Every finding on record at Help at Home LLC

This visit was for a Federal/State complaint survey of a Home Health Provider. Survey Dates: 06/22/2026-06/23/2026 Complaint #: 3026138 was investigated, WITH RELATED DEFICIENCIES CITED. 12-Month Unduplicated Skilled Admissions: 0 Abbreviations: HHA - Home Health Aide RN- Registered Nurse POC- Plan of Care QAPI-Quality Assessment Performance Improvement QR completed by Area 3 on 6/25/2026

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure accurate medical record documentation for 1 of 4 patient record reviews (Patient #2). Findings Include: The active clinical record for Patient #2, certification period 05/07/2026–07/05/2026, included a Plan of Care (POC) and comprehensive assessment dated 11/07/2025. These documents contained a 60‑day summary that listed RN 1 as completing the recertification visit. Former Employee 1, whose name carried forward in the template, had been terminated on 11/01/2025. Further review confirmed that the clinical documentation and visit information were accurate. The error occurred because the nurse did not update the auto‑populated/carry‑forward name field to reflect her own name. During an interview on 06/23/2026 at 3:05 PM, the Administrator acknowledged the name‑field carry‑forward error in the POC and comprehensive assessment 60‑day summary for Patient #2. The Administrator stated that a wide‑scale audit of RN 1’s caseload would be completed, and a performance improvement plan would be incorporated into the agency’s QAPI program to prevent similar documentation errors in the future. 410 IAC 17-15-1(a)(7)

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR §484.102 Survey Dates: 04/23/2025-04/25/2025 & 04/28/2025 Active Census: 188 At this Emergency Preparedness survey, Help at Home Skilled Care was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR §484.102.

This visit was for a Federal Recertification and State Re-Licensure survey of a Home Health Provider. Survey Dates: 04/23/2025-04/25/2025 & 04/28/2025 12-Month Unduplicated Skilled Admissions: 4 Fully Extended Survey was announced on 04/28/2025 at 11:35 AM. This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Refer to State Form for additional State Findings. Abbreviations: HHA-Home Health Aide POC-Plan of Care SOC- Start of Care RN-Registered Nurse PSA-Personal Service Agency

Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This ELEMENT is not met as evidenced by: Based on observation, record review and interview, the agency failed to provide services as ordered on the plan of care (POC) for 2 of 3 record reviews with an HHA home visit. (Patients #7, #8) Findings include: 2. During an observation on 04/24/2025 at 3:25 PM, HHA 5 waited in the home's living room, out of sight from Patient #7, until the patient ate and was ready to bathe. HHA 5 failed to prepare meals, observe the patient during mealtime, provide nail care, and perform light housekeeping. During an interview on 04/24/2025 at 3:25 PM, HHA 5 indicated she did not have a POC and did not have a list of tasks she provided during the visit. The HHA 5 indicated she usually does a shower, watches TV, listens to the radio, and has done laundry before. 3. A record review of Patient #7 included the following: A POC with a certification period of 02/26/2025 - 04/26/2025 indicates that the aide should assist with all ADLs, such as bathing, hair care, dressing, nail care, incontinence care, and light housekeeping. A 04/24/2025 "Daily Visit Sheet" indicates that the aide completed preparing meals, monitoring the patient during mealtime, and providing nail care and light housekeeping during the home visit on 04/25/2025. A 09/05/2023 "Business Associate Agreement" indicates Help at Home to provide personal care, light housekeeping, and ADL assistance. During an interview on 04/25/2025 at 11:55 AM, the Administrator indicated that the aides should provide all tasks listed on the POC and that they are to follow the POC; they should not document the services they did not provide during the home visit. The Administrator reviewed HHA 5's documentation from Daily Visit Sheet 04/24/2025 and confirmed that the aide documented she completed light housekeeping, nail care, monitoring patient during mealtime, and meal preparation. 1. A 01/27/2025 revised "Home Health Aide Care Service Plan" policy indicated that the HHA staff will follow the identified plan. The policy indicated that staff should place a copy of the Care Service Plan in the patient's home. The HHA staff should document the service rendered to the patient on the Daily Visit as directed in the Home Health Aide Care Service Plan. 2 3. The clinical record for Patient #8, SOC date 03/31/2025, was reviewed on the electronic medical record (EMR). The record evidenced that Patient #8 received HHA, Attendant Care, and Homemaker services. A review of the POC included orders for HHA services, 4 hours a day, six times a week. A review of the Plan of Care Service Plan indicated that Patient #8 should receive a tub bath or shower 6 times a week. A review of the Daily Visit Notes indicated the HHA did not provide a tub bath or shower on the following dates: 3/31/2025. 04/01/2025, 04/09/2025, 04/10/2025, 04/14/2025, 04/15/2025, 04/16/2025, 04/17/2025, 04/19/2025, 04/21/2025, 04/22/2025, 04/23/2025, and 04/24/2025. During an interview on 04/24/2025 at 2:30 PM, HHA 1 reviewed the Plan of Care Service Plan with the surveyor. HHA 1 stated she gives Patient #8 a tub bath or shower three times a week on Mondays, Wednesdays, and Fridays. HHA 1 could not explain why the Plan of Care Service Plan indicated a tub/shower 6 times a week. 4. During an interview on 04/25/2025 at 9:55 AM, the Administrator provided the Daily Visit Notes after two requests. She stated that the staff should have updated the Plan of Care Service Plan to reflect the tasks the HHA was supposed to do in the home.

