Every finding on record at Hearts at Peace Home Health Care Co

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR §484.102 Survey Dates: 02/02, 02/03, and 02/04/2026. Active Census: 10 At this Emergency Preparedness survey, Hearts At Peace Home Health Care Company was found to be in compliance with Emergency Preparedness Requirements for a Medicaid Participating Provider and Supplier, 42 CFR §484.102. QR completed by Area 3 on 2/9/2026.

This visit was for an Initial Federal Medicaid survey for a Home Health provider. Survey Dates: 02/02, 02/03, and 02/04/2026. 12 Month Unduplicated Admissions: 10 This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Refer to State Form for additional State Findings. Abbreviations: SOC Start of Care OASIS Outcome and Assessment Information Set POC Plan of Care DME Durable Medical Equipment SN Skilled Nurse ADLs Activities of Daily Living RN Registered Nurse HHA Home Health Aide QR completed by Area 3 on 2/9/2026.

At discharge CFR(s): 484.55(d)(3) At discharge. This ELEMENT is not met as evidenced by: Based on record reviews and interview, the agency failed to ensure OASIS discharge comprehensive assessments were completed on 2 of 2 discharged records reviewed. (Patients: #9 and 10) Findings Include: 1. A review of an undated agency policy titled “Client Transfer” indicated, but was not limited to. “ … 9. If the client is transferred to another provider, the Hearts At Peace Home Health will complete a discharge OASIS … ” 2. A review of an undated agency policy titled “Client Discharge Process” indicated, but was not limited to. “ … 6. Discharge OASIS will be conducted within 48 hours of (or knowledge of) discharge to the community … ” 3. A review of the clinical record for Patient #9, SOC date 12/03/2025, and discharge date of 12/23/2025, failed to evidence a discharge OASIS comprehensive assessment had been completed. A review of an agency document titled “Discharge/Transfer Summary” dated 12/29/2025, signed by the Clinical Manager, indicated but was not limited to, “ … Client admitted to hospital on 12/23/2025 for chest pain and pacemaker and will be going to a rehabilitation after hospital stay per granddaughter … ” 4. A review of the clinical record for Patient #10, SOC date 10/07/2025, and discharge date of 11/26/2025, failed to evidence a discharge OASIS comprehensive assessment had been completed. A review of an agency document titled “Discharge/Transfer Summary” dated 12/08/2025 with the last date of service 11/26/2025, indicated Patient #10’s primary care provider had been notified the agency had discharged Patient #10 for goals being met on 11/26/2025. During an interview on 02/03/2026 at10:20 AM, when asked for the location of OASIS discharge/transfer comprehensive assessment for Patient #9, and OASIS discharge comprehensive assessment for Patient #10, the Clinical Manager and Case Manager for Patients #9 and 10 reported they had only completed the summaries on the two patients and sent them to the patients’ providers. The Clinical Manager further indicated they were unaware of the required OASIS for discharge and transfer/discharge.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on observation, record review and interview, the agency failed to ensure the individualized plan of care included all pertinent diagnoses and their onset date, all supplies and equipment, all treatments, all safety measures, infection control precautions, a description of the patient's risk for emergency department visits and hospital readmission, all necessary interventions to address the underlying risk factors and the specific education and training to be provided, and patient specific education to be provided by the SN, measurable outcomes and goals identified by the home health agency and patient, rehabilitation potential, discharge plans, information related to advanced directives, and correct certification dates, for 8 of 8 active clinical records reviewed(Patients: #1, 2, 3, 4, 5, 6, 7, and 8) and 2 of 2 inactive clinical records reviewed. (Patients: #9 and 10) Findings Include: 1. An undated agency policy titled “Plan of Care” indicated, but was not limited to, “ … 2. The Plan of Care shall be completed in full to include: a. All pertinent diagnosis (es, principle and secondary, including dates of onset … c. Type, frequency, and duration of all visits/services …e. Need for/presence of home medical equipment and assistive devices … i. Rehabilitation potential … n. Medical supplies and equipment required. o. Any safety measures to protect against injury. p. Instructions to client/caregiver. q. treatment goals. r. Instructions for timely discharge or referral. s. Discharge plans … u. Other appropriate items … ” 2. A review of Patient #1's clinical record, SOC date10/07/2025, contained an OASIS Start of Care Comprehensive Assessment dated 10/07/2025, signed by the Clinical Manager. The OASIS comprehensive assessment listed the certification period 10/07/2025 to 12/06/2025. The OASIS reassessment section titled “Safety Measures” listed Slow Position Change, Use of Assistive Device, Support During Transfer and Ambulation, Emergency Plan Developed, Safety in ADLs, Standard Precautions/Infection Control, and Fall Precautions. The section titled “Psychosocial Status” listed Patient #1’s daughter as the primary caregiver and will be able to assist with shopping, ADLs, and medications, with supportive assistance from Entity 1, a Personal Care Agency. The section titled “Advance Directives” listed yes, Medical Power of Attorney, with copies on file. The section titled “Allergies” had checked No Known Allergies (NKA). The section titled “Primary Diagnosis/Other Diagnosis” listed Chronic Heart Failure (a condition of in which the heart’s inability to pump blood) with onset date 07/06/2018, Type 2 Diabetes (a condition of the body’s inability to regulate the amount of sugar in the blood), Chronic Kidney Disease (a condition of gradual loss of kidney function leading to the kidney’s inability to filter waste and excess fluids from the blood), and Hypertension (a condition of high blood pressure). The section titled “Risk for Hospital/ER Visit Interventions” had been left blank. The section titled “Prognosis” had been left blank. The section titled “DME and Supplies” listed Walker, Elevated Toilet seat, Tub/Shower Bench, Diabetic Supplies, and Needles. The section titled “Rehabilitation Potential” listed Fair. The section titled “Discharge Plans” listed the Patient’s Discharge Goal: ongoing until SN is no longer needed. Increased independence. Patient, Caregiver, and/or Representative (if any) agreed with and participated in the discharge plans. The section titled “Measurable Goals and Outcomes” listed goals and measurable timelines of 6 weeks and 60 days. A review of the POC for the initial certification period 10/07/2025 to 12/06/2025, included the Principal Diagnosis as Chronic Heart Failure, but failed to list the onset date, and Other Pertinent Diagnoses as Uncontrolled Diabetes Type 2, failed to list the onset date, and failed to list Chronic Kidney Disease and Hypertension. The section titled “DME and Supplies” listed rollator, shower chair, wheelchair, and ted hose, but failed to list elevated toilet seat, glucometer, diabetic supplies, and needles. The