Every finding on record at Home Care Network Inc

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102. Survey Dates: 08-06, and 08-07-2024. Active Census: 7 At this Emergency Preparedness survey, Pediatric Nursing Specialists of Indiana was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers at 42 CFR 484.102. QR completed by Area 3ts on 08-14-2024.

This visit was for a Federal Recertification and State Re-licensure survey of a Home Health Provider. Survey Dates: 08-06-2024 and 09-07-2024 12-month Unduplicated Skilled Admissions: 0 This deficiency report reflects State findings cited in accordance with 410 IAC 17. QR completed by Area 3ts on 08-14-2024.

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 ensure it provided Skilled Nursing and/or one other therapeutic service in 1 of 1 agency. Findings include: 1. A review of a policy dated Oct 2022 titled 'SERVICES PROVIDED CI-100' revealed "Agency will provide intermittent, part-time or extended hours of skilled nursing and home health aide services ... Agency will also provide Physical Therapy, Speech Therapy, Occupational Therapy, and Medical Social Services ...". 2. A review of the Home Health Agency Survey Report Form 1572 revealed the only service provided was Skilled Nursing services. 3. On 08/07/2024 at 9:22 AM, during the entrance conference, the Administrator indicated the only service the agency provided was Skilled Nursing services. 4. On 08/08/2024 at 2:35 PM, the Administrator indicated the agency had 2 Home Health Aides it hired. One was to obtain their CPR prior to being assigned a case and the other was going through training. The Administrator indicated they had not been able to hire therapy personnel so there were no therapy cases to date. The Administrator further indicated they can't accept new patients if they don't have the staff.

An Emergency Preparedness survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102. Survey Dates: 01/31/2024, 02/01/2024, 02/02/2024, 02/05/2024, 02/06/2024, 02/07/2024, 02/08/2024, 02/09/2024, and 02/12/2024 Active Census: 7 At this Emergency Preparedness survey, Pediatric Nursing Specialists of Indiana – Indianapolis was found to be out of compliance with Emergency Preparedness requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 484.102. QR completed by Area 3 on 2/17/2024.

EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This STANDARD is not met as evidenced by: Based on record review and interview the agency's Emergency Program failed to evidence testing and training as part of their plan, in 1 of 1 Emergency Preparedness program reviewed. Findings include: 1. A review of an agency document titled 'EMERGENCY PREPAREDNESS POLICY’ dated 02/08/2019, failed to evidence testing and training as part of the agency's program. 2. A review of the agency's Emergency Preparedness binder on 02/09/2024 failed to evidence a plan or procedure for testing and training the agency's Emergency Preparedness Plan. 3. On 02/09/2024 at 1:05 PM during an interview, Corporate Personnel 7 serving the role of the Administrator for the agency indicated they had developed an emergency preparedness training and testing program, they reviewed the program to make sure everyone was aware of the plan, but there was no documentation.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to participate in a full-scale exercise that is community-based or conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise in 1 of 1 Emergency Preparedness program reviewed. Findings include: 1. A review of an agency document dated 01/22/2020, titled 'EMERGENCY PREPAREDNESS POLICY' failed to evidence a testing and training plan or procedure as part of the agency's program. 2. A review of the agency's Emergency Preparedness binder on 02-05-2024 failed to evidence of a full-scale, community-based exercise or the agency’s own Emergency Preparedness exercise. 3. On 02/09/2024 at 1:09 PM, Corporate Personnel 7 serving the role of the Administrator for the agency indicated they were aware this was a requirement but hadn’t had time to conduct the exercise.

This visit was for a Federal and State Complaint survey of a Home Health provider conducted by the Indiana Department of Health. Survey Dates: 01-31-2024, 02-01-2024, 02-02-2024, 02-05-2024, 02-07-2024, 02-08-2024, 02-09-2024, and 02-12-2024. Complaint: 104465: Non-compliant, with related and unrelated deficiencies cited. 12 Month Unduplicated Admissions: zero (0) Survey was fully expanded on 01/31/2024, to include all three (3) Indiana agencies: CCN: 157197, CCN: 157428, and CCN: 15742. QR completed by Area 3 on 2/19/2024. This survey has been modified due to further developments after the initial plan of correction was received on 3/2/24. An updated 2567 will be sent to the provider. QR completed by Area 3 on 3/18/2024.

Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA's governing body. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the frequency and detail of the data collection in the development of the QAPI program was approved by the agency's governing body in 1 of 1 agency. Findings include: 1. A review of a policy titled "QAPI COMMITTEE" revised in January 2018, indicated under “SPECIAL INSTRUCTIONS … 3. Frequency and detail of data collection developed by QAPI committee and approved by governing body … “ 2. A review of the agency’s QAPI on 2/12/24 revealed an undated document identified as "tracking items", which was divided into two columns, the Administrative column listed: Governing Body meetings, missed visits, in-person assessments, job descriptions all updated, office coverage, Indiana Department of Health update, and in-person supervisory visits; under the Quality Column: Comprehensive assessments, and safety precautions updated and In-person supervisory visits. 3. A review of Governing Body Minutes dated 01/29/2024 revealed, ” … QAPI is being reviewed weekly and there are no concerns ... “ No other documents were provided to evidence other meetings which might identify governing body approval of the frequency and detail of data collection. 4. On 02/09/2024 at 9:10 AM during an interview, Corporate Personnel 7 serving the role of the Administrator for the agency indicated the undated document identified as “tracking items” were Performance Improvement Projects that were identified from the past survey and were discussed at the board meeting, but was unsure if they were approved by the governing body. 410 IAC 17-12-2(a)

Improvements are sustained CFR(s): 484.65(c)(3) The HHA must take actions aimed at performance improvement, and, after implementing those actions, the HHA must measure its success and track performance to ensure that improvements are sustained. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to establish a system to measure and track performance to ensure improvements were sustained. Findings include: 1. A review of a policy titled "QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT" revised in January 2018, indicated, “ … 4. Data will be systematically collected to measure process and outcome. 5. Data will be assessed to: a. Identify current level of performance b. Evaluate the stability of the processes c. Identify areas to be improved D. Identify strategies to stabilize or improve processes e. Evaluate whether outcomes were achieved f. Compare results with self, other standards, and best practices, using statistical techniques … “ 2. A review of the agency’s Quality Assessment Performance Improvement (QAPI) failed to evidence a system to measure and track performance to ensure improvements were sustained and failed to evidence a performance improvement grid. 3. On 02/09/2024 at 9:10 AM Corporate Personnel 7 serving the role of the Administrator for the agency indicated they developed a Performance Improvement grid and will have discussions of analysis at quarterly QAPI meetings, but hadn't initiated this yet. 410 IAC 17-12-2(a)

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure Performance Improvements Projects (PIPS) were documented, why they were conducting these projects, and measurable progress with each project in 1 of 1 agency. Findings include: 1. An agency policy number B-260, titled "QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT," dated Jan 2005 with the last revision date of Jan 2018 revealed, “ … OBJECTIVES OF THE PROGRAM … to identify deviations from agency and professional standards and pursue improvement opportunities by assessment, planning and evaluation. To identify, address, track and resolve problems in client care services … To meet state and federal regulatory requirements. To support the organization’s process improvement through data collection and outcome measurement … To reduce factors that contribute to unanticipated outcomes … SPECIAL INSTRUCTIONS 1. … Additional actives for performance improvement will be prioritized by the agency’s governing body … 2. Data will be collected … 4. … to measure process and outcome. 5. Data will be assessed to: a. Identify current level of performance b. Evaluate the stability of the process c. Identify areas to be improved d. Identify strategies to stabilize or improve processes e. Evaluate whether outcomes were achieved … “ 2. A review of the agency’s QAPI on 2/12/24 revealed an undated document identified as "tracking items", which was divided into two columns, the Administrative column listed: Governing Body meetings, missed visits, in-person assessments, job descriptions all updated, office coverage, Indiana Department of Health update, and in-person supervisory visits; under the Quality Column: Comprehensive assessments, and safety precautions updated and In-person supervisory visits. No other documentation was provided as to why these items were identified and measurable progress with each. 3. On 02/09/2024 at 9:10 AM during an interview, Corporate Personnel 7 serving the role of the Administrator for the agency indicated the undated document identified as “tracking items” were Performance Improvement Projects (PIPs) that were identified from the past survey, that they have trending forms, and might have action plan forms to complete, had Governing Body meeting for approval of the PIPs and the administrator would monitor.

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to have a Governing Body assume full legal authority and responsibility for the agency's overall management and operation, including its quality assessment and performance improvement program. Findings include: 1. A review of a policy titled "Governing Body" last reviewed in January 2018, indicated the duties and responsibilities of the Governing Body were not limited to Appointing a qualified Administrator under state and federal regulations, and agency mission; ensuring an ongoing Quality Assessment and Performance Improvement (QAPI) program for quality improvement and patient safety is defined, implemented, and maintained; reviewing policy and procedures; adopt and periodically review and approve the administrative and personnel policies and procedures. 2. A review of the agency's policy titled "Quality Assessment Performance Improvement" revised in January 2018, stated "Special Instructions: 1. The governing body appoints a committee that must include clinical administrator, representative of all disciplines/ services provided ... 3. Frequency and detail of data collection developed by QAPI committee and approved by governing body ... 13. The QAPI Committee meeting minutes will be maintained in writing and signed by the Administrator ... " 3. A review of the Governing Body Minutes dated 1/29/2024 indicated the Alternate Administrator/ Alternate Clinical Manager (Corporate Trainer), LPN 3, and Administrator/ Clinical Manager (Corporate Clinical Administrator) were on the Governing Body, as well as Corporate Representatives 1, 2, 14, 15, 16, 17, and 18. The state agency failed to be notified of board member changes. 4. A review of the Governing Body meeting minutes dated 03/10/2023, 11/20/2023, 11/30/23, 12/04/23, and 12/11/23, failed to evidence that the Governing Body ensured the Quality Assessment and Performance Improvement (QAPI) addressed the program and the agency's complexity of its organization and services it provides, including services provided under contract or arrangement, indicators related to improved outcomes, emergency care services, hospital admissions and readmissions, and any action that addresses the home health agency's performance. A review of the meeting minutes dated 1/29/24 indicated the "QAPI is being reviewed weekly and there are no concerns." During an interview on 02/05/24 at 1:10 PM, when asked if the frequency and detail of data collection were approved by the agency's Governing Body, LPN 3 indicated she was unsure if the Governing Body approved it. When asked how the Governing Body was involved, the Clinical Supervisor indicated there were weekly Monday meetings where the "checklist" was reported and there was collaboration. No documentation of these weekly meetings was provided by the date of exit. During an interview with the Administrator/ Clinical Manager and LPN 3 on 2/8/24 at 11:40 AM, when asked to explain the QAPI program, how it operated from auditing Performance Improvement Plans (PIPs), who is responsible for the plan, and who is on the committee, they indicated the administrators or designee completes chart and human resource audits. If a trend was found in a particular office, it gets documented, creates a correction plan, and submits this to the Governing Body. When asked how often they have QAPI, they indicated there is a grid, and is done monthly, and then quarterly it would be discussed with all of the Administrators and Governing Body together. If a problem comes up in an agency, it would be brought up on a Monday meeting, regularly quarterly, then as needed. They indicated the committee consists of all Administrators, including the Ohio Administrators. No other documents were provided to evidence meetings were held monthly by the date of exit. During an interview on 2/12/24 at 9:38 AM, when asked to verify who was the QAPI and Governing Body Members, the Clinical Manager indicated LPN 3 was the only person who resided in Indiana, and the remaining "members" were from Ohio. A review of the "Quality Program Administrator" job description, updated on 10/16/2023, the qualifications included but were not limited to graduating from an accredited nursing program with a current license as a Registered Nurse in the state(s) of practice. This document was signed by the Alternate Administrator on 10/16/23. A review of LPN 3's personnel file failed to evidence any documentation she held a Registered Nurse license. The Organization Chart indicates LPN 3 holds other positions within the agency, such as Quality Director/ Quality Nurse; Intake Director, Intake Nurse and Intake Specialist; and Recruiting Director / Recruiter. 410 IAC: 17-12-1(b) 410 IAC 17-12-2(a)

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 observation, record review, and interview, the Administrator failed to ensure they were available, able to respond to emergencies within a reasonable amount of time, failed to ensure they had a schedule of when they would be at this location on a frequent and consistent basis, and responsible for the day-to-day operations of the home health agency. Findings include: Upon entering the agency on 1/31/23 at 9:15 AM, the door was locked and a note on the window indicated to knock. Upon entering, it was noted only LPN 3 was working in the office. During the entrance conference on 1/31/24 starting at 9:30 AM, LPN 3 indicated a message that the Administrator/ Clinical Manager and the Alternate Administrator/ Alternate Clinical Supervisor were located in Ohio. LPN 3 indicated she was unsure if she was an employee of this agency but was just a helper to them. During the entrance conference on 1/31/24 starting at 9:30 AM, LPN 3 indicated a message was left with the Alternate Administrator/ Alternate Clinical Supervisor (Corporate Trainer), and the Administrator/ Clinical Manager (Corporate Clinical Administrator) was on a visit and would be in around noon. LPN 3 indicated that both the Alternate Clinical Manager/ Alternate Administrator and Administrator/ Clinical Supervisor were in Ohio. The Administrator/ Clinical Manager arrived at the Indy location and met with the surveyors at approximately around12 noon. A review of the State Agency notes in the National Database revealed the Alternate Administrator/ Alternate Clinical Manager and the Administrator/ Clinical Manager assumed their role effective 10/12/23. On 01/31/24 at 12:45 PM, the Clinical Manager indicated she comes to the office when needed, sometimes monthly to every other month, and works remotely in Ohio. The Clinical Manager indicated that she would get in her car and drive to Indiana if there were an emergency. A review of the Geographical Map that was completed, indicated this office service area is the entire state. A review of the Administrator's personnel file revealed the Administrator resides approximately 2 hours away from this office. This provider's service area requires additional travel time as it goes as far northwest as Lake County (Indiana/ Illinois/ Michigan state line) which is an approximate 4-hour drive, as far northeast as Steuban County (Ohio/ Indiana/ Michigan state line) which is approximately 3.25-hours away, and as far as southwest as Posey County (Illinois/ Indiana/ Kentucky state line) which is approximately 4.25 hours away per Google Maps. Should there be an emergency at this location, the Administrator would not be able to arrive within a reasonable amount of time. On 2/1/24 at 4:00 PM, LPN 3 and the Administrator/ Clinical Manager indicated the Alternate Administrator/ Alternate Clinical Manager was only at the office when needed and had not been back since 11/15/23. On 2/02/24 at 4:00 PM, the Administrator indicated she had not been back to the office since she was here for the other surveys a few months ago and indicated she could return when called to do so. On 01/31/24 at 12:45 PM, the Clinical Manager indicated she comes to the office when needed, sometimes monthly to every other month, and works remotely in Ohio. The Clinical Manager indicated that she would get in her car and drive to Indiana if there were an emergency. 410 IAC 17-12-(b)(3) 410 IAC 17-12-1(c)(1)

