Every finding on record at Golden Care Home Health Services LLC

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR §484.102 Survey Dates: 03/24/2026 and 03/25/2026. Active Census: 11 At this Emergency Preparedness survey, Golden Home Health Services LLC was found to be in compliance with Emergency Preparedness Requirements for Medicaid Participating Providers and Suppliers, 42 CFR §484.102. QR completed on 03/27/2026 by A4MC

This visit was for a Federal Recertification and State Re-Licensure survey of a Home Health Provider. Survey Dates: 03/24/2026 and 03/25/2026. 12-Month Unduplicated Skilled Admissions: 3 Partially Extended on 03/25/2026 at 1:36 PM This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Refer to State Form for additional State Findings. Abbreviations: HHA Home Health Aide DON Director of Nursing POC Plan of Care LPN Licensed Practical Nurse SOC Start of Care ROC Resumption of Care RN Registered Nurse DC Discharge SN Skilled Nursing OASIS Outcome and Assessment Information Set ADL Activities of Daily Living

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to submit OASIS within 30 days of assessment completion for 2 of 2 patients who received skilled services. (Patients: #1 and 2) Findings Include: Findings Include: 1. A review of a document titled “OASIS (a comprehensive assessment designed to collect information related to a home care recipient’s demographic, clinical, functional, and service needs) Home Health Agency Activity Report” for the reporting period of 03/23/2025 through 03/23/2026, indicated no data had been returned for Golden Care Home Health Services. 2. A review of a document titled “OASIS Agency Final Validation Report” for the reporting period 03/23/2025 through 03/23/2026, indicated there were no results for the report criteria. 3. A review of the active clinical record for Patient #1, with a SOC OASIS Assessment date of 01/17/2024 and an OASIS recertification assessment dated 01/02/2026. A review of the OASIS recertification dated 01/02/2026, completed by the Administrator for the reason of recertification reassessment, noted Patient #1’s SOC 01/17/2024, date of birth of 05/14/1988 (37 years of age), and the current payment source for home care had been Medicaid. The recertification reassessment in the section titled “Summary and Notes” indicated Patient #1 had received Home Health Aide services for total care assistance with ADL’s and including all feedings; and Skilled Nursing services for HHA supervision, catheter management for weekly irrigation 3 times a week and changing suprapubic catheter monthly or as needed, and weekly ostomy management. POC development and ongoing monitoring of patients’ needs and health status. The recertification reason to continue to provide home health aide services and skilled nursing services through prior authorization. The clinical record failed to evidence the recertification OASIS had been submitted. 4. A review of the active clinical record for Patient #2, with a SOC date of 11/25/2025, contained a SOC OASIS initial assessment dated 11/25/2025, and an OASIS recertification assessment dated 01/22/2026. A review of the OASIS Assessment completed 01/22/2026, completed by the Administrator for the reason of recertification reassessment, noted Patient #2’s SOC 11/25/2025, date of birth of 11/12/1965 (60 years of age), and the current payment source for home care had been Medicaid. The recertification reassessment in the section titled “Summary and Notes” indicated Patient #2 had received Home Health Aide services and Skilled Nursing services for supervision, plan of care development, and ongoing monitoring of the patient’s needs and health status, and weekly medication management and medication box setup. The recertification reason to continue to provide home health aide services and skilled nursing services through prior authorization. The clinical record failed to evidence the recertification OASIS had been submitted. On 03/24/2026 at 1:36 PM, when queried regarding OASIS submissions and review of the validation reports, the Administrator stated, “No one told me I had to, so I am out of compliance. I have been open since 2022 and have had 3 skilled patients, and I did not know I needed to submit OASIS for Medicaid patients. I thought that was for Medicare only.” When asked about the OASIS policy, the Administrator communicated that the agency did not have one. The Administrator further reported they were preparing their Medicare policy and procedure manual and had an OASIS policy for that manual to be used when they began their Medicare certification.