section titled “Safety Measures” listed High Fall Risk, but failed to list Slow Position Change, Use of Assistive Device, Support During Transfer and Ambulation, Emergency Plan Developed, Safety in ADLs, Standard Precautions/Infection Control, and Fall Precautions. The POC failed to list advance directives; call parameters for blood sugar, blood pressure, pulse, respirations, and temperature; caregiver status; a description of the patient's risk for emergency department visits and hospital readmission; and all necessary interventions to address the underlying risk factors. The section titled “Goals/Rehabilitation Potential/Discharge Plans” failed to list Rehabilitation Potential/Discharge Plans. The plan of care failed to evidence all required elements, failed to be individualized and patient-specific, objective, and measurable goals based on Patient #1's comprehensive assessment. A review of an OASIS Recertification Comprehensive Assessment dated 12/05/2025 had been signed by the Administrator. The section titled “Safety Measures” lists: Proper Position During Meals, Safety in ADLs, Standard Precautions/Infection Control, and Fall Precautions. The section titled “Psychosocial Status” listed Patient #1’s daughter as the primary caregiver and will be able to assist with shopping, ADLs, and medications, with supportive assistance from Entity 1, a Personal Care Agency. The section titled “Fall Prevention Interventions” listed Fall Prevention, Fall Risk Hazard, History of Falls, and interventions for Fall Prevention. The section titled “Allergies” listed NKA. The section titled “Risk for Hospital/ER Visit Interventions” had been left blank. The section titled “Notify Physician of” listed Temperature ranges left blank, Blood Pressure (BP) systolic > 180, Heart Rate >100. The section titled “Endocrine Interventions” lists Notify Physician of blood sugars over 400 and under 60. The section titled “Primary Diagnosis/Other Diagnosis” listed Chronic Heart Failure with onset date 07/06/2018, Type 2 Diabetes with the onset date 11/06/2012, Chronic Kidney Disease, and Hypertension. The section titled “DME and Supplies” lists Walker, Elevated Toilet seat, Tub/Shower Bench, Diabetic Supplies, and Needles. The section titled “Rehabilitation Potential” listed Fair. The section titled “Discharge Plans” listed the Patient’s Discharge Goal: ongoing until SN is no longer needed. Increased independence. Patient, Caregiver, and/or Representative (if any) agreed with and participated in the discharge plans. The section titled “Measurable Goals and Outcomes” listed goals and measurable timelines of 6 weeks and 60 days. A review of the POC recertification period for the incorrect dates of 12/05/2025 through 02/04/2026, included the Principal Diagnosis as Chronic Heart Failure, but failed to list the onset date, and Other Pertinent Diagnoses as Uncontrolled Diabetes Type 2, failed to list the onset date, and failed to list Chronic Kidney Disease and Hypertension. The section titled “DME and Supplies” listed rollator, shower chair, wheelchair, and ted hose, but failed to list elevated toilet seat, glucometer, diabetic supplies, and needles. The section titled “Safety Measures” listed High Fall Risk, but failed to list Slow Position Change, Use of Assistive Device, Support During Transfer and Ambulation, Emergency Plan Developed, Safety in ADLs, Standard Precautions/Infection Control, and Fall Precautions. The POC failed to list advance directives; call parameters for blood sugar, blood pressure, pulse, respirations, and temperature; caregiver status; a description of the patient's risk for emergency department visits and hospital readmission; and all necessary interventions to address the underlying risk factors. The section titled “Goals/Rehabilitation Potential/Discharge Plans” failed to list Rehabilitation Potential/Discharge Plans. The plan of care failed to evidence all required elements, failed to be individualized and patient-specific, objective, and measurable goals based on Patient #1's comprehensive reassessment. 3. During a home visit at Patient #2’s residence on 02/04/2026 at 10:00 AM, observed HHA 1 transfer Patient #2 to a standing position and pull of Patient #2’s depends. Observed in Patient #2’s wheelchair and in the patient’s hospital bed, disposable incontinent chucks and washable pads. Patient #2 required HHA 1 to assist with applying bilateral leg braces. Further observed while Patient #2 stood with assistance the Clinical Manager perform wound care to Patient #2 sacral area wound. The Clinical Manager cleansed the wound with wound cleanser and 4 x 4 gauze dressings, patted the wound dry, then applied a foam sacral dressing to Patient #2’s sacral area. A review of Patient #2's clinical record, SOC date12/11/2025, contained an OASIS Start of Care Comprehensive Assessment dated 12/11/2025, and signed by the Administrator. The OASIS comprehensive assessment listed the certification period 12/11/2025 to 02/10/2026. The OASIS assessment section titled “Safety Measures” listed Anticoagulation Precautions, Slow Position Change, Use of Assistive Device, Support During Transfer and Ambulation, Emergency Plan Developed, Safety in ADLs, Standard Precautions/Infection Control, and Fall Precautions. The section titled “Psychosocial Status” listed supportive assistance from Entity 1, a Personal Care Agency. The section titled “Advance Directives” listed no. The section titled “Allergies” had checked No Known Allergies (NKA). The section titled “Primary Diagnosis/Other Diagnosis” listed Impaired Mobility and ADLs, with the onset date listed unknown, Guillain Barr Syndrome (a rare autoimmune disorder where the immune system attacks the peripheral nerves, leading to muscle weakness and paralysis) with the onset date listed unknown, and Tetraparesis (a condition characterized in weakness in both the arms and legs) with onset date listed unknown. The section titled “Risk for Hospital/ER Visit Interventions” lists educating the patient on signs and symptoms, which include warning them to call the Home Health Agency, and instructing the patient to call the Home Health Agency. The section titled “Prognosis” listed fair. The section titled “DME and Supplies” lists: Walker/Rollator, Elevated Toilet Seat, Tub/Shower Bench, and Wheelchair. The section titled “Rehabilitation Potential” listed Fair. The section titled “Discharge Plans” listed the patient’s Discharge Goal: Free from falls within the 60-day certification period. The patient would like to gain strength and more independence. Caregiver and/or Representative (if any) agreed with and participated in the discharge plans. The section titled “Measurable Goals and Outcomes” listed goals and measurable timelines of 6 weeks and 60 days. A review of the POC for the initial certification period 12/11/2025 to 02/10/2026, included the Principal Diagnosis as Guillain-Barr Syndrome, but failed to list the onset date, and Other Pertinent Diagnoses as Impaired Mobility and ADLs, and Tetraparesis with no onset dates listed. The section titled “DME and Supplies” listed rollator, shower chair, wheelchair, hospital bed, and elevated toilet seat, but failed to list leg braces, wound care supplies, Depends, and chucks. The section titled “Safety Measures” listed High Fall Risk, but failed to list Anticoagulation Precautions, Slow Position Change, Use of Assistive Device, Support During Transfer and Ambulation, Emergency Plan Developed, Safety in ADLs, Standard Precautions/Infection Control, and Fall Precautions. The POC failed to list advance directives; call parameters for blood pressure, pulse, respirations, and temperature; caregiver status; a description of the patient's risk for emergency department visits and hospital readmission; and all necessary interventions to address the underlying risk factors. The section titled “Goals/Rehabilitation Potential/Discharge Plans” failed to list Rehabilitation Potential/Discharge Plans. The plan of care failed to evidence all required elements, failed to be individualized and patient-specific, objective, and measurable goals based on Patient #3's comprehensive assessment. 