Ensures qualified pre-designated person CFR(s): 484.105(b)(2) When the administrator is not available, a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator. The pre-designated person may be the clinical manager as described in paragraph (c) of this section. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the presumed Alternate Administrator had a schedule of when they would be at this location on a frequent and consistent basis and failed to ensure a qualified Alternate Administrator was appointed to assume the same responsibilities and obligations as the Administrator during their absence from this agency. Findings include: Upon entering the agency on 1/31/23 at 9:15 AM, the door was locked and a note on the window indicated to knock. Upon entering, it was noted only LPN 3 was working in the office. During the entrance conference on 1/31/24 starting at 9:30 AM, LPN 3 indicated a message was the Administrator/ Clinical Manager and the Alternate Administrator/ Alternate Clinical Supervisor were located in Ohio. LPN 3 indicated she was not sure if she was an employee of this agency but was just a helper to them. A review of the State Agency notes in the National Database revealed that the Alternate Administrator/ Alternate Clinical Manager assumed their role on October 12, 2023. A review of the personnel file evidenced a job description titled Alternate program Administrator dated 10/16/23. A review of the Governing Body minutes dated March 10, 2023, November 20, 2023, November 30, 2023, December 4, 2024, December 11, 2023, and January 8, 2024, failed to evidence that the Alternate Administrator/ Alternate Clinical Manager has been appointed by an agency appointed Governing body. On 01/31/24 at 12:45 PM, the Clinical Manager indicated she comes to the office when needed, sometimes monthly to every other month, and works remotely in Ohio. On 2/1/24 at 4:00 PM, LPN 3 and the Clinical Manager indicated the Alternate Administrator was only at the office when needed and had not been back since 11/15/23. On 2/02/24 at 4:00 PM, the Alternate Administrator indicated she had not been back to the office since she was here for the other surveys a few months ago and indicated she could return when called to do so. A review of the Alternate Clinical Manager's personnel file revealed the Administrator resides approximately 4 hours away from this office. This provider's service area requires additional travel time as it goes as far northwest as Lake County (Indiana/ Illinois/ Michigan state line) which is an approximate 4.5-hour drive, as far northeast as Steuban County (Ohio/ Indiana/ Michigan state line) which is approximately 2.5-hours away, as far as southeast as Switzerland County (Ohio/ Indiana/ Kentucky state line) which is approximately 4.25- hours away, and as far as southwest as Posey County (Illinois/ Indiana/ Kentucky state line) which is approximately 6-hours away per Google Maps. Should there be an emergency at this location, the Administrator would not be able to arrive within a reasonable amount of time. During an interview on 2/8/24 at 11:40 AM, when asked how one gets appointed to their positions, the Administrator/ Clinical Manager indicated they have discussions during the Governing Body meetings. When asked if there were Governing Body meeting minutes around October 2023 that would include the appointment of the Alternate Administrator/ Alternate Clinical Manager, the Alternate Administrator/ Alternate Clinical Manager indicated she is the secretary of the Governing Body, she knows it was discussed, and should have been there. No other documents were provided by the exit date of 2/12/24, that would indicate that an Alternate Administrator/ Alternate Clinical Manager was appointed. 410 IAC 17-12-1(d)(1)(2)(3)(4)

Clinical manager CFR(s): 484.105(c) Standard: Clinical manager. One or more qualified individuals must provide oversight of all patient care services and personnel. Oversight must include the following-- This STANDARD is not met as evidenced by: Based on record review and interview, the Clinical Manager and the Alternate Clinical Manager failed to ensure one was available upon surveyors' arrival, failed to ensure they were able to travel within a reasonable distance to the office/and or field, failed to ensure they had a schedule of when they would be at this location on a frequent and consistent basis responsible for the referrals, patient and personnel assignments, coordination of care, patient needs continually assessed, and the plan of care for this agency. Findings Include: Upon arrival at this home health agency on 1/31/24 at 9:30 AM, the door was found to be locked with a note to knock on the door. LPN (Licensed Practical Nurse) 3 was observed walking downstairs to allow surveyors in. No other person was observed in the office with LPN 3. LPN 3 indicated she had called the Administrator/ Alternate Clinical Manager (Corporate Trainer) and the Clinical Manager (Corporate Clinical Administrator), but both of whom reside in Ohio, were not available for the entrance conference. The entrance conference was held with LPN 3 (presumed Alternate Administrator). The Clinical Manager arrived at the Indy location and met with the surveyors at approximately around12 noon. A review of the State Agency notes in the National Database revealed the Alternate Clinical Manager and Clinical Manager assumed their roles effective 10/12/23. On 01/31/24 at 12:45 PM, the Clinical Manager indicated she comes to the office when needed, sometimes monthly to every other month, and works remotely in Ohio. The Clinical Manager indicated that she would get in her car and drive to Indiana if there were an emergency. When asked who manages faxes, physician orders, and referrals, the Clinical Manager indicated LPN 3 (presumed Alternate Administrator) manages them and uploads everything into the patient record. A review of the Geographical Map that was completed, indicated this office's service area was the entire state. A review of the Administrator's personnel file revealed the Administrator resides approximately 2 hours away from this office. This provider's service area requires additional travel time as it goes as far northwest as Lake County (Indiana/ Illinois/ Michigan state line) which is an approximate 4-hour drive, as far northeast as Steuban County (Ohio/ Indiana/ Michigan state line) which is approximately 3.25-hours away, and as far as southwest as Posey County (Illinois/ Indiana/ Kentucky state line) which is approximately 4.25 hours away per Google Maps. Should there be an emergency at this location, the Administrator would not be able to arrive within a reasonable amount of time. On 2/1/24 at 4:00 PM, LPN 3 and the Clinical Manager indicated the Alternate Clinical Manager was only at the office when needed and had not been back since 11/15/23. On 2/02/24 at 4:00 PM, the Alternate Clinical Manager indicated she had not been back to the office since she was here for the other surveys a few months ago and indicated she could return when called to do so. A review of the Alternate Clinical Manager's personnel file revealed the Administrator resides approximately 4 hours away from this office. This provider's service area requires additional travel time as it goes as far northwest as Lake County (Indiana/ Illinois/ Michigan state line) which is an approximate 4.5-hour drive, as far northeast as Steuban County (Ohio/ Indiana/ Michigan state line) which is approximately 2.5-hours away, as far as southeast as Switzerland County (Ohio/ Indiana/ Kentucky state line) which is approximately 4.25- hours away, and as far as southwest as Posey County (Illinois/ Indiana/ Kentucky state line) which is approximately 6-hours away per Google Maps. Should there be an emergency at this location, the Administrator would not be able to arrive within a reasonable amount of time. On 2/8/24 at 11:40 AM, the Clinical Manager, the Alternate Clinical Manager, and LPN 3 were interviewed. It was reported LPN 3 was responsible for making the patient and personnel assignments, coordinated care, and referrals. When asked who ensures a patient's needs are continually assessed, the Clinical Manager and the Alternate Clinical Manager reported LPN 3 and the RN Case Manager were responsible. The Clinical Manager and the Alternate Clinical Manager indicated the RN Case Manager creates the plan of care and LPN 3 sends it to the physician for signature. When asked how they oversee these tasks, both reported they communicate with the case managers, the "quality department", which is LPN 3, would review it and bring it to their attention, or she takes it directly to the case manager. Both indicated LPN 3 uploads the information to the patient record. A review of the job description for the Quality Administrator which LPN 3 holds indicated the employee must hold a Registered Nurse license. A review of the organizational chart revealed that Corporate Representative 6 also held the following positions: Quality Director and Quality Nurse; Intake Director, Intake Nurse, and Intake Specialist; and Recruiting Director and Recruiter for this agency. 410 IAC 17-12-1(d)

Primary HHA is responsible for patient care CFR(s): 484.105(e)(3) The primary HHA is responsible for patient care, and must conduct and provide, either directly or under arrangements, all services rendered to patients. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure 2 of 2 service contracts under arrangement were able to provide therapy services that cover the entire state of Indiana. Findings include: 2. A review of an agency document titled 'ANCILLARY SERVICES AGREEMENT' indicated a contract was created between the agency and Entity G, a therapy company, to provide physical and occupational therapy services to home health patients. Page 2 stated, "This agreement is entered into on the 11th day of January, 2024, by and between Home Care Network/Pediatric Nursing Specialists (herein referred as "Agency") whose principal place of business is located [the Corporate office in Ohio's address was given] (Corporate Office) ..." The contract was signed by Corporate Representative 2 on 01-12-2024. The contract failed to specify which of the three Indiana agencies the agreement had been made with and failed to evidence the services would be pediatric-specific. A review of an agency document titled '[Entity E, a Therapy company] Contract/Partnership Agreement' indicated a contract was created between the corporation, Home Care Network, Inc., and Entity E, to provide physical, occupational, and speech therapy services, as well as social work services "for Indiana and Ohio". The therapy company listed an Ohio address. The corporation, Home Care Network, Inc., also listed an Ohio address. The contract was signed by Corporate Representative 2 on 01-12-2024. The contract failed to specify which of the three Indiana agencies the agreement had been made with and failed to evidence the services would be pediatric-specific. 3. On 01-01-2024 at 9:30 AM during the entrance conference, Corporate Representative 16 indicated the agency had recently secured contracts with two therapy companies but was not yet providing therapy services to patients. On 01-31-2024 at 12:35 PM, Corporate Representative 16 indicated had conferred with Corporate Representative 2, and newly obtained therapy contracts were not individualized to each of the three Indiana agencies, but with Indiana as a whole. On 01-31-2024 at 12:51 PM, Corporate Representative 6 indicated that the two newly contracted Therapy companies, Entities E and G, were chosen to ensure coverage of the entire state. On 01-31-2024 at 2:51 PM, during a telephone call, Person F With Entity E, a Physical Therapy company, indicated was based in Ohio, stated “We don’t service Indiana” and further indicated they had no therapists who were dually licensed in both Ohio and Indiana to provide therapy services. On 01-31-2024 at 3:06 PM, during a telephone call, Person H with Entity G, a Physical Therapy company, indicated the company did not service the entire state of Indiana. Indicated further, for example, the company would be unable to staff anyone in Evansville, IN if a patient needed to be serviced the following day. On 01-31-2024 at 4:08 PM, during a telephone call, Corporate Representative 1 indicated when vetting out therapy agencies to contract with, they attempted to ensure such agencies could service pediatric patients. When queried as to who had vetted Entities E and G, Corporate Representative 1 indicated Corporate Representatives 2, 6, and 16 had done so. When informed Entity E indicated they did not service Indiana, and Entity G indicated they could not service the whole of Indiana, Corporate Representative 1 indicated having had this same kind of problem “wherever we go”, indicating further such companies were also short-staffed. 410 IAC 17-12-2(e) 1. During the entrance conference on 1/31/24 from 9:30 AM to 10:27 AM, when asked if other Registered Nurses (RN) were working in the field besides management, Corporate Representative 6 indicated there were none, other than Corporate Representative 10, a Case Manager, and the field staff was mostly Licensed Practical Nurses (LPN). When asked if she held an undergraduate degree, Corporate Representative 6 indicated she did not due to not finishing school. A review of the employee list indicated that 2 Registered Nurses were working in the office and 7 Registered Nurses and 2 LPNs were working in the field. On 1/31/24 at 12:31 PM, the employee list was reviewed with Corporate Representative 6 and she confirmed there were other Registered Nurses in the field and she misunderstood the question. Upon review of the employee list, Corporate Representative 6 is listed as a Registered Nurse and not that of an LPN. Personnel files were requested on 1/31/24 at 11:30 AM. Corporate Representative 6 failed to have a personnel file for this agency. A review of the personnel file for Corporate Representative 7 contained an I-9 tax form dated 2021 which indicated the employer business is in Centerville, Ohio. No other tax forms were noted in the file. A review of the personnel file for Corporate Representative 8 contained an I-9 tax form dated 2020 which indicated the employer's business is in Perrysburg, Ohio. No other tax forms were noted in the file. A review of the personnel file for Corporate Representative 10, an RN Case Manager, contained an I-9 tax form that indicated the employer as Home Care Network/ Pediatric Nursing located in Jackson Ohio. The authorized representative was signed by a Corporate Human Resource. The W-4 Employee's Withholding Certificate indicated the Employer's name and address as Home Care Network in Dayton Ohio. On 01/31/2024 at 2:00 PM, Corporate Representatives 6 and 7 were asked for the W-2s for this agency and were also asked if they were paid by this agency, at which Corporate Representative 7 indicated that all W-2s come from the corporation in Ohio and no W-2s come from the agency. On 2/9/24 at 12:38 PM, Corporate Representative 5 provided 2023 W-2s. A review of Corporate Representatives 10 and 11 W-2s indicated the employer's name and address was that of the Home Care Network, Inc. in Dayton Ohio. Corporate Representative 5 confirmed at 1:44 PM that the Employer ID number was directly tied to the Home Care Network and not directly connected to the agency in Indiana and all Indiana W-2s are affiliated with the Home Care Network in Dayton Ohio, and not the agency in Indiana.

This visit was for a Federal and State Complaint survey of a Home Health provider, conducted by the Indiana Department of Health. Survey Dates: 09-21-2023, 09-22-2023, 09-25-2023, 09-26-2023, and 09-27-2023. The Survey was expanded on 09-21-2023 to include all three (3) Indiana agencies: CCN: 157428, 157197, and 157276. The Survey was fully extended on 09-25-2023, inclusive of all three (3) Indiana agencies. Complaint: IN00101425 12 Month Unduplicated Skilled Admissions: 0 During this Federal Complaint Survey, Pediatric Nursing Specialists of Indiana was found to be out of compliance with 484.105 Organization and Administration of Services. Based on the Condition-level deficiencies during the 09-27-2023 survey, your HHA was subject to a partial or extended survey pursuant to section 1891(c)(2)(D) of the Social Security Act on 09-25-2023. Therefore and pursuant to section 1891(a)(3)(D)(iii) of the Act, your agency is precluded from operating a home health aide training, skills competency and/or competency evaluation program(s) for a period of two years beginning 09-27-2023 and continuing through 09-26-2025 QR by Area 3 on 10-06-2023.

HHA can no longer meet the patient's needs CFR(s): 484.50(d)(1) The transfer or discharge is necessary for the patient's welfare because the HHA and the physician or allowed practitioner, who is responsible for the home health plan of care agree that the HHA can no longer meet the patient's needs, based on the patient's acuity. The HHA must arrange a safe and appropriate transfer to other care entities when the needs of the patient exceed the HHA's capabilities; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to discharge patients when the agency could no longer provide physician ordered services in 1 of 4 active clinical records reviewed. (Patient #12) A review of an agency’s policy titled ‘CLIENT ADMISSION PROCESS C-140’ dated Aug 2016 revealed, “ … POLICY Services shall be provided to all persons … SPECIAL INSTRUCTIONS … d. The client’s needs can safely and adequately be met at home. This includes the ongoing availability of personnel … 15. If the agency cannot fulfill the required health care need, a referral will be made to other appropriate community resources and referral source will be notified …” The review of the clinical record of Patient #12 on 9/21/2023 revealed a home health certification and plan of care for the certification period of 09/10/23 to 11/08/2023 signed by RN (registered nurse) 2 with orders for but not limited to skilled nursing services 40 hours a week. The record review failed to evidence skill nursing visits from 08/10/2023 through 09/21/2023. On 09/21/2023 at 1:35 PM during an interview with Person 12 (family member) of Patient #12 indicating the last visit occurred on 08/09/2023, the agency indicated to Person 12 they were trying to recruit nurses. When queried if the agency had suggested a transfer to an agency that could staff, Person 12 indicated they had not. On 09/25/2023 at 2150 PM Person 13, an RN from Entity 14 indicated Person 15, the ordering physician for Patient #12 was not aware of the agency not performing the skilled nursing visits. On 09/25/2023 at 1:03 PM corporate clinical administrator and the administrator indicated there were not any communication notes about the lack of staff or transfer to another agency in Patient #12's clinical record.

