Every finding on record at Good Samaritan Home Care Services of Vincennes In

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR §484.102 Survey Dates: 02/18/2026, 02/19/2026, 02/20/2026 & 02/23/2026, 02/24/2026 Active Census: 155 At this Emergency Preparedness survey, Good Samaritan Home Care Services was found to be in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR §484.102. QR completed Area 3 on 02/27/202.

This visit was for a Federal Recertification and State Re-Licensure survey of a Home Health Provider. Survey Dates: 02/18/2026, 02/19/2026, 02/20/2026 & 02/23/2026, 02/24/2026 12-Month Unduplicated Skilled Admissions: 737 Partially Extended on 02/24/2026 at 9:30 AM This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Refer to the State Form for additional State Findings. QR completed by Area 3 on 02/27/2026.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to provide services as ordered by the physician for 1 of 1 active records reviewed with patients receiving HHA services (Patient #1), 10 of 10 active records reviewed with patients receiving SN services (Patients #2, #3, #4, #6, #7, #8, #9, #10, #11, #12), and 4 of 5 inactive records reviewed with patients receiving SN services (Patients #13, #15, #16, #17) Findings include: 1. A revised 03/05/2024 policy titled "Plan of Care and Physician and Allowed Practitioner Orders" indicates the POC was developed by the clinician with the physician and sent to the office for signature. The policy states that a written verification by the clinician must accompany a verbal order from the physician. The policy states that a verbal order was sufficient to implement the POC until a signed POC is returned. 2. The review of Patient #1’s record for the certification period 12/29/2025 to 02/26/2026 showed the agency received a verbal start-of-care order from the physician on 12/30/2025. The agency provided Home Health Aide services on 01/02/2026 and 01/07/2026 before obtaining a detailed verbal order or a signed POC from the physician. 3. A review of Patient #2's record for the certification period 1/16/2026 to 03/16/2026 showed a Communication Note dated 01/21/2026 indicating the agency received a verbal start-of-care from the physician. The agency provided Skilled nursing services on 01/17/2026, 01/21/2026, 01/28/2026, and 02/04/2026 before obtaining a detailed verbal order or a signed POC from the physician. 4. A review of Patient #3’s record for the certification period of 01/26/2026 to 03/23/2026 showed a Communication Note dated 01/24/2026 indicating the agency received a verbal start-of-care from the physician. The agency provided physical therapy services on 01/27/2026, 02/04/2026, 02/11/2026, and 02/11/2026; occupational therapy services on 01/29/2026, 02/06/2026, 02/09/2026, and 02/16/2026; and skilled nursing on 01/30/2026 and 02/13/2026. The agency provided these services without obtaining a detailed verbal order or a signed Plan of Care (POC) from the physician. 5. A review of Patient #4's record for the certification period 11/23/2025 to 01/21/2026 showed a Communication Note dated 12/04/2025 indicating the agency received a verbal start-of-care from the physician. The agency provided Skilled nursing services on 12/02/2025 before obtaining a detailed verbal order or a signed POC from the physician. 6. A review of Patient #5's record for the certification period 02/07/2026 to 04/07/2026 showed a Communication Note dated 02/09/2026 indicating the agency received a verbal start-of-care from the physician. The agency provided Physical therapy services on 02/09/2026, 02/11/2026, 02/13/2026, 02/16/2026, and 02/18/2026 before obtaining a detailed verbal order or a signed POC from the physician. 7. A review of Patient #6's record for the certification period 01/12/2026 to 03/12/2026 showed a Communication Note dated 01/12/2026 indicating the agency received a verbal start-of-care from the physician. The agency provided Skilled nursing services on 02/19/2026 before obtaining a detailed verbal order or a signed POC from the physician. 8. A review of Patient #7’s record for the certification period 12/30/2025 to 2/27/2026 showed a Communication Note dated 01/02/2026 indicating the agency received a verbal start‑of‑care order from the physician. The agency provided Skilled nursing services on 01/05/2026, 01/09/2026, 01/12/2026, and 01/16/2026 before obtaining a detailed verbal order or a signed POC from the physician. 