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, record review, and interview, the Administrator/Director of Nursing failed to ensure infection control precautions were maintained during the use of reusable equipment for one of two skilled nursing observations, and the home health aide failed to bathe the patient from clean to dirty areas without cross‑contamination for 1 of 1 home health aides observed providing personal care. (HHA 2) Findings Include: 1. A review of an undated agency policy titled “Precautions For All Health Care Workers” indicated but was not limited to, “ … 1. Standard Precautions will be observed by every healthcare worker for all patients receiving care … 6. Cross contamination must be prevented … ” 2. A review of an undated agency policy titled “Equipment And Supplies” indicated, but was not limited to, “ … To maximize infection control and minimize potential for cross contamination of infectious microorganisms, … 5. … Employees must cleanse hands before entering/removing supplies from a bag, before examination, and place supplies on the clean side of a barrier … ” 3. During a home visit at Patient #1’s residence on 03/25/2026 at 10:20 AM, the Administrator/DON, who was the case manager for Patient #1, conducted an assessment of Patient #1. The Administrator/DON performed hand hygiene, obtained their blood pressure cuff, thermometer, stethoscope, and pulse oximeter from their bag, and placed the vital sign equipment on Patient #1’s bed. The Administrator/DON failed to place the vital sign equipment on a barrier after removing the clean equipment from their bag. During an interview on 03/25/2026 at 11:00 AM, when asked about infection control practices and the placement of vital sign equipment, the Administrator/DON confirmed they had placed the equipment on Patient #1’s bed sheets, not on a barrier, per agency policy. 4. During a home visit at Patient #1 on 03/25/2026 at 8:00 AM, HHA 2 was observed giving the patient a shower and assisting them with dressing. HHA 2 used a wash cloth to wash the patient's chest, abdomen, right arm, and then proceeded to the patient's perineum. Using the same rag, the HHA was observed washing the patient's legs, feet, and left arm. When the HHA dried the patient, they used a towel to dry the patient's perineal area and used the same towel to dry the patient's left leg and foot. A review of HHA 2's personnel file evidenced the patient had training and was tested on infection control on 01/26/2026. During an interview with HHA 2 on 03/25/2026 at 8:55 AM, they indicated the patient's buttocks and perineum were considered dirty. They explained when washing a patient they washed the top part of the body first and the bottom half of the body last. 410 IAC 17-12-1(m) During a home visit at Patient #1’s residence on 03/25/2026 at 10:20 AM, the Administrator/DON, who was the case manager for Patient #1, conducted an assessment of Patient #1. The Administrator/DON performed hand hygiene, obtained their blood pressure cuff, thermometer, stethoscope, and pulse oximeter from their bag, and placed the vital sign equipment on Patient #1’s bed. The Administrator/DON failed to place the vital sign equipment on a barrier after removing the clean equipment from their bag. During an interview on 03/25/2026 at 11:00 AM, when asked about infection control practices and the placement of vital sign equipment, the Administrator/DON confirmed they had placed the equipment on Patient #1’s bed sheets, not on a barrier, per agency policy.4. During a home visit at Patient #1 on 03/25/2026 at 8:00 AM, HHA 2 was observed giving the patient a shower and assisting them with dressing. HHA 2 used a wash cloth to wash the patient's chest, abdomen, right arm, and then proceeded to the patient's perineum. Using the same rag, the HHA was observed washing the patient's legs, feet, and left arm. When the HHA dried the patient, they used a towel to dry the patient's perineal area and used the same towel to dry the patient's left leg and foot. A review of HHA 2's personnel file evidenced the patient had training and was tested on infection control on 01/26/2026. During an interview with HHA 2 on 03/25/2026 at 8:55 AM, they indicated the patient's buttocks and perineum were dirty. They explained when washing a patient, they washed the top part of the body first and the bottom half of the body last. 410 IAC 17-12-1(m)