Completion of the comprehensive assessment CFR(s): 484.55(b) Standard: Completion of the comprehensive assessment. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to ensure comprehensive assessments were conducted in person by a skilled registered nurse and included skilled hands-on physical assessment, and instead utilized telehealth for recertification assessments and resumption of care assessments in 1 of 4 clinical records reviewed (Patient #11). Findings include: A review of an agency’s policy titled ‘CLIENT REASSESSMENT/UPDATE OF COMPREHENSIVE ASSESSMENT C-155’ dated 08/2016 revealed, “The comprehensive assessment will be updated and revised as often as the clients’ condition warrants … PURPOSE To identify decline or improvement in health status, modify the plan of care and document changes …SPECIAL INSTRUCTION 1. Clients are reassessed to determine their response to care 2. Clients are reassessed when significant changes occur in their condition … 3. Each professional discipline will be responsible for reassessing care/services at least every 56-60 days … 5. Special attention will be paid to client-centered goals … 6. The assessment will identify the problems, needs, strengths of the client and the care the family can provide … The initial and ongoing assessments include: a. Specific individualized client needs … 7. Client needs … will be considered in the care planning … 8. Interim assessments on skilled patients will be completed using an assessment tool that includes OASIS data elements and other information … 11. Formal reassessments are to be performed by a Registered Nurse …”. The record review of Patient #11 on 09/25/2023 revealed Patient #11 had been hospitalized 02/07/2023 through 02/21/2023, with a Resumption of Care Assessment dated 02/22/2023 signed by corporate clinical administrator on 02/22/23 evidenced the assessment was completed via telehealth, with Person 9 (family member) reporting the following but not limited to, "temperature 97.7, weight reported 2/12/23 45.9 lbs (pounds), normal vision, no chest pain, that heart sounds regular, head and neck no problems identified, no reported respiratory issues, no reported changes with circulatory system, no reported problems with genitourinary system, and reported a soft abdomen". Respirations Breaths / minute [left blank] Regular or Irregular: [left blank] Blood pressure Right (systolic / diastolic) [left blank] Left (systolic / diastolic) [left blank] … Heart rate Pulse (beats / minute) : [left blank] Pulse Location: [left blank] Regular or Irregular Pulse: [left blank] Activity: [left blank]. Communicated with Physician marked No …" The record review of Patient #11 on 09/25/2023 revealed a ‘HCN Recertification/Interim – Pediatric Unskilled Assessment’ dated 09/11/2023, signed by RN 2 which evidenced, “ … Weight reported : 48 lbs (pounds) on 8/15, failed to weigh on discharge and Person 9 said scale at home not accurate … Pediatric Cardiovascular Comments/Problems unable to assess HR and sounds due to telehealth … Pediatric Gastrointestinal abdomen: Soft … Comments/Problems/Bowel Program abdomen soft per Person 9, unable to assess BS (bowel sounds) (telehealth) … Pediatric Mouth Oral mucosa pink moist … Throat Dysphagia Pediatric Musculoskeletal Poor coordination Weakness Delay development Contracture: Left elbow is fused Muscle tone Poor … Mental Status Other Orient to familiar people and places Other Mental Status Alert Neurologically impaired Cooperative Impaired judgement … Speech deficit: nonverbal, makes noises … Respiratory … other no current issues reported, non labored breathing Comments: no current issues reported, non labored breathing per Person 9 Respiratory/Lung Assessment Lung Sounds Clear: no audible wheezing per Person 9 … Skin assessment: Color: Pink per Person 9 Temperature/Moisture : Warm per Person 9 … Wound: None present Vital signs readings: … Respirations Breaths / minute [left blank] Regular or Irregular: [left blank] Blood pressure Right (systolic / diastolic) [left blank] Left (systolic / diastolic) [left blank] … Heart rate Pulse (beats / minute) : [left blank] Pulse Location: [left blank] Regular or Irregular Pulse: [left blank] Activity: [left blank] Temperature: [left blank] Comments: Unable to do vitals, telehealth …”. The agency failed to ensure comprehensive assessments were conducted in person by a skilled registered nurse and included skilled hands-on physical assessment. On 09/20/2023 at 4:46 PM, the corporate clinical administrator indicated RN’s (Registered Nurses) were to complete assessments and care plans, assessments should be a complete head to toe assessment, and they would rather assessments be completed in person than relying on other staff or family members to answer questions via telehealth.

Content of the comprehensive assessment CFR(s): 484.55(c) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the following information: This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the content of the comprehensive accurately reflected the patient's status in 1 of 4 clinical record reviews. (Patient #11) Findings include: 1. A review of an agency’s policy titled ‘COMPREHENSIVE CLIENT ASSESSMENT C-145’ DATED 06/2012 revealed, “POLICY A thorough, well-organized, comprehensive and accurate assessment … The depth and frequency of ongoing assessments will depend on client needs … will be done at least every sixty (60) day period … SPECIAL INSTRUCTIONS The Comprehensive Assessment will be completed by a Registered Nurse … 3. In addition to general health status/system assessment, the agency comprehensive assessment tool … will include: … d. Respiratory status … f. Elimination status … h. integumentary status i. Neuro/emotional/behavioral status, k. Medications … 4. Nutritional status … a. weight loss … 6. Assessment and documentation are made regarding whether the home is environment is suitable … 9. Assessment will be completed by registered nurses … 10. Client populations with specialized needs, i.e., pediatric services, will be assessed by professionals with appropriate skills … 11. Client needs are assessed and care guidelines established based on the assessment data … 13. Reassessments are conducted based on clients needs, physician orders, professional judgement … or other regulatory requirements … “ A review of an agency’s policy titled ‘CLIENT REASSESSMENT/UPDATE OF COMPREHENSIVE ASSESSMENT C-155’ dated 08/2016 revealed, “The comprehensive assessment will be updated and revised as often as the clients’ condition warrants … PURPOSE To identify decline or improvement in health status, modify the plan of care and document changes …SPECIAL INSTRUCTION 1. Clients are reassessed to determine their response to care 2. Clients are reassessed when significant changes occur in their condition … 3. Each professional discipline will be responsible for reassessing care/services at least every 56-60 days … 5. Special attention will be paid to client-centered goals … 6. The assessment will identify the problems, needs, strengths of the client and the care the family can provide … The initial and ongoing assessments include: a. Specific individualized client needs … 7. Client needs … will be considered in the care planning … 8. Interim assessments on skilled patients will be completed using an assessment tool that includes OASIS data elements and other information … 11. Formal reassessments are to be performed by a Registered Nurse …” The record review of Patient #11 on 09/25/2023 revealed Patient #11 had been hospitalized 02/07/2023 through 02/21/2023, with a resumption of care assessment dated 02/22/2023 signed by corporate clinical administrator on 02/22/23 evidenced the assessment was completed via telehealth, with Person 9 (a family member) reporting Patient #11’s temperature, that heart sounds regular, and lung sounds unable to obtain due to virtual visit, non-labored breathing noted and no reported issues per Person 9, circulatory no reported changes per [Person 9] , findings reported by [Person 9]. The agency failed to ensure the recertification assessment accurately reflected the patient's status. The record review of Patient #11 on 09/25/2023 revealed a ‘HCN Recertification/Interim – Pediatric Unskilled Assessment’ dated 09/11/2023, signed by RN 2 which evidenced, “ … Weight reported : 48 lbs [pounds] on 8/15, failed to weigh on discharge and Person 9 said scale at home not accurate … Pediatric Cardiovascular Comments/Problems unable to assess HR and sounds due to telehealth … Pediatric Gastrointestinal abdomen: Soft ... Comments/Problems/Bowel Program abdomen soft [Person 9], unable to assess BS [bowel sounds] (telehealth) … Pediatric Mouth Oral mucosa pink moist … Throat Dysphagia Pediatric Musculoskeletal Poor coordination Weakness Delay development Contracture: Left elbow is fused Muscle tone Poor … Mental Status Other Orient to familiar people and places Other Mental Status Alert Neurologically impaired Cooperative Impaired judgement … Speech deficit: nonverbal, makes noises … Respiratory …other no current issues reported, non labored breathing Comments: no current issues reported, non labored breathing per mom Respiratory/Lung Assessment Lung Sounds Clear: no audible wheezing per [Person 9] … Skin assessment: Color: Pink per [Person 9] Temperature/Moisture : Warm per [Person 9] … Wound: Non present Vital signs readings: … Respirations Breaths / minute [left blank] Regular or Irregular: [left blank] Blood pressure Right (systolic / diastolic) [left blank] Left (systolic / diastolic) [left blank] … Heart rate Pulse (beats / minute) : [left blank] Pulse Location: [left blank] Regular or Irregular Pulse: [left blank] Activity: [left blank] Temperature: [left blank] Comments: Unable to do vitals, telehealth …”. The agency failed to ensure the recertification assessment accurately reflected the patient's status. On 09/20/2023 at 4:46 PM, the corporate clinical administrator indicated RN’s (Registered Nurses) are to complete assessments and care plans, assessments should be a complete head to toe assessment. 410 IAC 17-15-1(a)

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure an accurate and complete assessment was completed to reflect the patient's current health status in 1 of 2 records reviewed. (Patients #11) Findings include: A review of an agency’s policy titled ‘COMPREHENSIVE CLIENT ASSESSMENT C-145’ DATED 06/2012 revealed, “POLCIY A thorough, well-organized, comprehensive and accurate assessment … SPECIAL INSTRUCTIONS The Comprehensive Assessment will be completed by a Registered Nurse … 3. In addition to general health status/system assessment, the agency comprehensive assessment tool … will include: … d. Respiratory status … f. Elimination status … h. integumentary status i. Neuro/emotional/behavioral status, k. Medications … 4. Nutritional status … a. weight loss … 6. Assessment and documentation are made regarding whether the home is environment is suitable …" The record review of Patient #11 on 09/25/2023 revealed Patient #4 had been hospitalized 02/07/2023 through 02/21/2023, with a resumption of care assessment dated 02/22/2023 signed by corporate clinical administrator on 02/22/23 evidenced the assessment was completed via telehealth, with mom reporting Patient #11’s temperature, heart sounds regular, and lung sounds unable to obtain due to virtual visit, non-labored breathing noted and no reported issues per mother, circulatory no reported changes per mother, findings reported by mother 04/14/2023 through 04/16/2023, and 8/15/2023 through 09/03/2023. The record failed to evidence a complete, accurate assessment by a registered nurse on Patient #11. The record review of Patient #11 on 09/25/2023 revealed a ‘HCN Recertification/Interim – Pediatric Unskilled Assessment’ dated 09/11/2023, signed by RN 2 which evidenced, “ … Weight reported : 48 lbs [pounds] on 8/15, failed to weigh on discharge and mom said scale at home not accurate … Pediatric Cardiovascular Comments/Problems unable to assess HR and sounds due to telehealth … Pediatric Gastrointestinal abdomen: Soft, Stools every other day, brown, soft-loose, diapers, Anus Patient, with normal bowel elimination, Comments/Problems/Bowel Program abdomen soft per mom, unable to assess BS [bowel sounds] (telehealth) … Pediatric Mouth Oral mucosa pink moist … Throat Dysphagia Pediatric Musculoskeletal Poor coordination Weakness Delay development Contracture: Left elbow is fused Muscle tone Poor … Mental Status Other Orient to familiar people and places Other Mental Status Alert Neurologically impaired Cooperative Impaired judgement … Speech deficit: nonverbal, makes noises … Respiratory …other no current issues reported, non labored breathing Comments: no current issues reported, non labored breathing per mom Respiratory/Lung Assessment Lung Sounds Clear: no audible wheezing per mom … Skin assessment: Color: Pink per mom Temperature/Moisture : Warm per mom … Wound: Non present Vital signs readings: … Respirations Breaths / minute [left blank] Regular or Irregular: [left blank] Blood pressure Right (systolic / diastolic) [left blank] Left (systolic / diastolic) [left blank] … Heart rate Pulse (beats / minute) : [left blank] Pulse Location: [left blank] Regular or Irregular Pulse: [left blank] Activity: [left blank] Temperature: [left blank] Comments: Unable to do vitals, telehealth …”. The record failed to evidence a complete, accurate assessment by a registered nurse on Patient #11. On 09/20/2023 at 4:46 PM, the corporate clinical administrator indicated RN’s (Registered Nurses) were to complete assessments and care plans, assessments should be a complete head to toe assessment. 410 IAC 17-14-1(a)(1)(B)

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 patient-specific interventions were identified in the care plans of 4 of 4 clinical records reviewed. (Patients #11, 12, 13, and 14) Findings include: A review of an agency’s policy titled, ‘PLAN OF CARE C-580IN’ dated 06/10/2021 revealed, “POLICY … The Plan of Care is based on a comprehensive assessment … SPECIAL ISNTRUCTIONS … 2. The Plan of Care Shall be completed in full to include: … i. Functional limitations and precautions … k. Specific dietary or nutritional requirements or restrictions l. Medications, treatments, and procedures … n. Any safety measures to protect against injury … u. … all necessary interventions to address the underlying risk factors … “. The clinical record review of Patient #11 on 09/25/2023 revealed a home health certification and plan of care for the certification period of 09/15/2023 to 11/13/2023 signed and dated 9/11/2023 by RN 2 which evidenced but not limited to a mini cardiopulmonary assessment (Obtain vital signs, interview the patient, general observation of the patient, assess for shortness of breath, auscultation of the heart), every 2 hours, seizure precautions with an intervention to assess and monitor seizures and notify MD. The care plan failed to identify patient specific seizure precaution interventions. The clinical record review of Patient #12 on 9/21/2023, revealed a home health certification and plan of care for the certification period of 09/10/23 to 11/08/2023 signed and dated 09/05/2023 by RN 2 with orders for but not limited to: skilled nursing services 40 hours a week and aspiration precautions. The record review failed to evidence patient specific aspiration precaution interventions. The clinical record review of Patient #13 on 9/21/2023, revealed a Home Health Certification and Plan of Care for the certification period of 9/11/2023 to 11/9/2023, signed and dated 09/07/2023 by RN 2 with orders for but not limited to: aspiration precautions. The record review failed to evidence patient specific aspiration precautions. The clinical record review of Patient #14 on 9/22/2023, revealed a Home Health Certification and Plan of Care for the certification period of 09/16/2023 to 11/4/2023, signed and dated 09/01/2023 by RN with orders for but not limited to: seizure precautions fall precautions and respiratory precautions, and to notify the physician if temperature (left blank). The record review failed to evidence patient specific interventions for seizure precautions and respiratory precautions. On 09/27/2023 at 1:42 PM the administrator indicated patient specific interventions need to be in place for specific precautions. 410 IAC 17-13-1(a)(1)(B) 410 IAC 17-1(a)(1)(C) 410 IAC 17-13-1(a)(1)(D)(i-xii)