4. During a home visit at Patient #3’s residence on 02/04/2026 at 11:10 AM, observed HHA 2 assist Patient #3 with a tub bath and ADL assistance. Observed hanging off the patient’s lower bed frame: 3 urinals. A review of Patient #3's clinical record, SOC date 12/15/2025, contained an OASIS Start of Care Comprehensive Assessment dated 12/15/2025 and signed by the Clinical Manager. The OASIS comprehensive assessment listed the certification period 12/15/2025 to 02/13/2026. The OASIS assessment section titled “Safety Measures” listed: Use of Assistive Device, Support During Transfer and Ambulation, Emergency Plan Developed, Safety in ADLs, Standard Precautions/Infection Control, and Fall Precautions. The section titled “Psychosocial Status” listed supportive assistance from Entity 1, a Personal Care Agency. The section titled “Advance Directives” listed yes, living will, and copies on file at the agency. The section titled “Allergies” lists Duloxetine (a drug used to treat depression). The section titled “Primary Diagnosis/Other Diagnosis” listed Chronic Low Back Pain, with the onset date listed unknown, Coronary Artery Disease (a condition of narrowing or blocked arteries from plaque buildup reducing blood flow to the heart muscles) with the onset date listed unknown, and Diabetes Mellitus Type 2 (a condition of the body’s inability to regulate the amount of sugar in the blood), with onset date listed unknown. The section titled “Risk for Hospital/ER Visit Interventions” lists educating the patient on signs and symptoms, which include warning them to call the Home Health Agency, instructing the patient to call the Home Health Agency, and educating the patient on medication use and medication regimen. The section titled “Prognosis” listed fair. The section titled “DME and Supplies” listed Walker/Rollator, and Tub/Shower Bench. The section titled “Rehabilitation Potential” listed Fair. The section titled “Discharge Plans” listed the Patient’s Discharge Goal: Discharge when skilled care is no longer needed. Discharge when the patient gains independence in ADLs. Discharge when pain and vital signs are consistently stable, and there are no falls. Caregiver and/or Representative (if any) agreed with and participated in the discharge plans. The section titled “Measurable Goals and Outcomes” listed goals and measurable timelines of 6 weeks and 60 days. A review of the POC for the initial certification period, 12/15/2025 to 02/14/2026, included the Principal Diagnosis as Dementia, but failed to list the onset date, and Other Pertinent Diagnoses as Chronic Back Pain, Primary Hypertension, and Type 2 Diabetes Mellitus, with no onset dates listed. The section titled “DME and Supplies” listed Rollator, Shower Chair, Arm Brace, Shoe Inserts, and Grab Bars, but failed to list Urinals. The section titled “Safety Measures” listed High Fall Risk, but failed to list Use of Assistive Device, Support During Transfer and Ambulation, Emergency Plan Developed, Safety in ADLs, Standard Precautions/Infection Control, and Fall Precautions. The POC failed to list advance directives; call parameters for blood sugar, blood pressure, pulse, respirations, and temperature; caregiver status; a description of the patient's risk for emergency department visits and hospital readmission; and all necessary interventions to address the underlying risk factors. The section titled “Goals/Rehabilitation Potential/Discharge Plans” failed to list Rehabilitation Potential/Discharge Plans. The plan of care failed to evidence all required elements, failed to be individualized and patient-specific, objective, and measurable goals based on Patient #3's comprehensive assessment. 5. A review of Patient #4's clinical record, SOC date10/27/2025, contained an OASIS Start of Care Comprehensive Assessment dated 10/27/2025, signed by the Clinical Manager. The OASIS comprehensive assessment listed the certification period from 10/27/2025 to 11/26/2025. The OASIS assessment section titled “Safety Measures” listed Slow Position Change, Use of Assistive Device, Support During Transfer and Ambulation, Emergency Plan Developed, Keep Pathways Clear, Safety in ADLs, Standard Precautions/Infection Control, and Fall Precautions. The section titled “Psychosocial Status” listed Patient #4’s daughter as the primary caregiver. The section titled “Advance Directives” listed no. The section titled “Endocrine” listed notify physician of blood sugar over 400 and below 60. The section titled “Primary Diagnosis/Other Diagnosis” listed History of Stroke (a condition when blood flow to part of the brain has been blocked or a vessel in the brain bursts causing the brain cells to die) with onset date 01/01/2025, Status Post (S/P) Cardiovascular Accident with Residual Weakness (a condition where a patient has experienced a stroke that have left them with physical limitation or deficits), Abnormality of Gait (a condition of the walking pattern being altered), Diabetes Type 2 (a condition of the body’s inability to regulate the amount of sugar in the blood), Hypertension (a condition of high blood pressure) and Chronic Kidney Disease (CKD) (a condition of gradual loss of kidney function leading to the kidney’s inability to filter waste and excess fluids from the blood).The section titled “Risk for Hospital/ER Visit Interventions” lists educating the patient on signs and symptoms, which include warning them to call the Home Health Agency, and instructing the patient to call the Home Health Agency. The section titled “Prognosis” listed Fair. The section titled “Cardiac Status” listed notify physician of blood pressure Systolic >180 and Diastolic > 80. The section titled “DME and Supplies” lists Walker, Tub/Shower Bench, and Wheelchair. The section titled “Rehabilitation Potential” had been left blank. The section titled “Discharge Plans” were left blank. The section titled “Measurable Goals and Outcomes” listed goals and measurable timelines of 6 weeks and 60 days. A review of the POC for the initial certification period 10/27/2025 to 11/26/2025, included the Principal Diagnosis as History of Stroke with onset date 01/01/2025, and Other Pertinent Diagnoses as Congestive Heart Failure onset date 03/26/2025, which failed to be listed on the comprehensive assessment, Hypertension with onset date of 03/26/2025, and Type 2 Diabetes, with onset date of 03/09/2000, but failed to list Chronic Kidney Disease, and S/P Cardiovascular Accident with Residual