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 staff wore gloves during patient care and failed to perform hand hygiene before applying gloves and after removing gloves for 2 of 3 home visit observations. (Patients #7, #8) Findings include: 2. During an observation on 04/24/2025 at 3:25 PM, HHA 5 assisted Patient #7 with toileting with gloved hands, removed gloves, and touched their hand on the shower facet handle. The HHA 5 failed to perform hand hygiene after removing gloves and before touching clean surfaces. HHA 5 washed Patient #7 hair with gloved hands, removed gloves, and re-gloved. HHA 5 failed to perform hand hygiene after removing gloves and before re-gloving. HHA 5 washed Patient #7 legs, arms, chest, and back, then removed gloves and re-gloving. HHA 5 failed to perform hand hygiene after removing gloves and before re-gloving. HHA 5 washed Patient #7 private area. HHA 5 removed gloves, helped Patient #7 out of the shower, and dried the patient with a towel. HHA 5 failed to practice hand hygiene after removing gloves and before touching the clean toilet. During an interview on 04/24/2025 at 3:25 PM, HHA 5 indicated she should have hand hygiene before and after gloving. HHA 5 indicated the agency had annual education that included hand hygiene. 5. During an interview on 04/25/2025 at 11:55 AM, the Administrator indicated hand hygiene should be performed upon arrival, with glove change, after touching the patient, going from dirty to clean, before touching the patient, and after touching dirty clothes. 1. A revised 01/27/2025 policy titled "Infection Prevention and Control Plan" requires staff to wear gloves during patient contact. The policy stated that staff must perform hand hygiene after removing their gloves. 2. 3. During an observation on 04/24/2025 at 2:30 PM, HHA 1 failed to wear gloves and perform hand hygiene before and after transferring Patient #8 from the recliner to bed. During an interview on 04/24/2025 at 2:45 PM, HHA 1 stated she doesn't use hand sanitizer because it gets old and becomes sticky. She stated she washes her hands when providing direct care, but she did not indicate why hand hygiene was not done during the visit. 4. During an interview on 04/25/2025 at 1:30 PM, the Administrator stated staff should wear gloves and perform hand hygiene with direct patient contact, including when transferring patients. 5. 410 IAC 17-12-1(m)

Direct support and administrative control CFR(s): 484.105(d)(2) The parent HHA provides direct support and administrative control of its branches. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure clarity and formal documentation of lines of authority, delegation of responsibility, and clear administrative control of the branch location for 1 of 1 home health agency with a branch location. Findings include: A revised 02/01/2022 Branch Manager 1's job description indicated they oversee the day-to-day operations and report to the Director of Regional Operations. The acceptance letter states she oversees the Evansville location (parent agency). The job description did not indicate that the Branch Manager was to report to the Administrator. During an interview on 04/23/2024 at 12:33 PM, Branch Manager 1 stated she was dually employed and implied she manages the New Albany branch. During an interview on 04/28/2025 at 12:28 PM, the surveyor asked the Administrator why the "New Albany" Branch office showed a direct connection to the "Evansville License" but no connection to the rest of the organizational chart. She explained that this indicated that the branch operates under the Evansville license. She stated that Branch Manager 2 reports to someone associated with the Evansville license, while Branch Manager 1 does not supervise the New Albany office and is managed by Branch Manager 2. She stated that anyone can report to whoever is on the chart.