Communication with all physicians CFR(s): 484.60(d)(1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure the ordering physicians for patients were notified of recertification and resumption of care assessments were being performed via telehealth with staff or a family member in 1 of 4 active clinical records review. (Patient #11) Findings include: A review of an agency’s policy titled ‘MEDICAL SUPERVISION C645’ dated 09/2012 revealed, “ … 4. Physician will be contacted when any of the following occurs: Any change in client condition or agency services … The results will be communicated with the physician for approval prior to making changes in the plan of care … 13. Agency responsibilities include: …. d. Periodic updates on client and condition/progress …. ". The record review of Patient #11 on 09/25/2023 revealed a home health certification and plan of care for the certification period of 01/18/2023 to 03/18/2023 signed and dated 01/17/2023 by Corporate Clinical Administrator which evidenced but not limited to diagnoses mandibulofacial Dysostosis (a disorder characterized by developmental delay and abnormalities of the head and face that may cause airway obstruction, speech impairment, hearing loss, and feeding difficulties), Pediatric feeding disorder, chronic, and gastrostomy complication. Patient #4 has a G-Tube (Gastrojejunostomy Tube) (a tube inserted through the belly that enables nutrition to pass directly to the middle section of the small intestine) and receives nutrition through the g-tube, Nourish peptide 880 milliliters once a day continuous feeding pump rate at 90 milliliters per hour, respiratory precautions with interventions: CPT vest (High-frequency chest wall oscillation involves an inflatable vest that is attached to a machine. The machine mechanically performs chest physical therapy by vibrating at a high frequency that promotes airway clearance and improves bronchial drainage utilizing High Frequency Chest Compression) to be applied 2 times a day for 30 minutes, may use a handheld mini percussor 2 times a day as needed. Medications to be administered but not limited to are: Albuterol Sulfate inhalation Nebulization Solution (2.5 milligram/3 milliliters) 0.083%/ 3 milliliters/Inhalation/PRN (as needed) every 4 hours as needed, may be given with mask, and to evaluate and document response and effectiveness of inhalation therapy, a mini cardiopulmonary assessment (Obtain vital signs, interview the patient, general observation of the patient, assess for shortness of breath, auscultation of the heart). Patient #11 is to receive 641 hours of respite skilled nursing services. Other skilled nursing services include but are not limited to: assess for and document seizure activity and notify MD (medical doctor), prn (as needed), evaluate and document response and effectiveness of inhalation therapy, document any seizures and length seizure occurred, make parents and MD aware, notify if temp [left blank] feeding tube care performed every shift and PRN with changes. The 60 day summary indicated the recertification was completed with mother via telehealth visit with patient present. The record review of Patient #11 on 09/25/2023 revealed Patient #11 had been hospitalized 02/07/2023 through 02/21/2023, with a Resumption of Care Assessment dated 02/22/2023 signed by corporate clinical administrator on 02/22/23 evidenced the assessment was completed via telehealth, with Person 9 (family member) reporting the following but not limited to, "temperature 97.7, weight reported on 2/12/23 45.9 lbs (pounds), normal vision, no chest pain, heart sounds regular, head and neck: no problems identified, no reported respiratory issues, no reported changes with circulatory system, no reported problems with genitourinary system, and reported a soft abdomen". Respirations Breaths / minute [left blank] Regular or Irregular: [left blank] Blood pressure Right (systolic / diastolic) [left blank] Left (systolic / diastolic) [left blank] … Heart rate Pulse (beats / minute) : [left blank] Pulse Location: [left blank] Regular or Irregular Pulse: [left blank] Activity: [left blank]. Communicated with Physician marked No. The record review failed to evidence a complete, accurate assessment by a registered nurse on Patient #11. The record review of Patient #11 on 09/25/2023 revealed a ‘HCN Recertification/Interim – Pediatric Unskilled Assessment’ dated 09/11/2023, signed by RN 2 which evidenced the assessment was completed via telehealth with Person 9 reporting the following but not limited to, "Weight reported : 48 lbs [pounds] on 8/15, failed to weigh on discharge and Person 9 said scale at home not accurate … Pediatric Gastrointestinal abdomen: Soft, with normal bowel elimination, Comments/Problems/Bowel Program abdomen soft per Person 9, Respiratory, no current issues reported, non labored breathing Comments: no current issues reported, non labored breathing per Person 9, Respiratory/Lung Assessment Lung Sounds Clear: no audible wheezing per Person 9, Skin assessment: Color: Pink per Person 9 Temperature/Moisture : Warm per Person 9, Wound: Non present. RN 2 indicated they were unable to assess the following: BS [bowel sounds] (telehealth) Pediatric Cardiovascular Comments/Problems unable to assess HR and sounds due to telehealth, Vital signs readings: Respirations Breaths / minute [left blank], Regular or Irregular: [left blank], Blood pressure Right (systolic / diastolic) [left blank], Left (systolic / diastolic) [left blank], Heart rate Pulse (beats / minute) : [left blank], Pulse Location: [left blank], Regular or Irregular Pulse: [left blank], Activity: [left blank], Temperature: [left blank], Comments: Unable to do vitals, telehealth. The record review failed to evidence a complete, accurate assessment by a registered nurse on Patient #11 On 09/20/2023 at 4:48 PM, corporate clinical administrator indicated they are communicating with the physicians with any changes and telehealth visits. On 09/22/2023 at 11:22 AM, Person 11, an RN (registered nurse) from Entity 10 indicated Person 12, the ordering physician was not aware recertification and resumption of care assessments were completed via telehealth and their expectations is the RN’s should be performing in-home visits for assessments. 410 IAC 17-14-1(a)(1)(G)

Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure skilled nursing supervisory visits identified the nurse being supervised in 1 of 4 active clinical record reviews. (Patient #11) Findings include: A review of an agency’s policy titled ‘SUPERVISION OF STAFF C-315 dated April 2022 revealed “POLICY All Staff providing home care services will be supervised as outlined by federal and state regulations and accepted standards of practice … 6. An RN (registered nurse) must observe a skill being performed and document the staff member’s competency in performance of a skill/task during supervisory visits when the staff member is present … Home Health Aide Staff … ". The record review of Patient #11 on 09/25/2023 revealed a PDN Supervisory Visit electronically signed by Corporate Clinical Administrator on 01/17/2023 for Caregiver: Corporate Clinical Administrator which evidenced but not limited to, “Is the SN Present?: No: … Demonstration of Tasks?: Yes :reported by mother … Are Task/procedures performed per protocols of HCN?: Yes … Was the Care Plan Reviewed with Client and Employee?: Yes: reviewed and updated … The SN is following Universal Precautions?: Yes:…” The supervisory visit failed to identify who was being supervised, was completed via telehealth, and with no staff/caregiver was available, the Corporate Clinical administrator would not be able to assess tasks, tasks/procedures are performed per protocol, and review the care plan with the employee. The record review on 09/25/2023 of Patient #11 revealed a PDN Supervisory Visit dated 09/11/2023 Caregiver Name: RN 2, signed by RN on 09/11/23 evidenced, “ … PDN Supervision Is the SN Present?: No: Demonstration of Tasks?: No: Are Task/procedures performed per protocols of HCN?: Yes Is safety demonstrated with use of procedures and/or equipment?: Yes … The SN is following Universal Precautions?: Yes:… “. The supervisory visit failed to identify who was being supervised, was completed via telehealth, and with no staff/caregiver was available, RN 2 would not be able to assess tasks/procedures performed per protocols of HCN, safety use of procedures and/or equipment, and universal precautions of staff. 3. On 09/27/2023 a 1:20 PM, the administrator indicated they weren’t sure why the supervisor is listed as the caregiver, there must be a glitch in the electronic medical record system, and they would have to check into that. 410 IAC 17-14-1(a)(1)(J)-RN

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: Based on observation, record review, and interview the governing body failed to ensure failed to ensure patients were receiving appropriate home health services (registered nurse not performing in-person comprehensive assessments) (G0942), the acting Administrator failed to be responsible for day to day operations of the agency (G0948), and failed to ensure the Administrator or designee was available during all operating hours (G0956). The cumulative effect of these systemic problems resulted in the agency's inability to ensure patients received appropriate services which could result in the agency not providing quality health care for all patients. .

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on record review and interview the Governing Body failed to assume full responsibility for the agency's overall management and operations related to the provision of skilled nursing services by the registered nurse, in relation to performing comprehensive assessments and supervisory visits via telehealth for 1 of 1 Governing Body's. Findings Include: On 09-20-2023 at 4:43 PM, the Corporate Clinical Administrator and Corporate Person 2 indicated that comprehensive assessments and recertification visits should be done an RN (Registered Nurse) in-person. 410 IAC 17-12-1(b) Review of an agency document dated titled, ‘GOVERNING BODY-100’ stated, “POLICY The Governing Body shall assume full legal authority and responsibility for operation of Agency … Purpose to ensure lines of authority are established. To ensure clients are provided with appropriate, quality services … SPECIAL INSTRUCTIONS The duties and responsibilities of the Governing Body shall include: 1. Appoint a qualified Administrator. Delegate to that individual the authority and responsibility for the provision of home care services in accordance with state and federal regulations … 4. Adopt and periodically review and approve the administrative and personnel policies, client care policies and procedures … 6. Define the corporate structure and clearly indicate lines of authority …” Review of an agency document reviewed November 2011, titled, ‘POLICY DEVELOPMENT B-210’ stated, “POLICY Policies and procedures will … address significant operational areas of the agency. The policies will conform to the state and federal regulations … for home health … Selected policies and procedures will be reviewed and revised at least annually by the professional advisory committee. Other policies and procedures will be reviewed as defined by the organization and as needed based on review clinical managers and quality improvement committee. The governing body makes the final approval … SPECIAL INSTRUCTIONS ... 2. … New or revised policies will be approved. Review of an agency document dated March 10, 2023 titled, ‘Minutes of the Annual Meeting of the Board of Directors/Governing Body and Administrator’ stated, “Whereas the Chairperson stated the next item on the agenda was the reviewed and approval of nine items to be monitored and reported to the Board quarterly … 9. Policies and Protocols that are revised … " On 09-20-2023 at 10:50 AM, a requested agency document dated May 2023 titled, ‘Telehealth Services CI-941’ was received from the Corporate Clinical Administrator. This policy had not been approved by the Governing Body. 410 IAC 17-12-1(b)

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 the Administrator or their alternate was responsible for the day to day operation of the agency; failed to ensure staff were available during operating hours and for survey activities, failed to ensure comprehensive assessment visits were performed by a registered nurse, and failed to ensure identification of the nursing staff being supervised in 1 of 1 agency home health agency surveyed. Findings include: Review of an agency document dated April 04, 2014 titled, 'JOB DESCRIPTION: Clinical Administrator' stated, "POSITION SUMMARY Provides direction, coordination, supervision, and implementation of professional and supportive services to clients in safe, cost effective manner … ESSENTIAL FUNCTIONS/AREAS OF ACCOUNTABILITY … Planning … 1. Plans, directs, and participates in delivery of professional services to home care clients … Coordination of Services … 1. Coordinates and directs programs and staffing to promote quality services for clients … 6. Establishes and implements priorities for services within the limitations of available resources … Policies and Procedures … 1. Assures compliance with requirements of state licensure, Medicare certification, and compliance with regulatory agencies through policy and procedure development, staff education, and ongoing monitoring activities …" Review of an agency document dated April 2022, titled, 'SUPERVISION OF STAFF C-315' stated, "POLICY All staff providing home care services will be supervised as outlined by federal and state regulations and accepted standards of practice PURPOSE To ensure staff is demonstrating competence in the area of communication, identifying and responding to clients needs, and performing procedures/techniques properly …" 2. On 9-19-2023 at 2:36 PM, in an in-person interview, the Corporate Clinical Manager, based out of Ohio, indicated she was actively serving as the RN (Registered Nurse) Case Manager for Indiana and further indicated had been performing Recertification visits for patients via telehealth while a skilled nurse or parent was in the home. Indicated these were ‘video’ calls. When queried as who had given the directive for this practice, indicated the Corporate Operating Officer had. Further indicated this practice had been occurring since the agency lost two case managers at the end of 2022, but that she had been conducting telehealth visits on more regular basis since April of 2023. On 09-20-2023 AM at 10:00 AM the Corporate Clinical Administrator stated, “I do telehealth supervisory visits” and indicated they had been done in person in the past. On 09-20-2023 at 4:43 PM, the Corporate Clinical Administrator and Corporate Person 2 indicated the comprehensive assessments and recertification visits should be completed by an RN, in-person. The Corporate Clinical Administrator indicated it was her preference to perform in person visits but is currently performing visits ‘virtually’. 410 IAC 17-12-1(b)(3) 410 IAC 17-12-1(c)(1) .

Available during all operating hours CFR(s): 484.105(b)(3) The administrator or a pre-designated person is available during all operating hours. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview the agency failed to ensure an Administrator or alternate was in place, available during operating hours, and available for survey activities, in 1 of 1 home health agencies surveyed. Findings include: On 09-19-2023 at 8:55 AM, upon arrival the agency, the office was empty and there was no reply to knocking at the door. A note on the door stated, “PLEASE KNOCK FOR ASSISTANCE If we missed you we are out in the community caring for our patients. For immediate assistance, please call …” and indicated Administrative Staff Person A or the Corporate Clinical Administrator could be reached by phone. On 09-19-2023 at 8:59 AM, a telephone call was made to the Corporate Clinical Administrator, a message was left informing State surveyors were currently at the agency and requested a call back. On 09-19-2023 at 9:27 AM, received a call from the Chief Operating Officer who indicated the Corporate Clinical Administrator was on her way and would arrive in approximately two (2) hours, as she was currently in the Dayton, Ohio area. On 09-19-2023 at 9:38 AM, the Chief Operating Officer was contacted and queried as to who the Clinical Manager was and whether there were any staff local who could help surveyors gain entry to the agency, indicated has made sure everyone was being contacted. Indicated there was no Clinical Manager and Administrative Staff Person A was currently ‘covering’ as such, but was on PTO (Paid Time off) out of state, but that RN 1 was the Administrator. Indicated would gather additional information, would find availability of staff, in relation their schedules, and would call this surveyor back with more information. On 09-19-2023 at 10:49 AM, during a phone call, the Corporate Clinical Administrator indicated she would be arriving at 1:00 PM and a locksmith had been called to gain entry into the office. When queried as to the need for a locksmith, indicated could not locate her own key and this needed to be done anyway, as building management also did not have a key. On 09-19-2023 at 2:00 PM, locksmith arrived, the Corporate Clinical Administrator and surveyors gained entry to the agency. Review of an agency document, received 09-21-2023 at 8:30 AM, dated Jan2023 titled, ‘Organizational Chart’ indicated Corporate Clinical Administrator was the Administrator and Corporate Staff 2 was the Alternate Administrator. On 09-21-2023 at 9:26 AM, when queried as to who was Administrator for the agency, the Corporate Clinical Administrator indicated they were and Corporate Administrative Staff 2 was the Alternate Administrator, with the Corporate Clinical Administrator acting as the Clinical Supervisor, and Corporate Administrative Staff 2 acting as their Alternate Clinical Supervisor.

An Emergency Preparedness Survey was conducted by the Indiana State Department of Health in accordance with 42 CFR 484.102. Survey Dates: 1/3/2022-1/7/2022, 1/10/2022, 1/11/2022 Facility Number: IN005942 Census = 10 active At this Emergency Preparedness survey, Pediatric Nursing Specialists of Indiana was found not to be in compliance with Emergency Preparedness Requirements for Medicare Participating Providers and Suppliers, 42 CFR 484.102. QR Completed 1/27/2022 A4