Weakness. The section titled “DME and Supplies” listed Shower Chair, Wheelchair, and Walker, but failed to list Glucometer and Diabetic Supplies. The section titled “Safety Measures” listed High Fall Risk, but failed to list Slow Position Change, Use of Assistive Device, Support During Transfer and Ambulation, Emergency Plan Developed, Safety in ADLs, Standard Precautions/Infection Control, and Fall Precautions. The POC failed to list advance directives; call parameters for blood sugar, blood pressure, pulse, respirations, and temperature; caregiver status; a description of the patient's risk for emergency department visits and hospital readmission; and all necessary interventions to address the underlying risk factors. The section titled “Goals/Rehabilitation Potential/Discharge Plans” failed to list Rehabilitation Potential/Discharge Plans. The plan of care failed to evidence all required elements, failed to be individualized and patient-specific, objective, and measurable goals based on Patient 4's comprehensive assessment. A review of an OASIS Recertification Comprehensive Assessment dated 12/26/2025 had been signed by the Clinical Manager. The section titled “Safety Measures” lists: Slow Position Change, Use of Assistive Device, Support During Transfer and Ambulation, Emergency Plan Developed, Keep Pathways Clear, Safety in ADLs, Standard Precautions/Infection Control, and Fall Precautions. The section titled “Psychosocial Status” listed Patient #4’s daughter as the primary caregiver and will be able to assist with shopping, ADLs, and medications. The section titled “Fall Prevention Interventions” listed Fall Prevention, Fall Risk Hazard, History of Falls, and interventions for Fall Prevention. The section titled “Risk for Hospital/ER Visit Interventions” lists educating the patient on signs and symptoms, which include warning them to call the Home Health Agency, and instructing the patient to call the Home Health Agency. The section titled “Endocrine Interventions” lists Notify Physician of blood sugars over 400 and under 60. The section titled “Primary Diagnosis/Other Diagnosis” listed History of Stroke with onset date 01/2025, S/P Cardiovascular Accident with Residual Weakness, with onset date 01/2025, Abnormality of Gait with onset date unknown, Diabetes Type 2, with onset date unknown, Hypertension with onset date unknown, and Chronic Kidney Disease, with onset date unknown. The section titled “Cardiac Status” listed notify physician of blood pressure Systolic >180 and Diastolic > 80. The section titled “DME and Supplies” lists Walker, Tub/Shower Bench, and Wheelchair. The section titled “Rehabilitation Potential” listed Fair. The section titled “Discharge Plans” listed the patient’s Discharge Goal: Prevent rehospitalization. Patient, Caregiver, and/or Representative (if any) agreed with and participated in the discharge plans. The section titled “Measurable Goals and Outcomes” listed goals and measurable timelines of 6 weeks and 60 days. A review of the POC recertification period for the incorrect dates of 12/26/2025 to 02/25/2026, included Principal Diagnosis as History of Stroke with onset date 01/01/2025, and Other Pertinent Diagnoses as Congestive Heart Failure onset date 03/26/2025, which failed to be listed on the comprehensive assessment, Hypertension with onset date of 03/26/2025, and Type 2 Diabetes, with onset date of 03/09/2000, but failed to list Chronic Kidney Disease, and S/P Cardiovascular Accident with Residual Weakness. The section titled “DME and Supplies” listed Shower Chair, Wheelchair, and Walker, but failed to list Glucometer and diabetic Supplies. The section titled “Safety Measures” listed High Fall Risk, but failed to list Slow Position Change, Use of Assistive Device, Support During Transfer and Ambulation, Emergency Plan Developed, Safety in ADLs, Standard Precautions/Infection Control, and Fall Precautions. The POC failed to list advance directives; call parameters for blood sugar, blood pressure, pulse, respirations, and temperature; caregiver status; a description of the patient's risk for emergency department visits and hospital readmission; and all necessary interventions to address the underlying risk factors. The section titled “Goals/Rehabilitation Potential/Discharge Plans” failed to list Rehabilitation Potential/Discharge Plans. The plan of care failed to evidence all required elements, failed to be individualized and patient-specific, objective, and measurable goals based on Patient #4's comprehensive assessment. 6. A review of Patient #5’s clinical record, SOC date 10/03/2025, contained an OASIS Start of Care Comprehensive Assessment dated 10/03/2025, signed by the Clinical Manager. The OASIS comprehensive assessment listed the certification period as 10/03/2025 to 12/02/2025. The OASIS assessment section titled “Safety Measures” listed: Support During Transfer and Ambulation, Emergency Plan Developed, Safety in ADLs, Standard Precautions/Infection Control, Fall Precautions, 24-hour Supervision, and Medication Safety/Storage. The section titled “Psychosocial Status” listed Entity 2, a Personal Services Agency-assisted Patient #5. The section titled “Advance Directives” listed no. The section titled “Endocrine” lists notifying the physician of blood sugar levels over 400 and below 60, and family tests glucose 3 times a day. The section titled “Primary Diagnosis/Other Diagnosis” listed Diabetes Type 2 (a condition of the body’s inability to regulate the amount of sugar in the blood), onset date unknown, Cerebral Palsy (a condition that affects a person’s ability to control their muscles affecting movement and maintaining posture due to abnormal brain development or damage during development), with no date of onset, and Autism (a developmental disorder affecting the brain that affects how people interact, communicate, learn, and behave) with no date of onset. The section titled “Risk for Hospital/ER Visit Interventions” lists educating the patient on signs and symptoms, which include warning them to call the Home Health Agency, and instructing the patient to call the Home Health Agency. The section titled “Prognosis” listed Fair. The section titled “DME and Supplies” lists Tub/Shower Bench, Wheelchair, Alcohol Pads, and Diabetic Supplies. The section titled “Rehabilitation Potential” had been left blank. The section titled “Discharge Plans” listed Patient‘s Discharge Goal: Ongoing care as long as skilled nursing is needed, with 60 days. The section titled “Measurable Goals and Outcomes” listed goals and measurable timelines of 6 weeks and 60 days. A review of the POC for the initial certification period 10/03/2025 to 12/02/2025, included the Principal Diagnosis as Diabetes Type 2, with no date of onset, and Other Pertinent Diagnoses as Cerebral Palsy with no date of onset, and Autism with no date of onset. The section titled “DME and Supplies” listed Shower Chair and Wheelchair, but failed to list Glucometer and diabetic Supplies. The section titled “Safety Measures” listed High Fall Risk, but failed to list Support During Transfer and Ambulation, Emergency Plan Developed, Safety in ADLs, Standard Precautions/Infection Control, Fall Precautions, 24-hour Supervision, and Medication Safety/Storage. The POC failed to list advance directives; call