Skilled services furnished CFR(s): 484.105(f) Standard: Services furnished. Skilled nursing services and at least one other therapeutic service (physical therapy, speech-language pathology, or occupational therapy; medical social services; or home health aide services) are made available on a visiting basis, in a place of residence used as a patient's home. An HHA must provide at least one of the services described in this subsection directly, but may provide the second service and additional services under arrangement with another agency or organization. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to maintain full operational capacity as a certified home health agency under the Indiana Medicaid program, which adopts the Medicare Conditions of Participation. Although the agency continues to serve a limited number of existing skilled patients, it has refused all new skilled admissions for an extended period without documentation of temporary suspension, licensure limitation, or resource-based justification. This restricts service access to eligible Medicaid beneficiaries and does not meet the operational expectations for a certified provider. Findings include: On 04/23/2025 at 9:41 AM, the surveyor called the agency as listed on their website. When asked about skilled care, the staff representative who answered the phone stated they do not have skilled services. On 04/23/2025 at 10:00 AM, the surveyor called the New Albany branch to inquire about skilled care services. The staff member stated they do not offer skilled care nursing services and expressed uncertainty about the services available at the Evansville location. On 04/23/2025, at 11:20 AM, the surveyors entered the agency located on Professional Boulevard. The Recruiting Specialist informed the surveyors that Help at Home Skilled Care operates at that address but does not offer skilled services. She was unsure of the Administrator or Alternate Administrator's whereabouts, but stated she would call them. During the entrance conference on 04/23/2025 at 11:33 AM, the Alternate Administrator stated stated they have four skilled patients at the branch location and zero at the parent agency in Evansville. She stated the agency can provide skilled services, but is not offering them. She stated there were no staffing issues. She stated that the agency collaborates with other skilled agencies to manage care. The surveyor reviewed the agency's brochure on 04/23/2025, which indicated that the agency offers skilled nursing services including ventilator care, tracheotomy care, wound care, medication management, catheter care, dressing, and bathing. The pamphlet indicated higher-level medical care was available, including blood draws, wound care, catheter changes, diabetic care, intravenous services, colostomy care, medication set-up, skilled skin care, and skilled transfers. During an interview on 04/23/2025 at 1:03 PM, the RN Nurse Supervisor stated that she could not comment on whether the agency admitted patients for skilled nursing services. She mentioned that she would need to consult the Administrator before answering. During an interview on 04/23/2025 at 1:30 PM, the Branch Manager for the parent company stated that the agency does not provide skilled services and only has Medicaid patients. During an interview on 04/23/3035 at 2:00 PM, the RN Supervisor stated they have had 7 Skilled admissions since their last survey in 2022. At 3:00 PM, the RN Nurse Supervisor stated that they used the Help at Home brochure for marketing purposes. During an interview on 04/25/25 at 1:20 PM, the Administrator indicated the last skilled patient admitted to the agency was before 12/2023; she did not review skilled nursing patient referrals. Referrals are not added to the EMR system until the referral team (non-clinical staff) and admission team (non-clinical staff) review and eliminate the new referrals. The Administrator indicated that once the referral and admission teams have completed their reviews, she can access a list of acceptable referrals; she doesn't receive a list of all the patients referred to the agency. The Administrator indicated that there is a list of rejected referrals, but she does not have access to it.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to send discharge summaries within five business days of the patient's discharge and failed to include detailed health information about the patient for 2 of 3 closed records reviewed. (Patient #5, #9) Findings include: 3. The clinical record for Patient #9, SOC date 03/23/2044, certification period 01/12/2024-03/11/2024, evidenced a Discharge Summary date of 03/04/2024. The Discharge Summary failed to include several essential elements: the name of the physician responsible for the home health plan of care, the reason for the patient's admission to home health, the type and frequency of services provided, laboratory data, the medications the patient was taking at the time of discharge, the patient's condition upon discharge, the outcomes related to meeting the goals outlined in the plan of care, and any post-discharge instructions for the patient and family. Furthermore, the agency could not provide evidence or confirm that it sent the Discharge Summary to the physician or any other healthcare professional. During an interview on 04/25/2025 at 2:00 PM, the Administrator reviewed Patient #9's record. She stated the discharge summary did not contain specific information. 1. A 01/16/2025 policy titled "Client Discharge Process" indicates the staff will complete a discharge summary to include the following: a. Client status at the time of admission to the agency b. Statement of care and interventions provided and outcomes of care c. Status at discharge/last visit/current medications, therapies, and continuing care needs d. Name of person or organization assuming responsibility for care e. Instructions and referrals were given to the client/family/caregiver f. Reason for discharge and date Of discharge The agency will send a discharge summary to the MD within 5 business days. 2. The record review of Patient # 5 included a discharge summary that failed to evidence the client's status upon admission, interventions provided and outcomes, status at discharge, last visit, current medication, continuing care needs, instructions/referrals given, and the physician was notified within 5 days of discharge. During an interview on 04/25/2024 at 12:37 PM, the Administrator indicated that the discharge summary in Patient #5's record was missing essential information related to the discharge summary. She confirmed that there was no proof in the record that the agency had notified the physician within 5 days of Patient #5's discharge. 3. MC 410 IAC 17-15-1 (a)(7)