9. A review of Patient #8's record for the certification period 10/03/2025 to 12/01/2026 showed a Communication Note dated 10/05/2025 indicating the agency received a verbal start-of-care from the physician. The agency provided Skilled nursing services on 10/08/2026 and 10/10/2026 before obtaining a detailed verbal order or a signed POC from the physician. 10. A review of Patient #9's record for the certification period 02/03/2026 to 04/03/2026 showed a Communication Note dated 02/03/2026 indicating the agency received a verbal-start-of-care from the physician. The agency provided Skilled nursing services on 02/010/2026, occupational services on 02/05/2026, and 02/09/2026 before obtaining a detailed verbal order or a signed POC from the physician. 11. A review of Patient #10's record for the certification period 01/08/2026 to 03/08/2026 showed a Communication Note dated 01/12/2026 indicating the agency received a verbal-start-of-care from the physician. The agency provided Skilled nursing and Occupational services on 01/15/2026 before obtaining a detailed verbal order or a signed POC from the physician. 12. A review of Patient #11's record for the certification period 02/07/2026 to 04/07/2026 showed a Communication Note dated 02/13/2026 indicating the agency received a verbal start-of-care from the physician. The agency provided Skilled nursing services on 02/12/2026, 02/14/2026, and 02/17/2026 before obtaining a detailed verbal order or a signed POC from the physician. 13. A review of Patient #12's record for the certification period 10/22/2025 to 12/20/2025 showed a Communication Note dated 10/23/2025 indicating the agency received a verbal start-of-care from the physician. The agency provided Skilled nursing services on 10/28/2025 before obtaining a detailed verbal order or a signed POC from the physician. 14. A review of Patient #13's record for the certification period 06/03/2025 to 08/01/2025 showed a Communication Note dated 06/03/2025 indicating the agency received a verbal start-of-care from the physician. The agency provided Skilled nursing services on 06/10/2025 before obtaining a detailed verbal order or a signed POC from the physician. 15. A review of Patient #14's record for the certification period 01/23/2025 to 03/23/2025 showed a Communication Note dated 01/27/2025 indicating the agency received a verbal start-of-care from the physician. The agency provided Physical therapy services on 01/24/2025 and 01/27/2025 before obtaining a detailed verbal order or a signed POC from the physician. 16. A review of Patient #15's record for the certification period 02/14/2025 to 04/14/2025 showed a Communication Note dated 02/28/2025 indicating the agency received a verbal-star-of-care from the physician. The agency provided Skilled nursing services on 02/19/2025, 02/21/2025, and 02/26/2025 before obtaining a detailed verbal order or a signed POC from the physician. 17. A review of Patient #16's record for the certification period 04/08/2025 to 06/06/2025 showed a Communication Note dated 04/29/2025 indicating the agency received a verbal start-of-care from the physician. The agency provided Skilled nursing services on 04/17/2025 and 04/22/2025 before obtaining a detailed verbal order or a signed POC from the physician. 18. A review of Patient #17’s record for the certification period 04/11/2025 to 06/09/2025 showed a Communication Note dated 04/11/2025 indicating the agency received a verbal start‑of‑care order from the physician. The agency provided Skilled nursing services on 04/18/2025 and 04/23/2025 before obtaining a detailed verbal order or a signed POC from the physician. 19. During an interview on 02/20/2025 at 10:30 AM, the Alternate Administrator stated the agency does not obtain a detailed verbal order to start care or obtain a physician-signed POC before providing services. She states that the staff obtained a verbal order, which was recorded in a Communication Note. 410 IAC 17-13-1(a)