parameters for blood sugar, blood pressure, pulse, respirations, temperature, and caregiver status; a description of the patient's risk of emergency department visits and hospital readmission; and all necessary interventions to address the underlying risk factors. The section titled “Goals/Rehabilitation Potential/Discharge Plans” failed to list Rehabilitation Potential/Discharge Plans. The plan of care failed to evidence all required elements, failed to be individualized and patient-specific, objective, and measurable goals based on Patient 5's comprehensive assessment. A review of an OASIS Recertification Comprehensive Assessment dated 12/02/2025 had been signed by the Clinical Manager. The OASIS assessment section titled “Safety Measures” listed: Support During Transfer and Ambulation, Emergency Plan Developed, Safety in ADLs, Standard Precautions/Infection Control, Fall Precautions, 24-hour Supervision, and Medication Safety/Storage. The section titled “Psychosocial Status” listed Entity 2, a Personal Services Agency-assisted Patient #5. The section titled “Advance Directives” listed no. The section titled “Endocrine” lists the family tests glucose 3 times a day. The section titled “Primary Diagnosis/Other Diagnosis” listed Diabetes Type, onset date unknown, Cerebral Palsy, with no date of onset, and Autism, with no date of onset. The section titled “Risk for Hospital/ER Visit Interventions” lists educating the patient on signs and symptoms, which include warning them to call the Home Health Agency, and instructing the patient to call the Home Health Agency. The section titled “Prognosis” listed Fair. The section titled “DME and Supplies” lists Tub/Shower Bench, Wheelchair, Alcohol Pads, and Diabetic Supplies. The section titled “Rehabilitation Potential” had been left blank. The section titled “Discharge Plans” listed Patient‘s Discharge Goal: Ongoing care as long as SN needed. The section titled “Measurable Goals and Outcomes” listed goals and measurable timelines of 6 weeks and 60 days. A review of the POC recertification period for the incorrect dates of 12/02/2025 to 02/01/2026, included Principal Diagnosis as Diabetes Type 2, with no date of onset, and Other Pertinent Diagnoses as Cerebral Palsy with no date of onset, and Autism with no date of onset. The section titled “DME and Supplies” listed Shower Chair and Wheelchair, but failed to list Glucometer and diabetic Supplies. The section titled “Safety Measures” listed High Fall Risk, but failed to list Support During Transfer and Ambulation, Emergency Plan Developed, Safety in ADLs, Standard Precautions/Infection Control, Fall Precautions, 24-hour Supervision, and Medication Safety/Storage. The POC failed to list advance directives; call parameters for blood sugar, blood pressure, pulse, respirations, temperature, and caregiver status; a description of the patient's risk of emergency department visits and hospital readmission; and all necessary interventions to address the underlying risk factors. The section titled “Goals/Rehabilitation Potential/Discharge Plans” failed to list Rehabilitation Potential/Discharge Plans. The plan of care failed to evidence all required elements, failed to be individualized and patient-specific, objective, and measurable goals based on Patient 5's comprehensive assessment. 7. A review of Patient #6's clinical record, SOC date12/09/2025, contained an OASIS Start of Care Comprehensive Assessment dated 12/09/2025, signed by the Administrator. The OASIS comprehensive assessment listed the certification period 12/09/2025 to 02/08/2026. The OASIS assessment section titled “Safety Measures” listed Slow Position Change, Use of Assistive Device, Support During Transfer and Ambulation, Emergency Plan Developed, Keep Pathways Clear, Safety in ADLs, Standard Precautions/Infection Control, and Fall Precautions. The section titled “Psychosocial Status” listed Entity 1, a Personal Care Service Agency. The section titled “Advance Directives” had been left blank. The section titled “Primary Diagnosis/Other Diagnosis” listed Traumatic Brain Injury (injury to the brain caused by an external force resulting in temporary or permanent impairments in cognitive, physical, and psychosocial functions) with onset date unknown, Undifferentiated Connective Tissue Disease (a condition where individuals exhibit symptoms of an autoimmune disorder attacking the immune system), with onset date unknown, Smoldering Multiple Myeloma (a type of blood cancer causing abnormal plasma cells in the bone marrow) with onset date unknown, and Spondylolisthesis Cervical Region (misalignment of the cervical spine vertebrae) with onset date unknown. The section titled “Risk for Hospital/ER Visit Interventions” lists educating the patient on signs and symptoms, which include warning them to call the Home Health Agency, and instructing the patient to call the Home Health Agency. The section titled “Prognosis” listed Fair. The section titled “DME and Supplies” lists Walker, Elevated Toilet Seat, Grab Bars, Tub/Shower Bench, and Wheelchair. The section titled “Rehabilitation Potential” had been left blank. The section titled “Discharge Plans” states that the patient is to be discharged when the skill is no longer needed. The section titled “Measurable Goals and Outcomes” listed goals and measurable timelines of 6 weeks and 60 days. A review of the POC for the initial certification period, 12/09/2025 to 02/08/2026, included the Principal Diagnosis as Traumatic Brain Injury with no onset date, and Other Pertinent Diagnoses as Undifferentiated Connective Tissue Disease with onset date unknown, Smoldering Multiple Myeloma with onset date unknown, and Spondylolisthesis Cervical Region with onset date unknown. The section titled “DME and Supplies” listed Rollator, Shower Chair, and Wheelchair, but failed to list Elevated Toilet Seat and Grab Bars. The section titled “Safety Measures” listed High Fall Risk, but failed to list Slow Position Change, Use of Assistive Device, Support During Transfer and Ambulation, Emergency Plan Developed, Safety in ADLs, Standard Precautions/Infection Control, and Fall Precautions. The POC failed to list advance directives; call parameters for blood pressure, pulse, respirations, and temperature; caregiver status; a description of the patient's risk of emergency department visits and hospital readmission; and all necessary interventions to address the underlying risk factors. The section titled “Goals/Rehabilitation Potential/Discharge Plans” failed to list Rehabilitation Potential/Discharge Plans. The plan of care failed to evidence all required elements, was not individualized and patient-specific, and lacked objective, measurable goals based on Patient 6's comprehensive assessment. 