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to adequately prepare and describe a plan for a surge in Covid-19 among administrative personnel that assume responsibility for two separate licensed agencies during a pandemic for Pediatric Nursing Specialists of Indiana and failed to ensure all employees participated in a tabletop exercise to test the agency’s emergency plan specifically for Pediatric Nursing Specialists of Indiana located in Evansville for 1 of 1 home health agency emergency preparedness review. Findings include: 1. A 1/22/2020 policy titled Emergency Preparedness Policy was provided by the Administrator on 1/3/2022 at 3:30 p.m. The policy indicated, but was not limited to, “Agency will have an identified plan in place to ensure the safety and well-being of clients and employees during periods of an emergency or disaster that might disrupt home health services. 2. All staff members will be oriented to the emergency preparedness plan and their associated responsibilities … 3. The agency conducts an analysis to identify (and establish priorities among) potential emergencies and the effects these emergencies may have on agency operations and demand for services. 4. The Emergency Disaster Plan identifies who is responsible for certain activities and when they are to assume responsibilities. … 20. If the EDP is implemented, it will be evaluated for effectiveness and documentation will be on file.” 2. Received 9 emails with 71 attachments from Person J on 1/11/2022 between 10:52 a.m. to 11:16 a.m. regarding Covid 19. Person J indicated in an email on 1/11/2022 at 11:16 a.m. the Administrator informed Person J the agency had no positive COVID cases until recently for the entire time he/she had been with the agency. The 11:16 a.m. email included an attachment titled Covid-19 Client Employee Call log. Review of the call log indicated 1 positive patient and 2 RN employee exposure to Covid. The agency failed to list the Administrator (also Clinical Supervisor) and Alternate Administrator on the call log for the agency. 3. An updated 3/9/20 Covid 19 Check List for Home Health Care was provided by Person J in an email on 1/22/2022 at 10:55 a.m. The check list indicated but was not limited to “Develop plans for possible surge capacity to account for managing staffing shortages due to illness in personnel … call [Person J]” An undated Covid 19 Check List for Infection Control and Screening was provided by Person J in an email on 1/22/2022 at 10:55 a.m. The check list indicated but was not limited to “Administrative Guidance: Any employee (office or field staff) who experience signs and symptoms of COVID-19 will be instructed by their health care provider/administrator to either be quarantined or return to work after not having a fever (without the use of medication) for at least 72 hours (three full days) AND symptoms have improved for at least 72 hours AND at least seven days have passed since symptoms first began. Communication must be maintained between employee, administrator, & physician. A health care providers’ note will not be required to validate the illness or return to work of employees’ sick with acute respiratory illness.” An undated policy titled Employee Safety D 470, was provided by Person J in an email on 1/22/2022 at 10:56 a.m. The policy indicated but was not limited to “In the event of a crisis or disaster, the COO and or Department Managers will determine what administrative employees may telecommute and provide appropriate equipment for home use. A 3/12/2020 untitled word document was provided by Person J on 1/22/2022 in an email at 10:59 a.m. The document indicated but was not limited to “Home Care Network - Go to Meeting 3/12/20 @ 10am Coronavirus [Person J] [5 non-employees] [Person O] [non-employees] Disaster plan effective as of this phone call: … “12. Need to come up with process on call-offs”. A 3/31/2020 document titled Employee Rights was provided by Person J on 1/22/2022 in an email at 10:59 a.m. The document indicated but was not limited to “An employee is entitled to take leave related to COVID-19 if the employee is unable to work, including unable to telework, because the employee: is subject to a Federal, State, or local quarantine or isolation order related to COVID-19; 2. has been advised by a health care provider to self-quarantine related to COVID-19; 3. is experiencing COVID-19 symptoms and is seeking a medical diagnosis; 4. is caring for an individual subject to an order described in (1) or self-quarantine as described in (2); 5. Is caring for his or her child …” 4. During a phone interview on 1/3/2022 at 9:27 a.m. the Administrator indicated he/she was in isolation (no symptoms) until Thursday due to a family member testing positive for Covid and that was why the office was closed. At 10:20 a.m. the Administrator called and stated he/she would come out of isolation to open the agency and begin the survey. The Administrator indicated his/her Alternate would be available by phone. During an interview on 1/4/2022 at 10:30 a.m. Person J indicated the Alternate Administrator would not be available due to a declining family member and the Alternate Clinical Supervisor would not be available due to covering for the Administrator at Entity 1 Indianapolis. During a phone interview on Sunday 1/9/2022 at 3:24 p.m. received a phone call from the Administrator indicating he/she and the Alternate Administrator both tested positive for Covid with symptoms and are in isolation and Person J was on the way from Ohio. The Administrator indicated Person O from Ohio instructed him/her to call the surveyor for guidance. Asked if the Alternate Clinical Supervisor would be available and if the Governing Body was notified to which he/she would check and call back. At 4:46 p.m. the Administrator indicated Person J called the Alternate Clinical Supervisor but had not heard back. During an interview on 1/10/2022 at 8:06 a.m. at the agency, Person J indicated the Alternate Administrator would not assist in the survey due to Covid and the Alternate Clinical Supervisor was the back-up for the Administrator at Entity 1 in Indianapolis and would not be available for the survey. The Administrator for Entity 1 Indianapolis and the Alternate Administrator for the Evansville location are the same person. The agency failed to ensure the authorized Alternate Administrator was available to assume the role as Administrator / Clinical Supervisor for the Evansville location during the survey and in an emergency pandemic. 5. The agency failed to have a plan in place for the back-up Alternate Administrator and Clinical Supervisor for 1/4/2022 to 1/7/2022. On 1/9/2022 the Administrator indicated he/she tested positive for Covid (with symptoms), the back-up Alternate tested positive (with symptoms) and the Alternate Clinical Supervisor would remain at Entity 1 to cover for the Administrator who was the Alternate Administrator for the Evansville agency. The agency failed to have a back-up for the Administrator, Clinical Supervisor, and Alternate Clinical Supervisor for the week of 1/10/22. Review of 71 attachments provided by Person J the agency failed to have a specific plan in place for the Evansville location. The agency failed to describe and demonstrate a plan regarding a Covid 19 surge among the administrative personnel that assume responsibility for two separate licensed agencies. 6. During an interview on 1/10/2022 at 9:45 a.m. Person J was asked what the plan was if the Administrator and the Alternate Administrator would end up hospitalized. Person J indicated he/she was a Registered nurse from Ohio and would be back at the agency then once the Alternate Administrator (Entity 1 Administrator) gets better, the Alternate Clinical Supervisor (Entity 1 employee) would come down. Person J indicated the Administrator (also Clinical Supervisor) would do telework this week for patient recertifications, wellness checks, and PPE (personal protective equipment) calls. 7. The Emergency Preparedness program binder set forth in writing in its entirety was provided by the Administrator on 1/4/2022 at 4:30 p.m. Review of the Emergency Preparedness binder on 1/11/2022 failed to evidence a sign-roster / attendance record for field staff, contracted staff, and administrative staff for the 2019 tornado tabletop exercise specific for the Evansville location. During an interview on 1/11/22 at 1:30 p.m. Person J was asked to provide the sign-in roster / attendance record for the March 2019 Tornado Watch tabletop exercise found in agency emergency preparedness binder. At 2:00 p.m. Person J was unable to provide documentation that a tabletop exercise was conducted for the Evansville agency’s field staff, contracted staff, and administrative staff that would demonstrate how the tabletop exercise addressed any risk(s) in the agency's risk assessment, communicated potential needs to local agencies, and provided medical information to support the patients' continuity of care, as well as identified lessons learned following the tabletop exercise. 8. Review of the QAPI (quality assurance performance improvement) provided by Person J on 1/11/2022 at 2:30 p.m. indicated a “Mock Survey BU71 7/27-7/30/21” took place and found “not appropriately documenting COVID updates … EDP binder is incomplete … unclear as to what the on call process is” Person J indicated he/she conducted the mock survey.

This visit was for a Federal re-certification and State re-licensure survey in conjunction with a focused Covid-19 survey of a home health agency. Partially Extended survey was announced on 1/3/2022 at 4:00 p.m. Fully Extended survey was announced on 1/10/2022 at 10:00 a.m. Survey Dates: 1/3/2022-1/7/2022, 1/10/2022, 1/11/2022 Unduplicated Census Last 12 Months: 18 Active Census: 10 These deficiencies reflect State Findings cited in accordance with 410 IAC 17. Refer to State Form for additional State findings. Based on the Condition-level deficiencies during the January 11, 2022, survey, Pediatric Nursing Specialists was subject to a fully extended survey pursuant to section 1891(c)(2)(D) of the Social Security Act, on November 19, 2021. Therefore, and pursuant to section 1891(a)(3)(D)(iii) of the Act, your agency continues to be precluded from operating or being the site of a home health aide training, skills competency and/or competency evaluation program for a period of two years beginning January 11, 2022 and continuing through January 10, 2024.

HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator's name, business address, and business phone number in order to receive complaints. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure patient/caregivers had current written contact information for the agency administrator to receive complaints for 2 of 5 caregiver interviews. (Patient 1, 5) Findings include: 1. A January 2018 policy titled Admission Policy was provided by Person J on 1/10/2022 at 9:15 a.m. The policy indicted, but was not limited to, “5. … f. Contact information for HHA administrator, including the administrator’s business address, and business phone number in order to receive complaints.” 2. During a home visit on 1/5/2022 at 10:20 a.m. patient 5’s parent did not know the agency’s administrator’s name when asked but had the agency’s phone number programed into his/her phone. Patient 5’s parent indicated he/she did not work for the agency and did not have current contact information in the home. 3. During an interview on 1/11/2022 at 8:57 a.m. patient 1’s parent did not know who the Administrator was for the agency when asked. Patient 1’s parent indicated he/she spoke with and met “[name]” but did not know he/she was the Administrator. Parent 1 indicated he/she did not work for the agency.

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 contact patient caregivers to offer or provide agency therapy services such as physical or occupational therapy and speech-language therapy on a visiting basis in the patient’s home since 2019 for 4 of 4 caregiver interviews. (Patient 1, 3, 8, 9) Findings include: 1. A signed September 20, 2021, Clinical Administrator job description was provided by the Administrator on 1/4/2022 at 4:00 p.m. The job description indicated, but was not limited to, “… Assures compliance with the requirements of state licensure, Medicare certification, and compliance with regulatory agencies through policy and procedures, staff education, and ongoing monitoring activities …” 2. During entrance conference on 1/3/2022 at 11:10 a.m. the Administrator was asked what services the agency provides. The Administrator indicated the agency offers skilled nursing and home health aide services. Queried if the agency offers therapy services. The Administrator indicated the agency does not offer physical, occupational, or speech therapies. The agency does not offer attendant care services or social work. Queried if the agency has any services provided under contract to which he/she replied, “not that I’m aware of but I will find out”. 3. On 1/3/2022 at 3:10 p.m. the Administrator provided a contract titled [Entity 3] Agreement for Therapy Services. The agreement indicated, but was not limited to, “This Agreement, herein after referred to as “Agreement”, is made on 2/21/2019, by and between [Entity 3], Texas LLC hereinafter referred to as “Contractor” and Home Care Network, Inc d/b/a Pediatric Nursing Specialist of Indiana a Ohio Corporation, herein after referred to as “Agency”. 4. During a home visit on 1/3/2022 at 12:58 p.m. patient 3’s caregiver indicated patient 3 receives PT, OT, and ST therapy services from an outside agency and skilled nursing services from Pediatric Nursing Specialists. The caregiver did not indicate why patient 3 does not receive therapy services from the home health agency. The agency failed to offer or provide agency therapy services. During an interview on 1/10/2022 at 3:26 p.m. the Administrator indicated the agency had not used the contracted therapy services since he/she started [Oct 4, 2021]. 5. During a phone interview on 1/11/2022 at 8:40 a.m. patient 9’s caregiver indicated the patient receives outside therapy from school and [name of agency] and skilled nursing services from Pediatric Nursing Specialists. Patient 9’s caregiver was asked if he/she was aware the home health agency provided therapy services. Patient 9’s caregiver indicated no one from the agency talked to him/her about therapy services or offered the agency’s therapy services. Patient 9’s caregiver had been with the home health agency for 10 years. The agency failed to contact the caregiver and offer or provide agency therapy services. 6. During a phone interview on 1/11/2022 at 8:57 a.m. patient 1’s caregiver indicated the patient receives outside therapy from [name of agency] and skilled nursing services from Pediatric Nursing Specialists. Patient 1’s caregiver was asked if he/she was aware the home health agency provided therapy services. Patient 1’s caregiver indicated no one from the agency talked to him/her about therapy services or offered the agency’s therapy services. Patient 1’s caregiver indicated he/she never knew the agency provided therapy and would be interested in the agency’s therapy services. The agency failed to contact the caregiver and offer or provide agency therapy services. 7. During a phone interview on 1/11/2022 at 3:30 p.m. patient 8’s caregiver indicated the patient receives outside therapy services from school and [name of agency] and skilled nursing services from Pediatric Nursing Specialists. Patient 8’s caregiver was asked if he/she was aware the home health agency provided therapy services. Patient 8’s caregiver indicated no one talked to him/her about therapy services or offered the agency’s therapy services. Patient 8’s caregiver indicated he/she would be interested in the agency’s therapy services. Patient 8 has been with the agency for 7 years. The agency failed to contact the caregiver and offer or provide agency therapy services. 8. During an interview on 1/11/2022 at 4:25 p.m. the Administrator and Person J were made aware of caregiver interviews during which the caregivers indicated that they did not know the agency provided therapy service and were not offered therapy services from the agency. Person J stated, “I showed you that we would be losing money if we bill Medicaid for those services and we would need prior authorization”. 17-12-3(b)(2)(D)(ii)(AA) 17-12-3(b)(2)(D)(ii)(BB)

Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure patients received all services outlined in the plan of care for 5 of 7 record reviews, with the potential to affect all patients. (Patients 2, 3, 5, 6, 7) Findings include: 1. A 6/10/2021 policy titled Plan of Care was provided by Person J on 1/10/2022 at 9:15. The policy indicated, but was not limited to, “To provide guidelines for agency staff to develop a plan of care for all clients admitted to the agency. To assure that the plan of meets state/federal guidelines, and all applicable laws and regulations. 2. … c. Type, frequency, and duration of all visits/services d. Specific procedures and modalities for therapy services … d. Specific procedures and modalities for therapy services. … h. Rehabilitation potential-to be addressed at each recertification … l. Medications, treatments, and procedures … p. Treatment goals … t. other appropriate items … v. All of the above items must always be addressed on the Plan of Care. 6. Orders for therapy services shall include the specific procedures and modalities to be used and the amount, frequency, and duration. 9. The client, Therapist, and other personnel shall participate in developing the Plan of Care. The client shall be informed of any changes in the Plan of Care. A signed September 20, 2021, Clinical Administrator job description was provided by the Administrator on 1/4/2022 at 4:00 p.m. The job description indicated, but was not limited to, “… Assures compliance with the requirements of state licensure, Medicare certification, and compliance with regulatory agencies through policy and procedures, staff education, and ongoing monitoring activities …” 2. During entrance conference on 1/3/2022 at 11:10 a.m. the Administrator was asked what services the agency provides. The Administrator indicated the agency offers skilled nursing and home health aide services. Queried if the agency offers therapy services. The Administrator indicated the agency does not offer physical, occupational, or speech therapies. The agency does not offer attendant care services or social work. Queried if the agency has any services provided under contract to which he/she replied, “not that I’m aware of”. 3. The complete clinical record for patient 2 was reviewed on 1/6/2022 and included a plan of care for the certification period 10/25/2021 to 12/23/2021, SOC date 9/6/2019, with orders for “[skilled nurse] hourly 39.00 Hours Weekly for 1 Certification Period (s) starting 10/25/2021 – Traditional 8-10 [hours]/day, 4-5 days/week. Not to exceed 39 [hours] in a calendar week …” Review of the Missed Visit note dated 12/18/2021 indicated “Cancelled by Agency-No Available Staff. Describe How the Patient’s Need Was Met: 30.5 out of 39 hrs [hours] not staffed over the course of 7 days. This is due to the caregiver being unable to cover all PA hours. The agency is actively seeking staff in the client area. Parent to provide care to the patient. These hours are out of MD ordered staffing frequency … Follow-Up Actions: Notified Caregiver [Administrator] Notified Physician [MD name] Notification Date: 12/18/2021 … Additional Follow-Up Comments: [Blank] … [Person N] signature, Date 12/18/2021” Review of the Missed Visit note dated 12/11/2021 indicated “Cancelled by Agency-No Available Staff. Describe How the Patient’s Need Was Met: 30 out of 39 hrs not staffed over the course of 7 days. This is due to the caregiver being unable to cover all PA hours. The agency is actively seeking staff in the client area. Parent to provide care to the patient. These hours are out of MD ordered staffing frequency … Follow-Up Actions: Notified Caregiver [Administrator] Notified Physician [MD name] Notification Date: 12/11/2021 … Additional Follow-Up Comments: [Blank] … [Person L] signature, Date 12/11/2021”. Review of the Missed Visit note dated 12/4/2021 indicated “Cancelled by Agency-No Available Staff. Describe How the Patient’s Need Was Met: 31 out of 39 hrs not staffed over the course of 7 days. This is due to the caregiver being unable to cover all PA hours. The agency is actively seeking staff in the client area. Parent to provide care to the patient. These hours are out of MD ordered staffing frequency … Follow-Up Actions: Notified Caregiver [Blank] Notified Physician [MD name] Notification Date: 12/4/2021 … Additional Follow-Up Comments: [Blank] … [Person L] signature, Date 12/8/2021”. Review of the Missed Visit note dated 11/27/2021 indicated “Cancelled by Agency-No Available Staff. Describe How the Patient’s Need Was Met: 31 out of 39 hrs not staffed over the course of 7 days. This is due to the caregiver being unable to cover all PA hours. The agency is actively seeking staff in the client area. Parent to provide care to the patient. These hours are out of MD ordered staffing frequency … Follow-Up Actions: Notified Caregiver [Blank] Notified Physician [MD name] Notification Date: 11/27/2021 … Additional Follow-Up Comments: [Blank] … [Person L] signature, Date 12/1/2021”. Review of the Missed Visit note dated 11/20/2021 indicated “Cancelled by Agency-No Available Staff. Describe How the Patient’s Need Was Met: 39 out of 39 hrs not staffed over the course of 7 days. This is due to the caregiver being unable to cover all PA hours. The agency is actively seeking staff in the client area. Parent to provide care to the patient. These hours are out of MD ordered staffing frequency … Follow-Up Actions: Notified Caregiver [Blank] Notified Physician [MD name] Notification Date: 11/20/2021 … Additional Follow-Up Comments: [Blank] … [Person N] signature, Date 11/20/2021”. Review of the Missed Visit note dated 11/13/2021 indicated “Cancelled by Agency-No Available Staff. Describe How the Patient’s Need Was Met: 31 out of 39 hrs not staffed over the course of 7 days. This is due to the caregiver being unable to cover all PA hours. The agency is actively seeking staff in the client area. Parent to provide care to the patient. These hours are out of MD ordered staffing frequency … Follow-Up Actions: Notified Caregiver [Blank] Notified Physician [MD name] Notification Date: 11/13/2021 … Additional Follow-Up Comments: [Blank] … [Person L] signature, Date 11/17/2021”. Review of the Missed Visit note dated 11/6/2021 indicated “Cancelled by Agency-No Available Staff. Describe How the Patient’s Need Was Met: 31 out of 39 hrs not staffed over the course of 7 days. This is due to the caregiver being unable to cover all PA hours. The agency is actively seeking staff in the client area. Parent to provide care to the patient. These hours are out of MD ordered staffing frequency … Follow-Up Actions: Notified Caregiver [Blank] Notified Physician [MD name] Notification Date: 11/6/2021 … Additional Follow-Up Comments: [Blank] … [Person L] signature, Date 11/10/2021”. Review of the Missed Visit note dated 10/30/2021 indicated “Cancelled by Agency-No Available Staff. Describe How the Patient’s Need Was Met: 31 out of 39 hrs not staffed over the course of 7 days. This is due to the caregiver being unable to cover all PA hours. The agency is actively seeking staff in the client area. Parent to provide care to the patient. These hours are out of MD ordered staffing frequency … Follow-Up Actions: Notified Caregiver [Blank] Notified Physician [MD name] Notification Date: 11/6/2021 … Additional Follow-Up Comments: [Blank] … [Person L] signature, Date 11/5/2021”. 4. During an interview on 1/6/2022 at 12:00 p.m. the Administrator was asked why the agency was unable to meet the ordered hours for patient 2 and why do they not hire home health aides to help cover the hours. The Administrator indicated the agency was recruiting for nurses but not for home health aides through INDEED (online job search) and have a campaign for recruitment on the local radio. The Administrator indicated he/she spoke with patient 2’s parent and indicated the parent was with the agency not being able to staff the hours and the parent was aware the agency was recruiting for help. At that time, Person J indicated the agency only offers skilled nursing services and does not offer home health aide services. Person J indicated Person L was applying for a contract through Indiana for home health aide services. At 12:25 p.m. Person J provided an email from Person L dated 1/6/2022 indicating “We signed a contract with Indiana’s Area on Aging 2 but have not accepted any clients under the contract since its signing. We are working on securing national contracts with other payor sources, i.e. [names] etc.: However, none have been finalized as of today.” Email from Person K dated 1/6/2022 indicated, “AAA2 is unrelated to care that would be provided within BU71 [Evansville]… It is located in the northern part of Indiana.” 5. The complete clinical record for patient 3 was reviewed on 1/4/2022 and included a plan of care for the certification period 11/20/2022 to 1/18/2022, SOC date 8/8/2018, with orders for “[skilled nurse] Hourly 49.00 Hour Weekly for 1 Certification Period(s) starting 11/20/2021 – Traditional 9[hours]/day [Monday, Wednesday, Friday] and 11 [hours] [Tuesday – Thursday] not to exceed 49 hrs a week …” Review of the Missed Visit note dated 12/25/2021 indicated “Cancelled by Agency-No Available Staff. Describe How the Patient’s Need Was Met: 20 out of 49 hrs not staffed over the course of 7 days. This is due to the caregiver being unable to cover all PA hours. The agency is actively seeking staff in the client area. Parent to provide care to the patient. These hours are out of MD ordered staffing frequency … Follow-Up Actions: Notified Caregiver [Administrator] Notified Physician [MD name] Notification Date: 12/25/2021 … Additional Follow-Up Comments: [Blank] … [Person L] signature, Date 12/29/2021” Review of the Missed Visit note dated 12/18/2021 indicated “Cancelled by Agency-No Available Staff. Describe How the Patient’s Need Was Met: 9 out of 49 hrs not staffed over the course of 7 days. This is due to the client being out of town for a medical appointment. Parent to provide care to the patient. These hours are out of MD ordered staffing frequency … Follow-Up Actions: Notified Caregiver [Administrator] Notified Physician [MD name] Notification Date: 12/18/2021 … Additional Follow-Up Comments: [Blank] … [Person N] signature, Date 12/18/2021” Review of the Missed Visit note dated 11/27/2021 indicated “Cancelled by Agency-No Available Staff. Describe How the Patient’s Need Was Met: 29 out of 49 hrs not staffed over the course of 7 days. This is due to the caregiver unable to staff all PA hours. Agency is actively recruiting for this client. Parent to provide care to the patient. These hours are out of MD ordered staffing frequency … Follow-Up Actions: Notified Caregiver [Blank] Notified Physician [MD name] Notification Date: 11/27/2021 … Additional Follow-Up Comments: [Blank] … [Person L] signature, Date 12/1/2021” 6. The complete clinical record for patient 5 was reviewed on 1/7/2022 and included a plan of care for the certification period 11/19/2022 to 1/17/2022, SOC date 6/13/2017, with orders for “[skilled nurse] Hourly 40.00 Hour Weekly for 1 Certification Period(s) starting 11/19/2021 – Traditional 6-10[hours]/day, 4-5 days/week, not to exceed 40 hours a week …” Review of the Missed Visit note dated 12/25/2021 indicated “Cancelled by Agency-No Available Staff. Describe How the Patient’s Need Was Met: 26 hours missed out of 40 over the course of 7 days. This is due to the caregiver being unable to staff all PA hours. Agency is seeking coverage in the client area. Parent to provide care to the patient. These hours are out of MD ordered staffing frequencies … Follow-Up Actions: Notified Caregiver [Administrator] Notified Physician [MD name] Notification Date: 12/25/2021 … Additional Follow-Up Comments: [Blank] … [Person L] signature, Date 12/29/2021” Review of the Missed Visit note dated 12/18/2021 indicated “Cancelled by Agency-No Available Staff. Describe How the Patient’s Need Was Met: 10 hours missed out of 40 over the course of 7 days. This is due to the caregiver being unable to staff all PA hours. Agency is seeking coverage in the client area. Parent to provide care to the patient. These hours are out of MD ordered staffing frequencies … Follow-Up Actions: Notified Caregiver [Administrator] Notified Physician [MD name] Notification Date: 12/18/2021 … Additional Follow-Up Comments: [Blank] … [Person N] signature, Date 12/18/2021” Review of the Missed Visit note dated 12/11/2021 indicated “Cancelled by Agency-No Available Staff. Describe How the Patient’s Need Was Met: 17 hours out of 40 not staffed over the course of 7 days. This is due to the caregiver being unable to staff all PA hours. Agency is seeking coverage in the client area. Parent to provide care to the patient. These hours are out of MD ordered staffing frequencies … Follow-Up Actions: Notified Caregiver [Administrator] Notified Physician [MD name] Notification Date: 12/11/2021 … Additional Follow-Up Comments: [Blank] … [Person L] signature, Date 12/14/2021” Review of the Missed Visit note dated 12/04/2021 indicated “Cancelled by Agency-No Available Staff. Describe How the Patient’s Need Was Met: 24 hours out of 40 not staffed over the course of 7 days. This is due to the caregiver being unable to staff all PA hours. Agency is seeking coverage in the client area. Parent to provide care to the patient. These hours are out of MD ordered staffing frequencies … Follow-Up Actions: Notified Caregiver [Blank] Notified Physician [MD name] Notification Date: 12/04/2021 … Additional Follow-Up Comments: [Blank] … [Person L] signature, Date 12/8/2021” Review of the Missed Visit note dated 11/27/2021 indicated “Cancelled by Agency-No Available Staff. Describe How the Patient’s Need Was Met: 24 hours out of 40 not staffed over the course of 7 days. This is due to the caregiver being unable to staff all PA hours. Agency is seeking coverage in the client area. Parent to provide care to the patient. These hours are out of MD ordered staffing frequencies … Follow-Up Actions: Notified Caregiver [Blank] Notified Physician [MD name] Notification Date: 11/27/2021 … Additional Follow-Up Comments: [Blank] … [Person L] signature, Date 12/1/2021” Review of the Missed Visit note dated 11/20/2021 indicated “Cancelled by Agency-No Available Staff. Describe How the Patient’s Need Was Met: 5 hours out of 40 not staffed over the course of 7 days. This is due to the caregiver being unable to staff all PA hours. Agency is seeking coverage in the client area. Parent to provide care to the patient. These hours are out of MD ordered staffing frequencies … Follow-Up Actions: Notified Caregiver [Administrator in training] Notified Physician [MD name] Notification Date: 11/20/2021 … Additional Follow-Up Comments: [Blank] … [Person N] signature, Date 11/20/2021” 7. The complete clinical record for patient 6 was reviewed on 1/7/2022 and included a plan of care for the certification period 6/30/2021 to 8/22/2021, SOC date 3/23/2017, with orders for “[skilled nurse] 32.00 Hour Weekly for 1 Certification Period(s) starting 6/30/2021 – Traditional; 7-9 hours a day, 3-4 days a week, not to exceed 32 hours a week …” Review of the Missed Visit note dated 08/07/2021 indicated “Cancelled by Agency-No Available Staff. Describe How the Patient’s Need Was Met: 22 out of 32 hrs not staffed over the course of 7 days. This is due to the caregiver being not being unable to staff all PA hours. The agency is actively seeking staff in the client area. Parent to provide care to the patient. These hours are out of MD ordered staffing frequency … Follow-Up Actions: Notified Caregiver [Person H] Notified Physician [MD name] Notification Date: 08/07/2021 … Additional Follow-Up Comments: [Blank] … [Person H] signature, Date 08/13/2021” Review of the Missed Visit note dated 07/24/2021 indicated “Cancelled by Agency-No Available Staff. Describe How the Patient’s Need Was Met: 2 out of 32 hrs not staffed over the course of 7 days. This is due to the caregiver not being unable to staff all PA hours. Agency is seeking coverage for this need. Parent to provide care to the patient. These hours are out of MD ordered staffing frequency … Follow-Up Actions: Notified Caregiver [Person H] Notified Physician [MD name] Notification Date: 07/24/2021 … Additional Follow-Up Comments: [Blank] … [Person H] signature, Date 07/24/2021” Review of the Missed Visit note dated 07/10/2021 indicated “Cancelled by Agency-No Available Staff. Describe How the Patient’s Need Was Met: 2 out of 32 hrs not staffed over the course of 7 days. This is due to the caregiver not being able staff all PA hours. Agency is seeking coverage for this need. Parent to provide care to the patient. These hours are out of MD ordered staffing frequency … Follow-Up Actions: Notified Caregiver [Person H] Notified Physician [MD name] Notification Date: 07/10/2021 … Additional Follow-Up Comments: [Blank] … [Person H] signature, Date 07/19/2021” Review of the Missed Visit note dated 07/-2/2021 indicated “Cancelled by Agency-No Available Staff. Describe How the Patient’s Need Was Met: 15.5 hrs not staffed out of 32 hrs over the course of 7 days. Caregiver not able to cover all PA hrs this week. Parent to provide care to patient. These hours are out of the MD ordered staffing frequency … Follow-Up Actions: Notified Caregiver [Person H] Notified Physician [MD name] Notification Date: 07/02/2021 … Additional Follow-Up Comments: [Blank] … [Person H] signature, Date 7/19/2021” 8. The complete clinical record for patient 7 was reviewed on 1/7/2022 and included a plan of care for the certification period 6/24/20211 to 8/22/2021, SOC date 7/10/2018, with orders for “[skilled nurse] hourly 80.00 Hour Weekly for 1 Certification Period (s) starting 6/24/2021 – Traditional 8-10 [hours]/day, 5-6 days/week, 1-2 shifts/day. Not to exceed 80 [hours] a week …” Review of the Missed Visit note dated 08/07/2021 indicated “Cancelled by Agency-No Available Staff. Describe How the Patient’s Need Was Met: 64 out of 80 hrs not staffed over the course of 7 days. This is due to the caregiver being unable to cover all PA hours. The agency is actively seeking staff in the client area. Parent to provide care to the patient. These hours are out of MD ordered staffing frequency … Follow-Up Actions: Notified Caregiver [Person H] Notified Physician [MD name] Notification Date: 008/07/2021 … Additional Follow-Up Comments: [Blank] … [Person H] signature, Date 8/13/2021” Review of the Missed Visit note dated 07/24/2021 indicated “Cancelled by Agency-No Available Staff. Describe How the Patient’s Need Was Met: 58 out of 80 hrs not staffed over the course of 7 days. This is due to the caregiver being unable to cover all PA hours. The agency is actively seeking coverage for this need. Parent to provide care to the patient. These hours are out of MD ordered staffing frequency … Follow-Up Actions: Notified Caregiver [Person H] Notified Physician [MD name] Notification Date: 07/24/2021 Unable to Reschedule Due to [Blank] Additional Follow-up Comments: [Blank] … [Person H] signature, Date 7/26/2021” Review of the Missed Visit note dated 07/10/2021 indicated “Cancelled by Agency-No Available Staff. Describe How the Patient’s Need Was Met: 65.5 out of 80 hrs not staffed over the course of 7 days. This is due to the caregiver being unable to cover all PA hours. The agency is actively seeking coverage for this need. Parent to provide care to the patient. These hours are out of MD ordered staffing frequency … Follow-Up Actions: Notified Caregiver [Person H] Notified Physician [MD name] Notification Date: 07/10/2021 Unable to Reschedule Due to [Blank] Additional Follow-up Comments: [Blank] … [Person H] signature, Date 7/19/2021” Review of the Missed Visit note dated 07/02/2021 indicated “Cancelled by Agency-No Available Staff. Describe How the Patient’s Need Was Met: 58.5 out of 80 hrs not staffed over the course of 7 days. This is due to the caregiver being unable to cover all PA hours. The agency is actively seeking coverage for this need. Parent to provide care to the patient. These hours are out of MD ordered staffing frequency … Follow-Up Actions: Notified Caregiver [Person H] Notified Physician [MD name] Notification Date: 07/02/2021 Unable to Reschedule Due to [Blank] Additional Follow-up Comments: [Blank] … [Person H] signature, Date 7/19/2021” 9. During an interview on 1/4/2022 at 4:20 p.m. the Administrator indicated he/she was not aware of Article 17, state licensure requirements, or the Administrative Code and was unable to provide any additional information or comments. 10. During exit conference on 1/11/2022 at 4:25 p.m. Person J indicated the agency would have home health aides if the doctor ordered it and there are no orders or authorization from the state for home health aides. The Administrator was unable to provide any additional comments or information. 17-13-1(a)

