees or that the report was reviewed or approved by the Governing Body. 4. During an interview with the Administrator on 2-22-23 at 10:10 AM she confirmed the agency has not had a governing board meeting recently or a QAPI program. She reported she has just begun to collect data and implement a QAPI program and has not put it all together. 410 IAC 17-12-2 (a)

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to notify the physician of services not being provided according to the orders on the plan of care for 1 (Patient #5) of 4 active clinical records reviewed. Findings Include: 1. On 02-21-2023 at 09:55 AM, the Administrator provided a Givingback 3 Inc admission folder with a document with a subtitle titled, “Decision Making.” The policy indicated but was not limited to, “… Establishing and revising the plan of care… the frequency of visits… any changes in the care to be furnished. The planning of care….” 2. On 02-22-2023 at 03:00 PM, a clinical record review for Patient #5 for the certification period 01-17-2023 through 03-17-2023 and a start of care (SOC) of 09-02-2021, was conducted. The plan of care (POC) included, but was not limited to, Home Health Aide (HHA) visits 2 hours a visit, 2 days a week for 26 weeks. A review of the clinical record for Patient #5 failed to evidence HHA visit notes for the following weeks: 01-17-2023 through 01-21-2023 01-22-2023 through 01-28-2023 01-29-2023 through 02-04-2023 02-05-2023 through 02-11-2023 02-12-2023 through 02-18-2023 02-19-2023 through 02-25-2023 02-26-2023 through 02-27-2023 The clinical record review of Patient #5’s chart failed to evidence communication notes to Person B, the physician, regarding the patient not receiving HHA services as listed on the plan of care. A review of Patient #5’s clinical record failed to evidence missed visit notes sent to the physician regarding the patient not receiving HHA services. On 02-23-2023 at 04:08 PM, during an interview with the Administrator regarding Patient #5’s services according to the plan of care, the Administrator indicated the patient was seen 1 visit a month and they notify the physician weekly. Missed visits were not evidenced in the patient’s clinical record. On 02-23-2023 at 09:10 AM, during an interview with the Office Manager/Scheduler regarding HHA visits for Patient #5, Office Manager/Scheduler stated, “it has been difficult to staff the patient with an HHA because the patient has roaches.” The Office Manager/Scheduler indicated the patient has hygienic issues, which make it difficult to keep an HHA in the patient's residence. The Office Manager/Scheduler indicated the patient has not received HHA services since June 2022. On 02-23-2023 at 11:27 AM, during a phone interview with Patient #5's physician's office, Entity A, Person C indicated there were no communication notes of missed visits for the patient's HHA services from the agency. On 02-23-2023 at 02:29 PM, during a phone interview with Patient #5, they confirmed a nurse comes out to set up their medications. The patient indicated they were given a bath by the agency. Patient #5 did not provide further information regarding the care they are being provided. 410 IAC 17-14-1 (a) (1) (G)

Licensing CFR(s): 484.100(b) (b) Standard: Licensing. The HHA, its branches, and all persons furnishing services to patients must be licensed, certified, or registered, as applicable, in accordance with the state licensing authority as meeting those requirements. This STANDARD is not met as evidenced by: Based on interview and observation the agency operated a branch location without obtaining approval from the state licensing authority for 1 of 1 branches reported by the agency. The Findings Include: 1. On 2-21-23 at 9:18 AM during the entrance conference the Agency’s Administrator reported a branch location in another city that housed the employee and patient files serviced by that branch. She reported the Alternate Administrator works from that location. 2. On 2-22-23 at 12:55 PM observed a building in another city with the Agency’s Name on the outside of the building. Entered and observed clinical records and employee records on-premises. The agency’s Human Resource Personnel provided access to records in a locked closet. 3. On 2-23-23 at 8:15 AM the Administrator reported she could not locate any documentation submitted to the state agency requesting the opening of a branch location. She reported the owner wrote the information on their last application for a state license renewal but did not submit any other paperwork necessary to meet the requirement for opening a branch. 4. On 2-23-23 at 8:15 AM the Owner and Administrator confirmed not knowing the process for opening a branch and the Owner reported he had only submitted the address on the renewal application. 5. On 2-23-23 at 10 AM the Owner reported that staff began working out of the branch "sometime" in 2021 but could not recall a date and had no further information to offer. 410 IAC 17-10-1(b)