8. A review of Patient #7's clinical record, SOC date12/03/2025, contained an OASIS Start of Care Comprehensive Assessment dated 12/03/2025, signed by the Clinical Manager. The OASIS comprehensive assessment listed the certification period as 12/03/2025 to 02/02/2026.The OASIS assessment section titled “Safety Measures” listed: Use of Assistive Device, Emergency Plan Developed, Safety in ADLs, Standard Precautions/Infection Control, and Fall Precautions. The section titled “Advance Directives” listed no. The section titled “Primary Diagnosis/Other Diagnosis” listed Uncontrolled Type 2 Diabetes (a condition of the body’s inability to regulate the amount of sugar in the blood) with onset date 01/2022, Type 2 Diabetes Mellitus with onset date 11/2023, Hypertension (a condition of high blood pressure) with onset date 01/2022, and Chronic Heart Failure (a condition of in which the heart’s inability to pump blood) with onset date 11/2022. The section titled “Risk for Hospital/ER Visit Interventions” lists educating the patient on signs and symptoms, which include warning them to call the Home Health Agency, and instructing the patient to call the Home Health Agency. The section titled “Prognosis” listed Fair. The section titled “DME and Supplies” lists Walker and Tub/Shower Bench. The section titled “Rehabilitation Potential” listed Fair. The section titled “Discharge Plans” listed Patient’s Discharge Goal: Congestive Heart Failure maintained by self, wound resolved with no signs of infection. The section titled “Measurable Goals and Outcomes” listed goals and measurable timelines of 6 weeks and 60 days. A review of the POC for the initial certification period 12/03/2025 to 02/02/2026, included the Principal Diagnosis as Heart Failure Unspecified, but failed to list the onset date, Surgical Procedure as Oral Cancer Surgery with no onset date, and Other Pertinent Diagnoses as Uncontrolled Diabetes Type 2, failed to list the onset date, and failed to list Hypertension. The section titled “DME and Supplies” listed: Rollator and Shower Chair, but failed to list glucometer, and diabetic supplies. The section titled “Safety Measures” listed High Fall Risk, but failed to list: Use of Assistive Device, Emergency Plan Developed, Safety in ADLs, Standard Precautions/Infection Control, and Fall Precautions. The POC failed to list advance directives; call parameters for blood sugar, blood pressure, pulse, respirations, and temperature; caregiver status; a description of the patient's risk for emergency department visits and hospital readmission; and all necessary interventions to address the underlying risk factors. The section titled “Goals/Rehabilitation Potential/Discharge Plans” failed to list Rehabilitation Potential/Discharge Plans. The plan of care failed to evidence all required elements, failed to be individualized and patient-specific, objective, and measurable goals based on Patient #7's comprehensive assessment. 9. A review of Patient #8’s clinical record, SOC date10/03/2025, contained an OASIS Start of Care Comprehensive Assessment dated 10/03/2025, signed by the Clinical Manager. The OASIS comprehensive assessment listed the certification period 10/03/2025 to 12/02/2025. The OASIS assessment section titled “Safety Measures” listed Anticoagulation Precautions, Emergency Plan Developed, Safety in ADLs, Seizure Precautions, Standard Precautions/Infection Control, and Fall Precautions. The section titled “Psychosocial Status” listed Entity 3, a Personal Care Service Agency. The section titled “Advance Directives” listed no. The section titled “Endocrine Interventions” lists Notify Physician of blood sugars over 400 and under 60. The section titled “Primary Diagnosis/Other Diagnosis” listed Diabetes Type 2 (a condition of the body’s inability to regulate the amount of sugar in the blood) with onset date unknown, Hypertension (a condition of high blood pressure) with onset date unknown, and Seizures with onset date unknown. The section titled “Risk for Hospital/ER Visit Interventions” lists educating the patient on signs and symptoms, which include warning them to call the Home Health Agency, and instructing the patient to call the Home Health Agency. The section titled “Prognosis” listed Fair. The section titled “DME and Supplies” lists Walker, Tub/Shower Bench, Diabetic Supplies, and Needles. The section titled “Rehabilitation Potential” listed Fair. The section titled “Discharge Plans” listed Patient’s Discharge Goal: had been left blank. The section titled “Measurable Goals and Outcomes” listed goals and measurable had been left blank. A review of the POC for the initial certification period 10/03/2025 to 12/02/2025, included the Principal Diagnosis Diabetes Type 2, but failed to list the onset date, and Other Pertinent Diagnoses Hypertension, but failed to list the onset date, and Seizure, but failed to list the onset date. The section titled “DME and Supplies” listed: Rollator and Shower Chair, but failed to list glucometer, and diabetic supplies. The section titled “Safety Measures” listed High Fall Risk but failed to list Anticoagulation Precautions, Emergency Plan Developed, Safety in ADLs, Seizure Precautions, Standard Precautions/Infection Control, and Fall Precautions. The POC failed to list advance directives; call parameters for blood sugar, blood pressure, pulse, respirations, and temperature; caregiver status; a description of the patient's risk for emergency department visits and hospital readmission; and all necessary interventions to address the underlying risk factors. The section titled “Goals/Rehabilitation Potential/Discharge Plans” failed to list Rehabilitation Potential/Discharge Plans. The plan of care failed to evidence all required elements, failed to be individualized and patient-specific, objective, and measurable goals based on Patient #8's comprehensive assessment. A review of an OASIS Recertification Comprehensive Reassessment dated 12/02/2025, listed the certification period 12/02/2025 to 02/01/2026. The OASIS reassessment section titled “Safety Measures” listed Anticoagulation Precautions, Emergency Plan Developed, Safety in ADLs, Seizure Precautions, Standard Precautions/Infection Control, and Fall Precautions. The section titled “Psychosocial Status” listed Entity 3, a Personal Care Service Agency. The section titled “Advance Directives” listed no. The section titled “Endocrine Interventions” lists Notify Physician of blood sugars over 400 and under 60. The section titled “Primary Diagnosis/Other Diagnosis” listed Diabetes Type 2 with onset date unknown, Hypertension with onset date unknown, and Seizures with onset date unknown. The section titled “Risk for Hospital/ER Visit Interventions” lists educating the patient on signs and symptoms, which include warning them to call the Home Health Agency, and instructing the patient to call the Home Health Agency. The section titled “Prognosis” listed Fair. The section titled “DME and Supplies” lists Walker, Tub/Shower Bench, Diabetic Supplies, and Needles. The section titled “Rehabilitation Potential” listed Fair. The section titled “Discharge Plans” listed Patient’s Discharge Goal: had been left blank. The section titled “Measurable Goals and Outcomes” listed goals and measurable had been left blank. A review of the POC for the recertification period showed incorrect dates of 12/02/2025 to 02/01/2026, included the Principal Diagnosis Diabetes Type 2, but failed to list the onset date, and Other Pertinent Diagnoses Hypertension, but failed to list the onset date, and Seizure, but failed to list the onset date. The section titled “DME and Supplies” listed: Rollator and Shower Chair, but failed to list glucometer, and diabetic supplies. The section titled “Safety Measures” listed High Fall Risk but failed to list Anticoagulation Precautions, Emergency Plan Developed, Safety in ADLs, Seizure Precautions, Standard Precautions/Infection Control, and Fall Precautions. The POC failed to list advance directives; call parameters for blood sugar, blood pressure, pulse, respirations, and temperature; caregiver status; a description of the patient's risk for emergency department visits and hospital readmission; and all necessary interventions to address the underlying risk factors. The section titled “Goals/Rehabilitation Potential/Discharge Plans” failed to list Rehabilitation Potential/Discharge Plans. The plan of care failed to evidence all required elements, failed to be individualized and patient-specific, objective, and measurable goals based on Patient #8's comprehensive assessment. 