This visit was for a Federal Recertification and State Re-Licensure survey of a Provider. Survey Dates: September 27 - October 7, 2022 Census: 176 This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Refer to State Form for additional State Findings. QR Competed 10/19/2022 A4

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure duration and frequency of services ordered by the physician were completed for 2 of 7 active patient records reviewed. (Patients 4 and 5) Findings include: 1. A revised January 4, 2022 policy titled Plan of Care was provided by the Administrator (AS1) on 9/28/2022 at 1:36 p.m. The policy indicated but was not limited to, "Policy: The plan of care/treatment shall be developed in consultation with the agency staff to ensure that care provided is appropriately [sic] and planned to meet each client’s specific assessment needs…" 2. The complete clinical record for patient 4, start of care date 3/22/22, was reviewed on 10/3/2022, and included a plan of care for the certification period 7/20/2022 to 9/17/2022 with orders for skilled nursing services 10 hours/day for 5 days/week, not to exceed 50 hours/week. For weeks 7/20/22-7/23/22, 7/24/22-7/30/22, 7/31/22-8/6/22, 9/4/22-9/10/22 and 9/11/22-9/17/22 there were 0 of 50 skilled nursing hours provided. The week of 8/7/22-8/13/22 8 of 50 hours of skilled nursing were provided and weeks 8/14/22-8/20/22 and 8/28/22-9/3/22 24 of 50 hours of skilled nursing were provided. The agency failed to provide the ordered number of hours for number of days each week of the certification period. 3. The complete clinical record for patient 5, start of care date 4/20/22, was reviewed on 10/3/2022, and included a plan of care for the certification period 8/18/2022 to 10/16/2022 with orders for home health aide services 1 hour/day for 5 days/week. For week 8/18/22-8/20/22 1.5 of 2 hours were completed. Completed hours for week 8/28/22-9/3/22 was 4.25 of 5, week 9/4/22-9/10/22 was 4.75 of 5, week of 9/11/22-9/17/22 was 3.50 of 5, and week 9/18/22-9/24/22 was 3.50 of 5. The agency failed to provide the ordered number of hours for number of days each week of the certification period. 4. During an interview with Branch Manager (AS3) and Alternate Administrator (AS2) on 10/5/2022 at 1:51 p.m., it was indicated that patient 4 did not receive all hours ordered due to staff shortage and that patient 4’s grandmother helped out with hours. The documentation for the missed hours was not uploaded to the patient record. AS3 and AS2 indicated other agencies had been contacted to find out if they could staff this patient as well without any luck. Both administrative staff stated the hours should be completed as ordered 410 IAC 17-14-1(a)(1)(H)-RN 410 IAC 17-14-1(a)(2)(F)-LPN