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: Based on observation and interview, the agency failed to evidence the Governing Body assumed responsibility for managing home health services, failed to provide services to Medicare-insured patients for the last 14 months of 30 months as a participant as a home health agency in the Medicare program, failed to ensure the Administrator and the alternate administrator were appointed by the Governing Body (G 946)(G954), and failed to receive approval for an added branch (G972), as noted over 3 of 3 survey days. These deficiencies had a potential cumulative effect on all 43 patients and 13 staff. The cumulative effect of these systemic problems resulted in the home health agency's inability to ensure the provision of quality health care in a safe environment for the Condition of Participation of 42 CFR 484.105, Organization and Administration of Services. The Findings include: 1. A record review of Patient #6 was identified by the Administrator as the last patient receiving Medicare paid reimbursement to the agency. The record revealed Patient #6 converted to Medicaid Insurance in December of 2021 and remained with the agency until discharge in January of 2023. 2. During an interview on 2-22-23 at 2:40 PM, the Administrator indicated the agency does not accept patients whose payment source is Medicare. She reported they have not offered to provide services with this payment source in over a year and have declined 2 referrals in the past 6 months. She reported the 2 referrals with Medicare required therapy services this agency does not provide. 3. The agency’s owner reported he was unable to locate paperwork sent to the Medicare Administrative Contractor (MAC) reporting their intention to not accept services to patients with Medicare as a payment source. 4. During an interview on 2-23-23 at 9:18 AM the Administrator confirmed the agency had not submitted information to the Medicare Administrative Contractor (MAC) reporting their withdrawal from the Medicare program. 410 IAC 17-12-1(a)(1) 410 IAC 17-12-1(a)(2)

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on record review and interview the Governing Body failed to demonstrate they were responsible for informing the state home health licensing agency of changes in service areas and review of the Quality Assurance Performance Improvement Plan (QAPI) for 2 of 3 years the Agency has operated. The Findings include: 1. A document received on 2-21-23 indicated the agency provided services in Bartholomew, Brown, Greene, Johnson, Monroe, Owen, and Shelby counties. A review of documents from the Agency’s original Home Health License indicated the agency provided services in Brown, Decatur, Greene, Jackson, Jennings, Johnson, Lawrence, Monroe, Morgan, Owen, Rush, and Shelby Counties. No other documents were submitted to the State Home Health Licensing Agency to request either additions or subtractions in counties served. 2. On 2-21-23 during an interview with the Administrator she reported she was not sure if the agency informed the state home health licensing agency of the changes in services and reported she would reach out to the owner, a member of the Agency’s Governing Body for more information…. 3. On 2-23-23 at 9:31 AM the Owner reported they have worked out of Columbus (Bartholomew County) since “sometime in 2021”. He reported the agency hired someone to file paperwork but was not able to locate any further information or provide further documentation. 4. A review of Governing Body Meeting Minutes received from the Administrator on 2-21-23 at 9:54 AM contained 3 meeting notes beginning in March of 2020 containing 1 of 3 signed/approved notes by the Governing Body and no information related to approval or process for adding and subtracting services or review of the agency's QAPI program since the March 2020 meeting. 5. During an interview with the Administrator on 2-22-23 at 10:10 AM she confirmed the Governing Body meeting minutes provided, did not contain evidence of review of the QAPI program, information related to new administrator appointment, alternate administrator appointment, changes in services and service area changes. 410 IAC 17-12-1(b)