A qualified HH aide successfully completed: CFR(s): 484.80(a)(1)(i-iv) A qualified home health aide is a person who has successfully completed: (i) A training and competency evaluation program as specified in paragraphs (b) and (c) respectively of this section; or (ii) A competency evaluation program that meets the requirements of paragraph (c) of this section; or (iii) A nurse aide training and competency evaluation program approved by the state as meeting the requirements of §483.151 through §483.154 of this chapter, and is currently listed in good standing on the state nurse aide registry; or (iv) The requirements of a state licensure program that meets the provisions of paragraphs (b) and (c) of this section. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure HHA competency tests were dated and graded for 2 of 3 HHA personnel records reviewed. (HHA 2 and 3) Findings Include: A review of HHA 2's personnel record evidenced a Competency Assessment Exam dated 07/21/2025. The test failed to evidence the HHA's grade they received. A review of HHA 3's personnel record evidenced a undated and ungraded Competency Assessment Exam. The test failed to evidence the HHA's grade they received and the date they took the test. During an interview with the Administrator/DON on 03/25/2026 at 3:17 PM, they indicated the competency tests should have included the grades and the dates the test was taken.410 IAC 17‑14‑1(L)(1)(A)

HHA maintains documentation of training CFR(s): 484.80(b)(4) The HHA must maintain documentation that demonstrates that the requirements of this standard have been met. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure all HHA personnel files contained a skills competency test for 1 of 1 HHA personnel file reviewed without a skills competency test. (HHA 1) Findings Include: A review of HHA 1's personnel record failed to evidence a skilled competency test. During an interview with the Administrator/DON on 03/25/2026 at 3:31 PM, they indicated HHA 1 must not have completed a skills competency test since it was not in the file. 410 IAC 17‑14‑1(L)(2)

Duties of a HH aide CFR(s): 484.80(g)(3) The duties of a home health aide include: (i) The provision of hands-on personal care; (ii) The performance of simple procedures as an extension of therapy or nursing services; (iii) Assistance in ambulation or exercises; and (iv) Assistance in administering medications ordinarily self-administered. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the HHAs performed tasks were within their scope of practice for 1 of 1 active clinical records reviewed with a HHA performing a task outside of their scope of practice. (HHA 3) Findings Include: A review of Patient #3's active clinical record evidenced a POC with a SOC of 03/06/2025 and a recertification period from 03/01/2026 to 04/29/2026. The POC revealed the patient received HHA services six hours a day, seven days a week for ADL assistance, meal preparation, bathing, dressing, transfer, and medication. Patient #3's Aide POC with an effective date of 02/27/2026 evidenced the HHA performed medication reminders. A review of Patient #3's active clinical record included HHA visit notes dated 01/28, 01/31, 02/02, 02/03, 02/05, 02/06, 02/07, 02/08, 02/09, 02/10, 02/12, 02/13, 02/14, 02/16, 02/18, 02/19, 02/21, 02/22, 02/24, 02/26, 02/27, 02/28, 03/01, 03/02, 03/03, 03/05, 03/07, 03/08, 03/11, 03/12, 03/13, 03/14, 03/15, 03/16, 03/18, 03/20, 03/21, 03/22, and 03/24/2026. The HHA visit notes evidenced HHA 3 prefilled the patient's medication planner. The visit notes failed to evidence the HHA performed tasks according to the POC and within their scope of practice. During an interview with Patient #3 on 03/25/2026 at 9:26 AM, they indicated HHA 3 set up their medications for them by placing the pills in the medication planner. During an interview with HHA 3 on 03/25/2026 at 9:35 AM, they confirmed they set up the patient's medications on Sundays and was trained by the home health agency and the patient's physician. They indicated they documented when they refilled the patient's medications on their visit notes. During an interview with the Administrator/DON on 03/25/2026 at 11:58 AM, they explained HHAs were to only remind the patient's to take their medications. They indicated if the HHA was supposed to do more with the medications, it would be included in the Aide POC. The Administrator/DON indicated they would never let an aide do a medication setup for a patient. They indicated HHA 3 was supposed to only hand the patient the pill organizer and remind the patient of the time to take the medication. 410 IAC 17-14-1(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 Registered Nurse (RN) completed Home Health Aide Supervisory visits for patients who received skilled services every 14 days for 2 of 2 clinical records reviewed. (Patients: #1 and 2) Findings Include: 1. A review of the clinical record for Patient #1, start of care 01/17/2024, contained a plan of care for the recertification period 01/06/2026 to 03/06/2026. The plan of care contained orders for the following: Skilled Nursing 3 times a week (Monday, Wednesday, and Friday) for two months for bladder irrigations, ostomy care, catheter changes, vital signs, every 56-60 days for recertification and supervisory visits; HHA services for 13 hours a day for 6 days a week for ADLs. A review of “Supervisory Visit Notes” documents revealed the Administrator documented HHA supervisory visits on 02/02, 02/18, and 03/04/2026. The record failed to evidence that the RN completed HHA supervisory visits every 14 days. During an interview on 03/25/2026 at 1:07 PM, when asked about the documentation of the supervisory visit being completed in the clinical record for Patient #1, upon review of the clinical record for Patient #1 the Administrator stated, “[Patient #1’s] supervisory visits should had been completed every 14 days. I must have missed it.” 2. A review of the clinical record for Patient #2, start of care 11/25/2025, contained a plan of care for the recertification period 01/24/2026 to 03/24/2026. The plan of care contained orders for the following: Skilled Nursing, one day a week for a medication refill; vital signs; sugar checks every 56-60 days for recertification; supervisory visits; and HHA services for 4 hours a day, 3 days a week, for ADLs. A review of “Supervisory Visit Notes” documents revealed the Administrator had documented HHA supervisory visits on 01/09/2026 and 03/16/2026. The record failed to evidence that the RN completed HHA supervisory visits every 14 days. During an interview on 03/24/2026 at 2:46 PM, when asked about the timeline for completing HHA supervisory visits for patients receiving skilled services, the Administrator stated, “Supervisory visits were to be completed on HHAs every 14 days.” When asked about the missing HHA supervisory visits in Patient #2’s clinical record, the Administrator, upon review of the clinical record for Patient #2, stated, “One was missed and should have been done.” 410 IAC 17‑14‑1(g)