10. A review of Patient #9's inactive clinical record, SOC date12/03/2025, contained an OASIS Start of Care Comprehensive Assessment dated 12/03/2025, signed by the Clinical Manager. The OASIS comprehensive assessment listed the certification period 12/03/2025 to 02/02/2026. The OASIS assessment section titled “Safety Measures” listed Anticoagulation Precautions, Slow Position Change, Use of Assistive Device, Support During Transfer and Ambulation, Emergency Plan Developed, Keep Pathways Clear, Safety in ADLs, Standard Precautions/Infection Control, and Fall Precautions. The section titled “Advance Directives” listed no. The section titled “Endocrine Interventions” lists Notify physician of blood sugar over 400 and under 60. The patient uses a glucometer daily to test. The section titled “Primary Diagnosis/Other Diagnosis” listed Chronic Heart Failure (a condition of in which the heart’s inability to pump blood) with onset date 01/2023, Type 2 Diabetes (a condition of the body’s inability to regulate the amount of sugar in the blood) with onset date 01/2022, Type 2 Diabetes Mellitus with onset date unknown, Bilateral Knee Pain with onset date unknown, and Recurrent Urinary Tract Infection (UTI) (a condition of an infection in the urinary system) with onset date unknown. The section titled “Risk for Hospital/ER Visit Interventions” lists educating the patient on signs and symptoms, which include warning them to call the Home Health Agency, and instructing the patient to call the Home Health Agency. The section titled “Prognosis” listed Fair. The section titled “DME and Supplies” listed: Walker, Hospital Bed, Tub/Shower Bench, and Diabetic Supplies. The section titled “Rehabilitation Potential” listed Fair. The section titled “Discharge Plans” listed Patient’s Discharge Goal: More independent with ADLs, no hospital admissions, recovery at home with help. The section titled “Measurable Goals and Outcomes” listed goals and measurable timelines of 6 weeks and 60 days. A review of the POC for the initial certification period 12/03/2025 to 02/02/2026, included the Principal Diagnosis as Chronic Heart Failure, failed to list the onset date, and Other Pertinent Diagnoses as Uncontrolled Diabetes Type 2, failed to list onset date, Bilateral Knee Pain, failed to list onset date, Fibromyalgia which failed to be on the comprehensive assessment, and Recurrent UTI failed to list onset date. The section titled “DME and Supplies” listed: Rollator and Shower Chair, Wheelchair, Hospital bed, Indwelling Foley Catheter, and Nebulizer, but failed to list glucometer, diabetic supplies, and catheter supplies. The section titled “Safety Measures” listed High Fall Risk but failed to list Anticoagulation Precautions, Slow Position Change, Use of Assistive Device, Support During Transfer and Ambulation, Keep Pathways Clear, Emergency Plan Developed, Safety in ADLs, Standard Precautions/Infection Control, and Fall Precautions. The POC failed to list advance directives; call parameters for blood sugar, blood pressure, pulse, respirations, temperature, and caregiver status; a description of the patient's risk of emergency department visits and hospital readmission; and all necessary interventions to address the underlying risk factors. The section titled “Goals/Rehabilitation Potential/Discharge Plans” failed to list Rehabilitation Potential/Discharge Plans. The plan of care failed to evidence all required elements, failed to be individualized and patient-specific, objective, and measurable goals based on Patient #9's comprehensive assessment. 11. A review of Patient #10's clinical record, SOC date10/07/2025, contained an OASIS Start of Care Comprehensive Assessment dated 10/07/2025, signed by the Clinical Manager. The OASIS comprehensive assessment listed the certification period 10/07/2025 to 12/06/2025.The OASIS reassessment section titled “Safety Measures” listed: Use of Assistive Device, Support During Transfer and Ambulation, Emergency Plan Developed, Safety in ADLs, Standard Precautions/Infection Control, Fall Precautions, and Medication Safety/Storage. The section titled “Psychosocial Status” listed Entity 1, a Personal Care Service Agency. The section titled “Advance Directives” listed no. The section titled “Primary Diagnosis/Other Diagnosis” listed Neuropathic Pain (a type of pain caused by damage or dysfunction in the nervous system) with onset date unknown, Arthritis (a condition of joint inflammation causing pain, stiffness and impaired mobility), with onset date unknown, Difficulty Walking, with onset date unknown, and Chronic Pain, with onset date unknown. The section titled “Risk for Hospital/ER Visit Interventions” lists educating the patient on signs and symptoms, which include warning them to call the Home Health Agency, and instructing the patient to call the Home Health Agency. The section titled “Prognosis” listed Fair. The section titled “DME and Supplies” lists Walker and Tub/Shower Bench. The section titled “Rehabilitation Potential” listed Fair. The section titled “Discharge Plans” listed Patient’s Discharge Goal: Increase independence, free from falls, and Hypertension stable. The section titled “Measurable Goals and Outcomes” listed goals and measurable timelines of 6 weeks and 60 days. A review of the POC for the initial certification period 10/07/2025 to 12/06/2025, included the Principal Diagnosis as Neuropathic Pain, but failed to list the onset date, and Other Pertinent Diagnoses as Hypertension, failed to list onset date, Insomnia, failed to list onset date, and Risk For Falls, and failed to list Arthritis, and Chronic Pain. The section titled “DME and Supplies” listed: Rollator and Shower Chair, and Hospital Bed, which had not been listed on the comprehensive assessment. The section titled “Safety Measures” listed High Fall Risk but failed to list: Use of Assistive Device, Support During Transfer and Ambulation, Emergency Plan Developed, Safety in ADLs, Standard Precautions/Infection Control, Fall Precautions, and Medication Safety/Storage. The POC failed to list advance directives; call parameters for blood pressure, pulse, respirations, and temperature; caregiver status; a description of the patient's risk for emergency department visits and hospital readmission; and all necessary interventions to address the underlying risk factors. The section titled “Goals/Rehabilitation Potential/Discharge Plans” failed to list Rehabilitation Potential/Discharge Plans. The plan of care failed to evidence all required elements, failed to be individualized and patient-specific, objective, and measurable goals based on Patient #10's comprehensive assessment. During an interview on 02/03/2026 at 9:25 AM, when reviewed the comprehensive assessments and POCs for Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, and 10, asking for the required elements and correct recertification dates, the Clinical Manager confirmed they complete all the POCs and were confused regarding the 5 day window and unaware of the 60 day certification day calculation. The Clinical Manager further communicated upon review of the comprehensive assessment, the area in red on the comprehensive assessment were the indicators for the POC, and should be on the POC, including call parameters, prognosis, caregiver status, hospital risk, education, discharge planning, all DME and supplies, advance directives, safety measures, and all diagnoses with dates of onset. 410 IAC 17-13-1(a)(1)(D)(i-xiii)