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 agency staff failed to follow infection control techniques for hand hygiene and wound care in 2 of 3 wound care observations (RN 1, RN 2); and failed to maintain appropriate bag technique in 1 of 1 home visit observations with an LPN. (LPN 1) Findings include: 1. The revised 11/14/2025 policy titled 'Hand Hygiene' required staff to perform hand hygiene after contact with body fluids and wound dressings, whether or not they wore gloves. 2. A revised 05/07/2024 policy titled "Bag Technique" required staff to use a suitable impervious container when the home environment did not appear clean, and to prepare the equipment for both clean and dirty areas. 3. During a home visit on 02/19/2026 at 10:30 AM, RN 1 applied gloves and removed the wound dressing from Patient #5's left upper thigh. RN 1 cleaned the wound and applied a new dressing without changing gloves or performing hand hygiene. During an interview on 02/23/2026 at 10:00 AM, RN 1 stated she changed gloves before and after removing soiled dressings and after direct patient contact. 4. During a home visit on 02/19/2026 at 3:00 PM, RN 2 applied gloves and removed the wound dressing from Patient #6's buttocks. RN 2 cleansed the wound and retrieved 4x4 gauze and a foam dressing from clean supplies. RN 1 failed to change gloves and perform hand hygiene after removing the soiled dressing and obtaining clean supplies. During an interview on 02/19/2026 at 3:30 PM, RN 2 stated she knew she must change gloves and perform hand hygiene when providing wound care. 5. During a home visit on 02/20/2026 at 3:00 PM, LPN 1 opened a clear container holding vital sign equipment (blood pressure cuff, thermometer, oxygen saturation device). She took Patient #7's vital signs, cleaned the equipment, and placed it on the inner lid of the container, which was designated the dirty area. She then placed the cleaned equipment back in the container, closed the lid, and thereby contaminated it. LPN 1 did not properly designate clean and dirty areas, which could have led to cross-contamination. During an interview on 02/20/2026 at 3:15 PM, LPN 1 stated she did not bring the agency equipment bag into homes with compromised environments. She used a clear container, designating the inside as the clean area and the inside lid as the dirty area. 410 IAC 17-12-1(m)

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on record review and interview, the Administrator failed to ensure staff completed all documentation on the day patient visits were assigned for 5 of 10 record reviews without home visits (Patients #8, 10, #11, #12, #16) Findings include: 1. The revised policy "Documentation in the Medical Record," dated 05/08/2025, required staff to complete timely, authenticated documentation in accordance with professional standards. 2. The record review for Patient #8, certification period 10/03/2025 to 12/01/2025, showed staff completed visit documentation late, outside the time frame set by the agency, on the following days: 10/10/2025, 10/15/2025, 10/17/2025, 10/21/2025, 10/25/2025, 10/27/2025, 10/29/2025, 11/05/2025, 11/07/2025, 11/08/2025, 11/19/2025, 11/21/2025, and 11/26/2025. 3. The record review for Patient #10, certification period 01/08/2026 to 03/08/2026, showed staff completed visit documentation late, outside the agency’s required time frame, on 01/02/2026. 4. The record review for Patient #11, certification period 02/07/2026 to 04/07/2026, showed staff completed visit documentation late, outside the agency’s required time frame, on 02/12/2026 and 02/17/2026. 5. The record review for Patient #12, certification period 10/22/2025 to 12/20/2025, showed staff completed visit documentation late, outside the agency’s required time frame, on 11/13/2025 and 12/08/2025. 6. The record review for Patient #16, certification period 04/08/2025 to 06/06/2025, showed staff completed visit documentation late, outside the agency’s required time frame, on 04/17/2025, 04/22/2025, and 05/01/2025. 7. During an interview on 02/25/2026 at 11:01 AM, the Alternate Administrator stated the agency expected staff to submit documentation within 24 hours of a visit. She stated that some staff struggled to turn in notes on time. 410 IAC 17-12-1(c)(1)

An Emergency Preparedness Survey was conducted by the Indiana State Department of Health in accordance with 42 CFR 484.102. Survey Dates: 03/20/2023 - 03/24/2023 Unduplicated Skilled Census Last 12 months: 965 At this Emergency Preparedness survey, Good Samaritan Home Care Services was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 484.102. QR Completed on 3/29/2023 A4

This visit was for a Federal Recertification and State Relicensure survey of a Home Health Provider. Partially Extended Survey Announced 03/23/203 at 3:30 PM. Survey Dates: 03/20/2023 - 03/24/2023 Unduplicated Skilled Census Last 12 months: 965 These deficiencies reflect State findings in accordance with 410 IAC 17. QR Completed on 3/29/2023 A4