Non-skilled direct observation every 60 days CFR(s): 484.80(h)(2) If home health aide services are provided to a patient who is not receiving skilled nursing care, physical or occupational therapy, or speech-language pathology services, — (A) The registered nurse must make an onsite, in person visit every 60 days to assess the quality of care and services provided by the home health aide and to ensure that services meet the patient's needs; and (B) The home health aide does not need to be present during this visit. (ii) Semi-annually the registered nurse must make an on-site visit to the location where each patient is receiving care in order to observe and assess each home health aide while he or she is performing non-skilled care This ELEMENT is not met as evidenced by: Based on record review and interview, DON failed to ensure supervisory visit documentation accurately reflected verification that the home health aide was following the individualized plan of care for 1 of 1 active clinical records reviewed with an aide performing tasks outside of their scope. (Administrator/DON) Findings Include: A review of Patient #3's active clinical record evidenced a POC with a SOC of 03/06/2025 and a recertification period from 03/01/2026 to 04/29/2026. The POC revealed the patient received HHA services six hours a day, seven days a week for ADL assistance, meal preparation, bathing, dressing, transfer, and medication. Patient #3's Aide POC with an effective date of 02/27/2026 evidenced the HHA performed medication reminders. A review of Patient #3's active clinical record included HHA visit notes dated 01/28, 01/31, 02/02, 02/03, 02/05, 02/06, 02/07, 02/08, 02/09, 02/10, 02/12, 02/13, 02/14, 02/16, 02/18, 02/19, 02/21, 02/22, 02/24, 02/26, 02/27, 02/28, 03/01, 03/02, 03/03, 03/05, 03/07, 03/08, 03/11, 03/12, 03/13, 03/14, 03/15, 03/16, 03/18, 03/20, 03/21, 03/22, and 03/24/2026. The HHA visit notes evidenced HHA 3 prefilled the patient's medication planner. A review of the HHA supervisory visit notes dated 01/29/2026 and 02/19/2026 by the Administrator/DON for HHA 3 evidenced the DON checked the box indicating the HHA followed the patient's POC. The DON failed to ensure they accurately indicated the HHA failed to perform tasks as ordered by the physician on the POC. During an interview with the Administrator/DON on 03/25/2026 at 3:55 PM, they indicated they thought HHA 3 was following the POC and confirmed it was why they marked "Yes" to the HHA following the POC.