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the medication review addressed compliance, response to drug therapy, adverse drug reactions, duplicate medications, side effects, and drug interactions for 7 of 7 records reviewed with the potential to affect all patients. (Patient 1,2,3,4,5,6,7) Findings include: 1. A September 2012 policy titled Medication Profile was provided by Person J on 1/10/2021 at 9:15 a.m. The policy indicated, but not limited to, “The Registered Nurse will complete the mediation profile for each client … the profile will be updated as needed to reflect current medications the client is taking … To identify possible ineffective drug therapy, adverse reactions, significant side effects, drug allergies, and contraindicated medications … evaluation of the client’s knowledge of the effects of these medications … identify discrepancies between client profile and the physician and/or agency profile … 8. The Nurse/Therapist shall review all medications with the client and or caregiver … 9. The Nurse shall review all medication effectiveness … 10. The Medication Profile shall be reviewed by a Registered Nurse (RN)/Therapist every 60 days and updated … The RN/Therapist shall sign and date the Medication Profile … 11. The original Medication Profile shall be filed in the clinical record … 12. Medication profiles created through electronic data entry will have a copy in the client record and client’s home …” A signed September 20, 2021, Clinical Administrator job description was provided by the Administrator on 1/4/2022 at 4:00 p.m. The job description indicated, but was not limited to, “… Assures compliance with the requirements of state licensure, Medicare certification, and compliance with regulatory agencies through policy and procedures, staff education, and ongoing monitoring activities …” 2. The complete clinical record for patient 1 was reviewed on 1/10/2022 and included a plan of care for the certification period 9/25/2021 to 11/23/2021, SOC (start of care) date 4/19/2017, with a Medication Profile. The agency failed to complete the Medication Review that addressed compliance, response to drug therapy, potential side effects, adverse drug reactions, duplicate medications, side effects, and drug interactions. 3. The complete clinical record for patient 2 was reviewed on 1/6/2022 and included a plan of care for the certification period 10/25/2021 to 12/23/2021, SOC date 9/6/2019, with a Medication Profile. The agency failed to complete the Medication Review that addressed compliance, response to drug therapy, potential side effects, adverse drug reactions, duplicate medications, side effects, and drug interactions. 4. The complete clinical record for patient 3 was reviewed on 1/4/2022 and included a plan of care for the certification period 11/20/2022 to 1/18/2022, SOC date 8/8/2018, with a Medication Profile. The agency failed to complete the Medication Review that addressed compliance, response to drug therapy, potential side effects, adverse drug reactions, duplicate medications, side effects, and drug interactions. 5. The complete clinical record for patient 4 was reviewed on 1/6/2022 and included a plan of care for the certification period 12/20/2021 to 2/17/2022, SOC date 3/7/2015, with a Medication Profile. The agency failed to complete the Medication Review that addressed compliance, response to drug therapy, potential side effects, adverse drug reactions, duplicate medications, side effects, and drug interactions. 6. The complete clinical record for patient 5 was reviewed on 1/7/2022 and included a plan of care for the certification period 11/19/2022 to 1/17/2022, SOC date 6/13/2017, with a Medication Profile. The agency failed to complete the Medication Review that addressed compliance, response to drug therapy, potential side effects, adverse drug reactions, duplicate medications, side effects, and drug interactions. 7. The complete clinical record for patient 6 was reviewed on 1/7/2022 and included a plan of care for the certification period 6/30/2021 to 8/22/2021, SOC date 3/23/2017, with a Medication Profile. The agency failed to complete the Medication Review that addressed compliance, response to drug therapy, potential side effects, adverse drug reactions, duplicate medications, side effects, and drug interactions. 8. The complete clinical record for patient 7 was reviewed on 1/7/2022 and included a plan of care for the certification period 6/24/20211 to 8/22/2021, SOC date 7/10/2018, with a Medication profile. The agency failed to complete the Medication Review that addressed compliance, response to drug therapy, potential side effects, adverse drug reactions, duplicate medications, side effects, and drug interactions. 9. During an interview on 1/4/2022 at 10:00 a.m. the Administrator was queried as to why the Medication reviews were not filled out and dated. The Administrator confirmed he/she did not complete that portion of the Medication Review. Person J indicated the Medication Review should be filled out. At 4:20 p.m. the Administrator indicated he/she was not aware of Article 17, state licensure requirements, or the Administrative Code and was unable to provide any additional information or comments. 17-14-1(a)(1)(B)

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure all services in the plan of care were met, with the potential to affect all patients (See G572); failed to ensure all orders were record in the plan of care to ensure staff were working from a current plan of care (See G576); failed to review and revise the plan of care to ensure staff were working from a current plan of care (See G586); failed to provide a written schedule that included visit frequencies that affects all active patients (See G614); failed to ensure patients or caregivers were provided with a written copy of the patient medication schedule and instructions that includes medication name, dosage, and frequency and which medications will be administered by agency personnel and persons acting on behalf of the agency, with the potential to affect all active patients (See G616); failed to ensure any other pertinent instructions specific to patient care needs (See G620) The cumulative effect of this systemic problem resulted in the agency being out of compliance with the Condition of Participation 484.55 Care planning, coordination, quality of care.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure all services in the plan of care were met for 5 of 7 record reviews, with the potential to affect all patients. (Patients 2, 3, 5, 6, 7) Findings include: 1. A 6/10/2021 policy titled Plan of Care was provided by Person J on 1/10/2022 at 9:15. The policy indicated, but was not limited to, “To provide guidelines for agency staff to develop a plan of care for all clients admitted to the agency. To assure that the plan of meets state/federal guidelines, and all applicable laws and regulations. 2. … c. Type, frequency, and duration of all visits/services d. Specific procedures and modalities for therapy services … d. Specific procedures and modalities for therapy services. … h. Rehabilitation potential-to be addressed at each recertification … l. Medications, treatments, and procedures … p. Treatment goals … t. other appropriate items … v. All of the above items must always be addressed on the Plan of Care. 6. Orders for therapy services shall include the specific procedures and modalities to be used and the amount, frequency, and duration. 9. The client, Therapist, and other personnel shall participate in developing the Plan of Care. The client shall be informed of any changes in the Plan of Care.” A signed September 20, 2021, Clinical Administrator job description was provided by the Administrator on 1/4/2022 at 4:00 p.m. The job description indicated, but was not limited to, “… Assures compliance with the requirements of state licensure, Medicare certification, and compliance with regulatory agencies through policy and procedures, staff education, and ongoing monitoring activities …” 2. During entrance conference on 1/3/2022 at 11:10 a.m. the Administrator was asked what services the agency provides. The Administrator indicated the agency offers skilled nursing and home health aide services. Queried if the agency offers therapy services. The Administrator indicated the agency does not offer physical, occupational, or speech therapies. The agency does not offer attendant care services or social work. Queried if the agency has any services provided under contract to which he/she replied, “not that I’m aware of”. 3. The complete clinical record for patient 2 was reviewed on 1/6/2022 and included a plan of care for the certification period 10/25/2021 to 12/23/2021, SOC date 9/6/2019, with orders for “[skilled nurse] hourly 39.00 Hour Weekly for 1 Certification Period (s) starting 10/25/2021 – Traditional 8-10 [hours]/day, 4-5 days/week. Not to exceed 39 [hours] in a calendar week …” Review of the Missed Visit note dated 12/18/2021 indicated “Cancelled by Agency-No Available Staff. Describe How the Patient’s Need Was Met: 30.5 out of 39 hrs [hours] not staffed over the course of 7 days. This is due to the caregiver being unable to cover all PA hours. The agency is actively seeking staff in the client area. Parent to provide care to the patient. These hours are out of MD ordered staffing frequency … Follow-Up Actions: Notified Caregiver [Administrator] Notified Physician [MD name] Notification Date: 12/18/2021 … Additional Follow-Up Comments: [Blank] … [Person N] signature, Date 12/18/2021” Review of the Missed Visit note dated 12/11/2021 indicated “Cancelled by Agency-No Available Staff. Describe How the Patient’s Need Was Met: 30 out of 39 hrs not staffed over the course of 7 days. This is due to the caregiver being unable to cover all PA hours. The agency is actively seeking staff in the client area. Parent to provide care to the patient. These hours are out of MD ordered staffing frequency … Follow-Up Actions: Notified Caregiver [Administrator] Notified Physician [MD name] Notification Date: 12/11/2021 … Additional Follow-Up Comments: [Blank] … [Person L] signature, Date 12/11/2021” Review of the Missed Visit note dated 12/4/2021 indicated “Cancelled by Agency-No Available Staff. Describe How the Patient’s Need Was Met: 31 out of 39 hrs not staffed over the course of 7 days. This is due to the caregiver being unable to cover all PA hours. The agency is actively seeking staff in the client area. Parent to provide care to the patient. These hours are out of MD ordered staffing frequency … Follow-Up Actions: Notified Caregiver [Blank] Notified Physician [MD name] Notification Date: 12/4/2021 … Additional Follow-Up Comments: [Blank] … [Person L] signature, Date 12/8/2021” Review of the Missed Visit note dated 11/27/2021 indicated “Cancelled by Agency-No Available Staff. Describe How the Patient’s Need Was Met: 31 out of 39 hrs not staffed over the course of 7 days. This is due to the caregiver being unable to cover all PA hours. The agency is actively seeking staff in the client area. Parent to provide care to the patient. These hours are out of MD ordered staffing frequency … Follow-Up Actions: Notified Caregiver [Blank] Notified Physician [MD name] Notification Date: 11/27/2021 … Additional Follow-Up Comments: [Blank] … [Person L] signature, Date 12/1/2021” Review of the Missed Visit note dated 11/20/2021 indicated “Cancelled by Agency-No Available Staff. Describe How the Patient’s Need Was Met: 39 out of 39 hrs not staffed over the course of 7 days. This is due to the caregiver being unable to cover all PA hours. The agency is actively seeking staff in the client area. Parent to provide care to the patient. These hours are out of MD ordered staffing frequency … Follow-Up Actions: Notified Caregiver [Blank] Notified Physician [MD name] Notification Date: 11/20/2021 … Additional Follow-Up Comments: [Blank] … [Person N] signature, Date 11/20/2021” Review of the Missed Visit note dated 11/13/2021 indicated “Cancelled by Agency-No Available Staff. Describe How the Patient’s Need Was Met: 31 out of 39 hrs not staffed over the course of 7 days. This is due to the caregiver being unable to cover all PA hours. The agency is actively seeking staff in the client area. Parent to provide care to the patient. These hours are out of MD ordered staffing frequency … Follow-Up Actions: Notified Caregiver [Blank] Notified Physician [MD name] Notification Date: 11/13/2021 … Additional Follow-Up Comments: [Blank] … [Person L] signature, Date 11/17/2021” Review of the Missed Visit note dated 11/6/2021 indicated “Cancelled by Agency-No Available Staff. Describe How the Patient’s Need Was Met: 31 out of 39 hrs not staffed over the course of 7 days. This is due to the caregiver being unable to cover all PA hours. The agency is actively seeking staff in the client area. Parent to provide care to the patient. These hours are out of MD ordered staffing frequency … Follow-Up Actions: Notified Caregiver [Blank] Notified Physician [MD name] Notification Date: 11/6/2021 … Additional Follow-Up Comments: [Blank] … [Person L] signature, Date 11/10/2021” Review of the Missed Visit note dated 10/30/2021 indicated “Cancelled by Agency-No Available Staff. Describe How the Patient’s Need Was Met: 31 out of 39 hrs not staffed over the course of 7 days. This is due to the caregiver being unable to cover all PA hours. The agency is actively seeking staff in the client area. Parent to provide care to the patient. These hours are out of MD ordered staffing frequency … Follow-Up Actions: Notified Caregiver [Blank] Notified Physician [MD name] Notification Date: 11/6/2021 … Additional Follow-Up Comments: [Blank] … [Person L] signature, Date 11/5/2021” 4. During an interview on 1/6/2022 at 12:00 p.m. the Administrator was asked why the agency was unable to meet the ordered hours for patient 2 and why do they not hire home health aides to help cover the hours. The Administrator indicated the agency was recruiting for nurses but not for home health aides through INDEED (online job search) and have a campaign for recruitment on the local radio. The Administrator indicated he/she spoke with patient 2’s parent and indicated the parent was with the agency not being able to staff the hours and the parent was aware the agency was recruiting for help. At that time, Person J indicated the agency only offers skilled nursing services and does not offer home health aide services. Person J indicated Person L was applying for a contract through Indiana for home health aide services. At 12:25 p.m. Person J provided an email from Person L dated 1/6/2022 indicating “We signed a contract with Indiana’s Area on Aging 2 but have not accepted any clients under the contract since its signing. We are working on securing national contracts with other payor sources, i.e. [names] etc.: However, none have been finalized as of today.” Email from Person K dated 1/6/2022 indicated, “AAA2 is unrelated to care that would be provided within BU71 [Evansville]… It is located in the northern part of Indiana.” 5. The complete clinical record for patient 3 was reviewed on 1/4/2022 and included a plan of care for the certification period 11/20/2022 to 1/18/2022, SOC date 8/8/2018, with orders for “[skilled nurse] Hourly 49.00 Hour Weekly for 1 Certification Period(s) starting 11/20/2021 – Traditional 9[hours]/day [Monday, Wednesday, Friday] and 11 [hours] [Tuesday – Thursday] not to exceed 49 hrs a week …” Review of the Missed Visit note dated 12/25/2021 indicated “Cancelled by Agency-No Available Staff. Describe How the Patient’s Need Was Met: 20 out of 49 hrs not staffed over the course of 7 days. This is due to the caregiver being unable to cover all PA hours. The agency is actively seeking staff in the client area. Parent to provide care to the patient. These hours are out of MD ordered staffing frequency … Follow-Up Actions: Notified Caregiver [Administrator] Notified Physician [MD name] Notification Date: 12/25/2021 … Additional Follow-Up Comments: [Blank] … [Person L] signature, Date 12/29/2021” Review of the Missed Visit note dated 12/18/2021 indicated “Cancelled by Agency-No Available Staff. Describe How the Patient’s Need Was Met: 9 out of 49 hrs not staffed over the course of 7 days. This is due to the client being out of town for a medical appointment. Parent to provide care to the patient. These hours are out of MD ordered staffing frequency … Follow-Up Actions: Notified Caregiver [Administrator] Notified Physician [MD name] Notification Date: 12/18/2021 … Additional Follow-Up Comments: [Blank] … [Person N] signature, Date 12/18/2021” Review of the Missed Visit note dated 11/27/2021 indicated “Cancelled by Agency-No Available Staff. Describe How the Patient’s Need Was Met: 29 out of 49 hrs not staffed over the course of 7 days. This is due to the caregiver unable to staff all PA hours. Agency is actively recruiting for this client. Parent to provide care to the patient. These hours are out of MD ordered staffing frequency … Follow-Up Actions: Notified Caregiver [Blank] Notified Physician [MD name] Notification Date: 11/27/2021 … Additional Follow-Up Comments: [Blank] … [Person L] signature, Date 12/1/2021” 6. The complete clinical record for patient 5 was reviewed on 1/7/2022 and included a plan of care for the certification period 11/19/2022 to 1/17/2022, SOC date 6/13/2017, with orders for “[skilled nurse] Hourly 40.00 Hour Weekly for 1 Certification Period(s) starting 11/19/2021 – Traditional 6-10[hours]/day, 4-5 days/week, not to exceed 40 hours a week …” Review of the Missed Visit note dated 12/25/2021 indicated “Cancelled by Agency-No Available Staff. Describe How the Patient’s Need Was Met: 26 hours missed out of 40 over the course of 7 days. This is due to the caregiver being unable to staff all PA hours. Agency is seeking coverage in the client area. Parent to provide care to the patient. These hours are out of MD ordered staffing frequencies … Follow-Up Actions: Notified Caregiver [Administrator] Notified Physician [MD name] Notification Date: 12/25/2021 … Additional Follow-Up Comments: [Blank] … [Person L] signature, Date 12/29/2021” Review of the Missed Visit note dated 12/18/2021 indicated “Cancelled by Agency-No Available Staff. Describe How the Patient’s Need Was Met: 10 hours missed out of 40 over the course of 7 days. This is due to the caregiver being unable to staff all PA hours. Agency is seeking coverage in the client area. Parent to provide care to the patient. These hours are out of MD ordered staffing frequencies … Follow-Up Actions: Notified Caregiver [Administrator] Notified Physician [MD name] Notification Date: 12/18/2021 … Additional Follow-Up Comments: [Blank] … [Person N] signature, Date 12/18/2021” Review of the Missed Visit note dated 12/11/2021 indicated “Cancelled by Agency-No Available Staff. Describe How the Patient’s Need Was Met: 17 hours out of 40 not staffed over the course of 7 days. This is due to the caregiver being unable to staff all PA hours. Agency is seeking coverage in the client area. Parent to provide care to the patient. These hours are out of MD ordered staffing frequencies … Follow-Up Actions: Notified Caregiver [Administrator] Notified Physician [MD name] Notification Date: 12/11/2021 … Additional Follow-Up Comments: [Blank] … [Person L] signature, Date 12/14/2021” Review of the Missed Visit note dated 12/04/2021 indicated “Cancelled by Agency-No Available Staff. Describe How the Patient’s Need Was Met: 24 hours out of 40 not staffed over the course of 7 days. This is due to the caregiver being unable to staff all PA hours. Agency is seeking coverage in the client area. Parent to provide care to the patient. These hours are out of MD ordered staffing frequencies … Follow-Up Actions: Notified Caregiver [Blank] Notified Physician [MD name] Notification Date: 12/04/2021 … Additional Follow-Up Comments: [Blank] … [Person L] signature, Date 12/8/2021” Review of the Missed Visit note dated 11/27/2021 indicated “Cancelled by Agency-No Available Staff. Describe How the Patient’s Need Was Met: 24 hours out of 40 not staffed over the course of 7 days. This is due to the caregiver being unable to staff all PA hours. Agency is seeking coverage in the client area. Parent to provide care to the patient. These hours are out of MD ordered staffing frequencies … Follow-Up Actions: Notified Caregiver [Blank] Notified Physician [MD name] Notification Date: 11/27/2021 … Additional Follow-Up Comments: [Blank] … [Person L] signature, Date 12/1/2021” Review of the Missed Visit note dated 11/20/2021 indicated “Cancelled by Agency-No Available Staff. Describe How the Patient’s Need Was Met: 5 hours out of 40 not staffed over the course of 7 days. This is due to the caregiver being unable to staff all PA hours. Agency is seeking coverage in the client area. Parent to provide care to the patient. These hours are out of MD ordered staffing frequencies … Follow-Up Actions: Notified Caregiver [Administrator in training] Notified Physician [MD name] Notification Date: 11/20/2021 … Additional Follow-Up Comments: [Blank] … [Person N] signature, Date 11/20/2021” 7. The complete clinical record for patient 6 was reviewed on 1/7/2022 and included a plan of care for the certification period 6/30/2021 to 8/22/2021, SOC date 3/23/2017, with orders for “[skilled nurse] 32.00 Hour Weekly for 1 Certification Period(s) starting 6/30/2021 – Traditional; 7-9 hours a day, 3-4 days a week, not to exceed 32 hours a week …” Review of the Missed Visit note dated 08/07/2021 indicated “Cancelled by Agency-No Available Staff. Describe How the Patient’s Need Was Met: 22 out of 32 hrs not staffed over the course of 7 days. This is due to the caregiver being not being unable to staff all PA hours. The agency is actively seeking staff in the client area. Parent to provide care to the patient. These hours are out of MD ordered staffing frequency … Follow-Up Actions: Notified Caregiver [Person H] Notified Physician [MD name] Notification Date: 08/07/2021 … Additional Follow-Up Comments: [Blank] … [Person H] signature, Date 08/13/2021” Review of the Missed Visit note dated 07/24/2021 indicated “Cancelled by Agency-No Available Staff. Describe How the Patient’s Need Was Met: 2 out of 32 hrs not staffed over the course of 7 days. This is due to the caregiver not being unable to staff all PA hours. Agency is seeking coverage for this need. Parent to provide care to the patient. These hours are out of MD ordered staffing frequency … Follow-Up Actions: Notified Caregiver [Person H] Notified Physician [MD name] Notification Date: 07/24/2021 … Additional Follow-Up Comments: [Blank] … [Person H] signature, Date 07/24/2021” Review of the Missed Visit note dated 07/10/2021 indicated “Cancelled by Agency-No Available Staff. Describe How the Patient’s Need Was Met: 2 out of 32 hrs not staffed over the course of 7 days. This is due to the caregiver not being able staff all PA hours. Agency is seeking coverage for this need. Parent to provide care to the patient. These hours are out of MD ordered staffing frequency … Follow-Up Actions: Notified Caregiver [Person H] Notified Physician [MD name] Notification Date: 07/10/2021 … Additional Follow-Up Comments: [Blank] … [Person H] signature, Date 07/19/2021” Review of the Missed Visit note dated 07/-2/2021 indicated “Cancelled by Agency-No Available Staff. Describe How the Patient’s Need Was Met: 15.5 hrs not staffed out of 32 hrs over the course of 7 days. Caregiver not able to cover all PA hrs this week. Parent to provide care to patient. These hours are out of the MD ordered staffing frequency … Follow-Up Actions: Notified Caregiver [Person H] Notified Physician [MD name] Notification Date: 07/02/2021 … Additional Follow-Up Comments: [Blank] … [Person H] signature, Date 7/19/2021” 8. The complete clinical record for patient 7 was reviewed on 1/7/2022 and included a plan of care for the certification period 6/24/20211 to 8/22/2021, SOC date 7/10/2018, with orders for “[skilled nurse] hourly 80.00 Hour Weekly for 1 Certification Period (s) starting 6/24/2021 – Traditional 8-10 [hours]/day, 5-6 days/week, 1-2 shifts/day. Not to exceed 80 [hours] a week …” Review of the Missed Visit note dated 08/07/2021 indicated “Cancelled by Agency-No Available Staff. Describe How the Patient’s Need Was Met: 64 out of 80 hrs not staffed over the course of 7 days. This is due to the caregiver being unable to cover all PA hours. The agency is actively seeking staff in the client area. Parent to provide care to the patient. These hours are out of MD ordered staffing frequency … Follow-Up Actions: Notified Caregiver [Person H] Notified Physician [MD name] Notification Date: 008/07/2021 … Additional Follow-Up Comments: [Blank] … [Person H] signature, Date 8/13/2021” Review of the Missed Visit note dated 07/24/2021 indicated “Cancelled by Agency-No Available Staff. Describe How the Patient’s Need Was Met: 58 out of 80 hrs not staffed over the course of 7 days. This is due to the caregiver being unable to cover all PA hours. The agency is actively seeking coverage for this need. Parent to provide care to the patient. These hours are out of MD ordered staffing frequency … Follow-Up Actions: Notified Caregiver [Person H] Notified Physician [MD name] Notification Date: 07/24/2021 Unable to Reschedule Due to [Blank] Additional Follow-up Comments: [Blank] … [Person H] signature, Date 7/26/2021” Review of the Missed Visit note dated 07/10/2021 indicated “Cancelled by Agency-No Available Staff. Describe How the Patient’s Need Was Met: 65.5 out of 80 hrs not staffed over the course of 7 days. This is due to the caregiver being unable to cover all PA hours. The agency is actively seeking coverage for this need. Parent to provide care to the patient. These hours are out of MD ordered staffing frequency … Follow-Up Actions: Notified Caregiver [Person H] Notified Physician [MD name] Notification Date: 07/10/2021 Unable to Reschedule Due to [Blank] Additional Follow-up Comments: [Blank] … [Person H] signature, Date 7/19/2021” Review of the Missed Visit note dated 07/02/2021 indicated “Cancelled by Agency-No Available Staff. Describe How the Patient’s Need Was Met: 58.5 out of 80 hrs not staffed over the course of 7 days. This is due to the caregiver being unable to cover all PA hours. The agency is actively seeking coverage for this need. Parent to provide care to the patient. These hours are out of MD ordered staffing frequency … Follow-Up Actions: Notified Caregiver [Person H] Notified Physician [MD name] Notification Date: 07/02/2021 Unable to Reschedule Due to [Blank] Additional Follow-up Comments: [Blank] … [Person H] signature, Date 7/19/2021” 9. During an interview on 1/4/2022 at 4:20 p.m. the Administrator indicated he/she was not aware of Article 17, state licensure requirements, or the Administrative Code and was unable to provide any additional information or comments. 10. During exit conference on 1/11/2022 at 4:25 p.m. Person J indicated the agency would have home health aides if the doctor ordered it and there are no orders or authorization from the state for home health aides. The Administrator was unable to provide any additional comments or information. 17-13-1(a)