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patients were provided with a schedule of when services would be provided for 3 of 3 agency binders reviewed during home visits. (Patients: #1, 2 and 3) Findings Include: 1. During a home visit at Patient #1’s residence on 02/02/2026 at 2:55 PM, observed the Administrator/RN for Patient #1 complete an assessment. The family member of Patient #1 provided the agency’s red admission binder for review. The agency’s red admission binder failed to evidence a schedule of when SN services were to be provided. During an interview on 02/02/2026 at 3:30 PM, when asked about the schedule for SN visits being provided to Patient #1 or the POC to provide frequency of SN services location in the binder, the Administrator/RN for Patient #1 communicated they had not provided the Patient #1 with a schedule of services provided they just called and let the patients know when they were on their way for a visit. The Administrator confirmed the agency's red admission binder had not contained a POC of the frequency of services or a schedule for when SN services were to be provided. 2. During a home visit at Patient #2’s residence on 02/04/2026 at 10:00 AM, observed HHA 1, and the Clinical Manager and Case Manager for Patient #2 perform care. The Clinical Manager provided the agency’s red admission binder for review. The agency’s red admission binder failed to evidence a schedule of when SN services were to be provided. During an interview on 02/04/2026 at 10:05 AM, when asked about Patient #2 being provided a schedule for SN visits and HHA visits, the Clinical Manager and Case Manager for Patient #2 stated, “There is no schedule provided or visit services written on the patient’s calendar. We just call and remind them on the day of our visits.” 3. During a home visit at Patient #3’s residence on 02/04/2026 at 11:10 AM, observed HHA 2, assisting Patient #3 with a tub bath. A review of the agency’s red admission binder failed to evidence a schedule of when SN and HHA services were to be provided. During an interview on 02/04/2026 at 11:30 AM, when asked how Patient #3 knew when the agency staff had visits scheduled, Patient #3 stated the staff called when they were coming.

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 HHAs were supervised at least every 14 days, for 2 of 2 active clinical records reviewed with SN and HHA services (Patients: #2 and 3) and 2 of 2 discharged records reviewed. (Patients: #9 and 10) Findings Include: 1. A review of an undated agency policy titled “Home Health Aide Supervision” indicated, but was not limited to. “ … 3. Supervisory visits of Home Health Aides shall be according to the following frequency: a. When skilled services are being provided to a client, a Registered Nurse/Therapist must make a supervisory visit to the client’s residence no less frequently than every 14 days … ” 2. During the entrance conference on 02/02/2026 at 10:06 AM, when asked about who had overseen HHA supervision the Clinical Manager stated, “I do.” When asked where the location of the supervisory visit would be located in the clinical records, the Clinical Manager communicated the supervisory visits were a separate note titled “Supervisory Visits.” 3. A review of the clinical record for Patient #2 SOC 12/11/2025, contained a POC for the initial certification period for 12/11/2025 to 02/10/2026. The POC indicated that Patient #2 had orders for SN services for a 60-day certification period, with HHA 10 hours weekly to begin the week of 12/30/2025, and SN weekly for wound care and skin assessment for the certification period. A review of the HHA weekly visit timesheets notes evidenced Patient #2 had been receiving HHA visits weekly from the week 12/28/2025 through 1/30/2026. The record failed to evidence any supervisory visits had been completed. 4. A review of the clinical record for Patient #3 SOC 12/15/2025, contained a POC for the initial certification period for 12/15/2025 to 02/14/2026. The POC indicated that Patient #3 had orders for SN biweekly for vital sign assessment, medication setup and education, blood sugar monitoring, diabetes education, and HHA 10 hours weekly to assist with ADLs, meals, and medication reminders. A review of the HHA weekly visit timesheets notes evidenced Patient #3 had HHA visits weekly from the weeks of 12/15/2025 through 1/30/2026. A review of a HHA supervisory visit note dated 01/15/2026, evidence an onsite HHA supervisory visit had been conducted by the Administrator/RN. The record failed to evidence that HHA supervisory visits were conducted at least every 14 days on 12/29/2025, 01/12/2026, or 01/26/2026. 5. A review of the inactive clinical record for Patient #9 SOC 12/03/2025, contained a POC for the initial certification period for 12/03/2025 to 02/02/2026. The POC indicated Patient #9 had orders for SN weekly, and HHA 10 hours weekly for ADL assistance and fall prevention for a 60-day certification period. A review of the HHA weekly visit timesheets notes evidenced Patient #9 had been receiving HHA visits weekly from the weeks of 12/03/2025 through 12/22/2025. The record failed to evidence any supervisory visits had been completed. 6. A review of the inactive clinical record for Patient #10 SOC 10/07/2025, and discharge date of 11/26/2025, contained a POC for the initial certification period for 10/07/2025 to 12/06/2025. The POC indicated Patient #10 had orders for SN biweekly, and HHA 10 hours per week for the 60-day certification period. A review of the HHA weekly visit timesheets notes evidenced Patient #10 had been receiving HHA visits for the weeks of 10/07/2025 through 11/26/2026. A review of a HHA supervisory visit note dated 11/07/2025, evidence an onsite HHA supervisory visit had been conducted by the Clinical Manager/RN. The record failed to evidence HHA supervisory visits were conducted at least every 14 days on 10/14/2025, 11/04/2025, or 11/18/2025. During an interview on 02/04/2026 at 10:40 AM, when asked for the HHA supervisory visits documentation for the clinical records for Patients #2, 3, 9, and 10, the Clinical Manager stated, “No, I thought every 60 days. The supervisory visit hadn’t been done due to not being 60 days.” When reviewing the agency’s policy for HHA supervisory visits, the Clinical Manager communicated the HHA supervisory visits for skilled patients should have been done every 14 days.