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 written instructions for medications, changes in care to be furnished, and frequency of visits, were provided and maintained for 1 or 2 home visit observation with Occupational Therapy services (Patient #5); and 2 of 3 home visit observations with Skilled Nursing services. (Patient #4, #7) Findings include: 1. A revised 02/12/2022 policy titled Occupational Therapy Services was provided by the Alternate Administrator on 03/23/2023 at 8:20 AM. The policy indicated, but was not limited to, “9. Other needed information that could impact the level of services required to meet the patient’s needs.” 2. A revised 11/2022 admission booklet titled Patient Orientation for Home Health Care Services was provided by the Alternate Administrator on 03/20/2023 at 1:00 PM. The admit booklet indicated, but not limited to, “Services … Physical, Occupational, and Speech Therapy services … Your therapist will provide specific information about the services and treatments you will receive. …” 3. The clinical record for Patient #4 SOC date 02/18/2023, certification date 02/18/2023 to 04/18/2023, was reviewed on 03/20/2023. The plan of care (POC) included orders for skilled nursing services 1 time a week for 2 weeks, 1 time every 2 weeks for 4 weeks, 1 time a week for 1 week, and 3 as needed visits. During a home visit on 03/22/2023 at 10:00 AM reviewed Patient #4’s admission packet that contained the signed Explanation of Service coverage dated 02/18/2023 which indicated Physical Therapy (PT) eval, Occupational Therapy (OT) eval and Skilled Nursing (SN) 1 time a week for 9 weeks. No copy of the current list of medications was found in the home. Patient #4 indicated he/she probably threw the medication list away. At that time, Registered Nurse 1 (RN 1) indicated the agency just started filling out the Election of Service coverage in the home admission booklet and acknowledged no written copy of medications were found in the home. 4. The clinical record for Patient #5 SOC date 03/06/2023, certification date 03/06/2023 to 05/04/2023, was reviewed on 03/22/2023. The POC included orders for “[Skilled Nursing] … [Physical Therapy] … [Occupational Therapy 1 time a week for 5 weeks] …”. The orders indicated skilled nursing was to teach and monitor the patient / caregiver on safe medication administration. During a home visit on 03/23/2023 at 11:10 AM Certified Occupational Therapy Assistant 1 (COTA 1) was observed instructing Patient #5 on home exercises. At that time, the COTA was asked if Patient #5 had a copy of the written exercises in the home for the patient. Patient #5 and COTA 1 were unable to find a copy of the home occupation exercises / instructions and a current medication list. Patient #5 was unfamiliar with the exercises COTA 1 was instructing on based on the prior visit from a different COTA/OT. The agency failed to ensure a written copy of the current medication list and home exercise program were kept in the home. 5. The clinical record for Patient #7 SOC date 02/28/2023, certification date 02/28/2023 to 04/28/2023, was reviewed on 03/22/2023. The POC included orders for skilled nursing 2 times a week for 1 week, 1 week for 1 week, 1 every other 2 weeks for 6 weeks, 1 week for 1 week and 3 as needed visits. The POC included orders for Physical Therapy (PT) services for 1 time a week for 9 weeks. During the home visit on 03/22/2023 at 10:00 AM reviewed Patient #7’s admission packet that included an Explanation of Service coverage dated 02/28/2023 indicating the skilled nurse to visit 2 times a week for 1 week, 1 time a week for 1 week, 1 time every other week for 7 weeks, and for PT services 1 time a week for 8 weeks. The agency failed to ensure a copy of the updated changes in the Explanation of Service coverage that reflected the patient’s POC was maintained in the home. 6. During an interview on 03/22/2023 at 4:02 PM the Alternate Administrator agreed that staff were to ensure written medication, home exercise instructions, and current Explanation of Services that reflect the POC were in the home at each visit. 410 IAC 17-12-3(b)(2)(D)(i)(AA)(BB) 410 IAC 17-12-3(b)(2)(D)(ii)(BB)