Administrator appointed by governing body CFR(s): 484.105(b)(1)(i) (i) Be appointed by and report to the governing body; This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to evidence the Administrator was appointed by the Governing Body. The Findings Include: 1. On 2-21-23 at 9:08 AM was greeted by a staff member who identified themselves as the Administrator. 2. A review of Governing Body Meeting Minutes from 2020 through 2023 failed to evidence the Governing Body had appointed this staff member as the Administrator. 3. On 2-23-23 at 9:18 AM the person identified as the Administrator confirmed there were no Governing Body Meeting Minutes evidencing her appointment to the Administrator position. 410 IAC 17-12-1(b) (1)

Ensures qualified pre-designated person CFR(s): 484.105(b)(2) When the administrator is not available, a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator. The pre-designated person may be the clinical manager as described in paragraph (c) of this section. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to evidence the Alternate Administrator was appointed by the Governing Body. The Findings include: 1. On 2-21-23 at 9:08 AM during the entrance conference, the Administrator the Alternate Administrator at Employee #2. 2. A review of Governing Body Meeting Minutes from 2020-2023 failed to prove Employee # 2 was appointed the Alternate Administrator. 3. On 2-23-23 at 9:18 AM the Administrator confirmed there was no evidence the Governing Body had appointed Employee #2 as alternate administrator. 410 IAC 17-12-1(d)(8)

Report all branch locations to SA CFR(s): 484.105(d)(1) The parent HHA is responsible for reporting all branch locations of the HHA to the state survey agency at the time of the HHA's request for initial certification, at each survey, and at the time the parent proposes to add or delete a branch. This ELEMENT is not met as evidenced by: Based on interview and observation the agency failed to submit a proposed branch location and failed to obtain approval for operating a branch for 1 of 1 branch locations observed. The Findings Include: 1. On 2-21-23 at 9:18 AM during the entrance conference the Agency’s Administrator reported a branch location in another city that housed the employee and patient files serviced by that branch. She reported the Alternate Administrator works from that location. 2. On 2-22-23 at 12:55 PM observed a building in another city with the Agency’s Name on the outside of the building. Entered and observed clinical records and employee records on-premises. The agency’s Human Resource Personnel provided access to records in a locked closet. 3. On 2-23-23 at 8:15 AM the Administrator reported she could not locate any documentation submitted to the state agency requesting the opening of a branch location. She reported the owner wrote the information on their last application for a state license renewal but did not submit any other paperwork necessary to meet the requirement for opening a branch. 4. On 2-23-23 at 8:15 AM the Owner and Administrator confirmed not knowing the process for opening a branch and the owner reported he had only submitted the address on the renewal application.

Protection of records CFR(s): 484.110(d) Standard: Protection of records. The clinical record, its contents, and the information contained therein must be safeguarded against loss or unauthorized use. The HHA must be in compliance with the rules regarding protected health information set out at 45 CFR parts 160 and 164. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to ensure patient’s rights by maintaining secure and confidential storage of clinical records over 1 of 3 survey days. The findings include: 1. Upon arrival at the agency on 1-21-23 at 8:55 AM observed a garage attached to the agency’s office with the garage door open and file cabinets in sight from the parking area. 2. During the entrance interview with the Administrator on 1-21-23 at 9:18 AM, she indicated patient records are kept confidential and secured by being locked in offices and that she, two staff registered nurses (RN), and a staff Licensed Practical Nurse (LPN) have access to those records. 3. On 1-21-21 at 1:35 during an interview with the Administrator queried regarding what was stored in the open garage file cabinets. She reported the files contained active and discharge patient information. While accompanying the Administrator to the garage to retrieve patient charts, observed the file cabinets were unlocked and the garage door remained open. The owner of the agency came out and confirmed the door should be closed and the files locked. The administrator reported she did not know where the file cabinet keys were. Both confirmed that this was not the way to store patients’ private medical information. 4. On 1-21-23 at 2:54 PM, the Administrator reported they had found the keys to the file cabinets and were securing all medical records in the garage. 410 IAC 17-15-1(C)