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the Plan of Care specified orientation and a psychosocial assessment on the Plan of Care for 7 of 7 record reviews with home visits, with the potential to affect all 175 active records. (Patients #1, #2, #3, #4, #5, #6, #7) Findings include: 1. A revised 04/15/2022 policy titled Plan of Care and Physician and Allowed Practitioner Orders was provided on 03/22/2023 at 3:02 PM. The policy indicated, but was not limited to, “The individualized POC … must include: … Patient’s mental status, … Types of services, Frequency and duration of visits, … Goals=; progress towards goals identified and measurable outcomes, … other relevant patient information …” 2. The clinical record for Patient #1, start of care (SOC) date 02/23/2022, certification date 02/23/2023 to 4/23/2023, was reviewed on 03/20/2023 which included a plan of care (POC) that described Patient #1’s mental status as “forgetful”. The agency failed to specify Patient #2’s mental status on the POC as indicated, but not limited to, the patient’s orientation to person, place, and time. 3. The clinical record for Patient #2, SOC date 02/21/2023, certification date 02/21/2023 to 4/21/2023, was reviewed on 03/21/2023 which included a POC that described Patient #2’s mental status as “oriented, forgetful”. No evidence of Patient #2’s psychosocial assessment. The agency failed to specify Patient #2’s mental status on the POC as indicated, but not limited to, the patient’s orientation to person, place, and time. The agency failed to complete a psychosocial assessment (interpersonal relationships in the immediate family, financial status, homemaker/household needs, family social problems, and transportation needs) on Patient #2’s POC. 4. The clinical record for Patient #3, SOC date 03/03/2023, certification date 03/03/2023 to 05/01/2023, was reviewed on 03/21/2023, included a POC that described Patient #3’s mental status as “oriented”. The agency failed to specify Patient #3’s mental status on the POC as indicated, but not limited to, the patient’s orientation to person, place, and time. The agency failed to complete a psychosocial assessment (interpersonal relationships in the immediate family, financial status, homemaker/household needs, family social problems, and transportation needs) on Patient #3’s POC. 5. The clinical record for Patient #4 SOC date 02/18/2023, certification date 02/18/2023 to 04/18/2023, was reviewed on 03/20/2023, included a plan of care POC that described Patient #4’s mental status as “oriented”. The agency failed to specify Patient #4’s mental status as indicated, but not limited to, the orientation to person, place, and time. The agency failed to complete a psychosocial assessment (interpersonal relationships in the immediate family, financial status, homemaker/household needs, family social problems, and transportation needs) on Patient #4’s POC. 6. The clinical record for Patient #5 SOC date 03/06/2023, certification date 03/06/2023 to 05/04/2023, was reviewed on 03/22/2023, included a plan of care POC that described Patient #5’s mental status as “oriented”. The agency failed to specify Patient #5’s mental status as indicated, but not limited to, the orientation to person, place, and time. The agency failed to complete a psychosocial assessment (interpersonal relationships in the immediate family, financial status, homemaker/household needs, family social problems, and transportation needs) on Patient #5’s POC. 7. The clinical record for Patient #6 SOC date 01/25/2022, certification date 03/21/2023 to 05/19/2023, was reviewed on 03/22/2023, included a plan of care POC that described Patient #6’s mental status as “oriented”. The agency failed to specify Patient #6’s mental status as indicated, but not limited to, the orientation to person, place, and time. The agency failed to complete a psychosocial assessment (interpersonal relationships in the immediate family, financial status, homemaker/household needs, family social problems, and transportation needs) on Patient #6’s POC. 8. The clinical record for Patient #7 SOC date 02/28/2023, certification date 02/28/2023 to 04/28/2023, was reviewed on 03/22/2023, included a plan of care POC that described Patient #7’s mental status as “oriented, forgetful”. The agency failed to specify Patient #6’s mental status as indicated, but not limited to, the orientation to person, place, and time. The agency failed to complete a psychosocial assessment (interpersonal relationships in the immediate family, financial status, homemaker/household needs, family social problems, and transportation needs) on Patient #7’s POC. 9. During an interview on 03/23/2023 at 3:20 PM the Alternate Administrator indicated he/she would expect to see mental status addressed as “orientation” on the POC. The Alternate Administrator indicated the electronic medical record (EMR) POC has limited choices / selections from a drop down menu when describing mental status / psychosocial assessment status. The Alternate Administrator was unsure if staff could free write a note on mental / psychosocial status on the POC. 410 IAC 17-13-1(a)(1)(D)(i-xiii)

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 agency failed to ensure standard infection control precautions were followed for 2 of 2 home visit observations involving wound care. (Patients #2, #6) Findings include: 1. A revised 09/06/2022 policy titled Application of Non-Sterile Dry Dressing was provided on 03/23/2023 at 8:45 AM. The policy indicated, but was not limited to, “Procedure … Ointment or medication and applicator … Action … If used, remove PPE and discard. Remove non-sterile gloves and discard. Perform hand hygiene … “ 2. The clinical record for Patient #2, SOC date 02/21/2023, certification date 02/21/2023 to 4/21/2023, was reviewed on 03/21/2023. The clinical record included a plan of care (POC) with orders for the skilled nurse (SN) to cleanse the right and left lower leg with saline, apply Santyl® (medication that removes dead tissue) to wound beds covered with Hydrofera Blue® (antibacterial dressing) moistened with saline, covered with 4x4 bordered Telfa™ (non-stick dressing). During a home visit on 03/21/2023 at 9:00 AM Registered Nurse 1 (RN 1) was observed applying Santyl ointment onto his/her glove and then applying the Santyl directly onto Patient #2’s right lower leg wound and left lower leg wound. RN 1 failed to use a sterile Q-tip applicator for each wound area. During an interview on 03/22/2023 at 4:02 PM the Alternate Administrator indicated the expectation was to follow best practice and use a sterile Q-tip to apply Santyl directly to each wound. 3. The clinical record for Patient #6 SOC date 01/25/2022, certification date 01/20/2023 to 03/20/2023, was reviewed on 03/22/2023. The clinical record included a POC with orders for skilled nursing to clean right leg wound with saline and apply moistened Endofoam™(antimicrobial dressing) to wound bed covered with Mepilex™ border dressing every three days. During a home visit on 03/24/2023 at 9:00 AM Registered Nurse 2 (RN2) provided wound care to Patient #6’s right lower leg. After applying the Mepilex dressing to the right lower leg wound, RN 2 failed to remove his/her gloves and perform hand hygiene before pulling up Patient #6’s clean pant leg to assess the left lower leg. During an interview on 03/24/2023 at 10:00 AM the Alternate Administrator agreed that RN 2 was to remove soiled gloves and perform hand hygiene immediately after completing wound care. 410 IAC 17-12-1(m)

Development and evaluation of plan of care CFR(s): 484.75(b)(2) Development and evaluation of the plan of care in partnership with the patient, representative (if any), and caregiver(s); This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the agency failed to provide instruction, education, and reinforcement as indicated on the plan of care for 1 of 2 home visit observations in an Assisted Living Facility (ALF). (Patient #2) Findings include: A revised 11/2022 admit booklet titled Patient Orientation for Home Health Care Services was provided by the Alternate Administrator on 03/20/2023 at 1:00 PM. The admit booklet indicated, but was not limited to, “Plan of Care: Your plan of care is developed, and your specific measurable outcomes and goals are identified … plan of care is reviewed and updated as needed … The plan of care may include the following interventions and goals: Nursing Care (including instruction in self- care) Medication Management … Personal Care …” The clinical record for Patient #2, start of care (SOC) date 02/21/2023, certification date 02/21/2023 to 4/21/2023, was reviewed on 03/23/2023 which included a Plan of Care (POC) indicating a diagnosis of Pressure Ulcer II (partial thickness skin loss), Type II (2) Diabetes (too much sugar in the blood), and Venous Insufficiency (damaged veins in the lower legs), Hypertensive heart disease (result of chronic high blood pressure). The POC indicated the Skilled Nurse (SN) was to provide skilled teaching for the following: Skilled teaching related to altered cardiovascular status including pathophysiology, nutrition, medication regimen, weight/edema management, and permitted activities. Skilled nurse to provide skilled teaching / reinforcement of management of hypertension (high blood pressure). Skilled nurse to provide instruction / reinforcement of managing diabetes to include diet, skin care, medication management, blood glucose testing and diabetic foot care. During a home visit in an Assisted Living Facility (ALF) on 03/21/2023 at 10:00 AM Registered Nurse 1 (RN 1) failed to teach/educate/instruct/reinforce Patient #2 on altered cardiovascular status including pathophysiology, nutrition, medication regimen, weight/edema management, and permitted activities. RN 1 failed to provide skilled teaching / reinforcement of management of hypertension (high blood pressure) and failed to provide instruction / reinforcement of managing diabetes to include diet, skin care, medication management, blood glucose testing and diabetic foot care as indicated on the Plan of Care. At that time, RN 1 indicated Patient 2 had memory issues. No family, caregiver, or ALF staff were present during the home visit. 410 IAC 17-14-1(a)(1)(C)-RN

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure accurate information was recorded in the patients’ medical record for 1 of 2 wound record reviews. (Patient #2) Findings include: 1. A revised 03/08/2023 policy titled Documentation in the Medical Record was provided by the Alternate Administrator on 03/23/2023 at 8:45 AM. The policy indicated, but was not limited to, “ … Enter the correct information … 6. Only documentation directly related to the care, treatment and services of the patient are part of the Medical Record. …” 2. During a home visit on 03/21/2023 at 10:00 AM Registered Nurse 1 (RN 1) was providing wound care for Patient #2’s right lower leg, left lower leg, and coccyx. RN 1 did not measure wounds on the home visit. 3. The clinical record for Patient #2, start of care (SOC) date 02/21/2023, certification date 02/21/2023 to 4/21/2023, was reviewed on 03/23/2023. The clinical record included a Skilled Visit Note that indicated wound measurements were taken by RN 1 during the 03/21/2023 home visit. The Visit Note did not accurately reflect the care provided by RN 1 while in the home. 4. During an interview on 03/23/2023 at 8:45 AM the Alternate Administrator indicated the agency had no specific policy on who was to measure the wounds while the patient was seen at the wound clinic. The Alternate Administrator indicated the expectation was for the agency to measure patient wounds weekly. The Alternate Administrator indicated the wound measurements that were recorded on the skilled visit note were probably from the wound clinic. 410 IAC 17-14-1(a)(1)(E)-RN

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure all administrator and managing personnel were reported to the state agency for 1 of 1 home health agency. Findings include: An undated Director of Area Operations/Administrator job description was provided by the Manager of Operations on 03/23/2023 at 2:00 PM. The job description indicated, but was not limited to, “The Director, Operations/Administrator is accountable for the overall business management of operations including leading, coordinating, facilitating, and monitoring patient care and support provided to patients and their caregivers in the assigned locations served.” Review of the state data base on 03/20/2023 indicated the Governing Body (GB) / management members as GB 1, GB 2, GB 4, and GB 6. Review of the Governing Body members provided by the Alternate Administrator on 03/23/2023 indicated GB 1, GB 2, GB 3, GB 4, GB 5, GB 6, GB 7, GB 8, GB 9, and GB 10 as Governing Body members as of 2023. The agency failed to inform the state agency of all corporate, administrative, and management changes. Review of a document titled Agency Staff Change Notification Form Division of Acute Care Home Health was provided by the Alternate Administrator on 03/23/2023 that indicated changes for Administrator, Alternate Administrator, and Alternate Clinical Supervisor as of 12/19/2022. The agency was unable to provide a confirmation email or letter from the state department indicating the administrative changes were acknowledged. During an interview on 03/24/2023 at 10:45 AM the Alternate Administrator indicated the Administrator was responsible for providing the change in Administration and any management information to the state agency. The Alternate Administrator indicated the administrative changes took place in 12/2022. The agency was unable to provide any confirmation emails or letters from the state department indicating the administrative changes were acknowledged. 410 IAC 17-12-1(b)(3) 410 IAC 17-12-1(c)(1)