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure all orders were recorded in the plan of care to ensure staff were working from a current plan of care for 3 of 3 home visit observations with the potential to affect all patients. (Patient 3,4,5) Findings include: 1. A revised 6/10/2021 policy titled Plan of Care was provided by Person J on 1/10/2022 at 9:15 a.m. The policy indicated, but was not limited to, “Policy … The Plan of Care will be reviewed with the physician/nurse … to ensure that the client needs are net and updated as necessary … The Plan of Care shall be completed in full to include: … l. Medications, treatments, and procedures … 11. Professional Staff shall promptly alert the physician/nurse … to any changes that suggest a need to alter the Plan of Care” 2. A September 2012 policy titled Medication Profile was provided by Person J on 1/10/2022 at 9:15 a.m. The policy indicated, but was not limited to, “5. If the physician changes the medication orders, the nurse must add newly ordered drugs or medication changes to the Medication Profile. … 6. … the reason for the medication change … 7. … change shall be documented … Plan of Care. … 10. … Medication Profile … copy … in the clients home.” 3. During a home visit on 1/4/2022 at 12:58 p.m. patient 3’s Medication Profile and Plan of Care provided by the agency was reviewed along with RN (registered nurse) G. RN G indicated Poly-Vi-Oral Solution (vitamin) 50 MG (milligrams)/ML (milliliters) 1 dose per G-tube (tube inserted into the stomach to deliver medications and feedings) once a day, start date 7/7/202, was not given once a day. RN G indicated Poly-Vi-Oral Solution was given while patient 3 was in the hospital and was now given as needed. The Medication Profile and Plan o]f Care did not accurately reflect what patient 3 was receiving. 4. During a home visit on 1/5/2022 at 10:20 a.m. patient 5’s Medication Profile and Plan of Care provided by the agency to the surveyor was reviewed along with RN H. The Medication Profile and Plan of Care indicated patient 5 received Culturelle Probiotics (stomach medication) Kids Oral Packet 5 B CELL 1 packet per G-tube once a day, start date 5/27/2020. RN H indicated patient 5 had not received Culturelle Probiotics. RN H indicated the parents only give Culturelle Probiotics if the patient was on antibiotics. RN H confirmed the Medication Profile and Plan of Care did not accurately reflect what was currently given to patient 5. 5. During a home visit on 1/6/2022 at 3:30 p.m. patient 4’s Medication Profile and Plan of Care provided by the agency to the surveyor was reviewed along with RN F. The Medication Profile and Plan of Care indicated patient 4 received risperidone Oral Solution (nervous system medication) 1 MG/ML 0.25 ml per G-tube twice a day, start date 12/18/2021. RN F indicated patient 4 currently received 0.3 ml instead of 0.25 ml. Asked RN F if Diastat AcuDial Rectal Gel (seizure medication) was kept in the home. RN F and the caregiver indicated Diastat Gel was given to the patient 4’s school for emergency use. Patient 4’s caregiver indicated the physician gave them a supply of Diastat Gel and Valtoco (seizure medication) spray back in June of 2021. Patient 4’s caregiver indicated he/she gave the school the Diastat Gel and kept the Valtoco spray at home. The caregiver indicated Valtoco spray was not covered by insurance. RN F confirmed Valtoco spray 5 mg 1 spray in nose as needed was not on the Medication Profile or Plan of Care to accurately reflect medication that was currently in the home at the time of the home visit.

Review and revision of the plan of care CFR(s): 484.60(c) Standard: Review and revision of the plan of care. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to review and revise the plan of care to ensure staff were working from a current plan of care for 3 of 3 home visit observations with the potential to affect all patients. (Patient 3,4,5) Findings include: 1. A revised 6/10/2021 policy titled Plan of Care was provided by Person J on 1/10/2022 at 9:15 a.m. The policy indicated, but was not limited to, “Policy … The Plan of Care will be reviewed with the physician/nurse … to ensure that the client needs are net and updated as necessary … The Plan of Care shall be completed in full to include: … l. Medications, treatments, and procedures … 11. Professional Staff shall promptly alert the physician/nurse … to any changes that suggest a need to alter the Plan of Care” 2. A September 2012 policy titled Medication Profile was provided by Person J on 1/10/2022 at 9:15 a.m. The policy indicated, but was not limited to, “5. If the physician changes the medication orders, the nurse must add newly ordered drugs or medication changes to the Medication Profile. … 6. … the reason for the medication change … 7. … change shall be documented … Plan of Care. … 10. … Medication Profile … copy … in the clients home.” 3. During a home visit on 1/4/2022 at 12:58 p.m. patient 3’s Medication Profile and Plan of Care provided by the agency to the surveyor was reviewed along with RN (registered nurse) G. RN G indicated Poly-Vi-Oral Solution (vitamin) 50 MG (milligrams)/ML (milliliters) 1 dose per G-tube (tube inserted into the stomach to deliver medications and feedings) once a day, start date 7/7/202, was not given once a day. RN G indicated Poly-Vi-Oral Solution was given while patient 3 was in the hospital and was now given as needed. The agency failed to review and revise the Medication Profile and Plan of Care to accurately reflect care that patient 3 had received. 4. During a home visit on 1/5/2022 at 10:20 a.m. patient 5’s Medication Profile and Plan of Care provided by the agency to the surveyor was reviewed along with RN H. The Medication Profile and Plan of Care indicated patient 5 received Culturelle Probiotics (stomach medication) Kids Oral Packet 5 B CELL 1 packet per G-tube once a day, start date 5/27/2020. RN H indicated patient 5 had not received Culturelle Probiotics. RN H indicated the parents only give Culturelle Probiotics if the patient was on antibiotics. RN H confirmed the agency failed to review and revise the Medication Profile and Plan of Care to accurately reflect care that patient 5 had received. 5. During a home visit on 1/6/2022 at 3:30 p.m. patient 4’s Medication Profile and Plan of Care provided by the agency to the surveyor was reviewed along with RN F. The Medication Profile and Plan of Care indicated patient 4 received risperidone Oral Solution (nervous system medication) 1 MG/ML 0.25 ml per G-tube twice a day, start date 12/18/2021. RN F indicated patient 4 currently received 0.3 ml instead of 0.25 ml. Asked RN F if Diastat AcuDial Rectal Gel (seizure medication) was kept in the home. RN F and the caregiver indicated Diastat Gel was given to the patient 4’s school for emergency use. Patient 4’s caregiver indicated the physician gave them a supply of Diastat Gel and Valtoco (seizure medication) spray back in June of 2021. Patient 4’s caregiver indicated he/she gave the school the Diastat Gel and kept the Valtoco spray at home. The caregiver indicated Valtoco spray was not covered by insurance. RN F confirmed Valtoco spray 5 mg 1 spray in nose as needed was not on the Medication Profile or Plan of Care to accurately reflect medication patient 4 had received.

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 provide a written schedule that included visit frequency for 3 of 3 home visits with the potential to affect all active patients. (Patients 3, 4, 5) Findings include: 1. A January 2018 policy titled Admission Policy was provided by Person J on 1/10/2022 at 9:15 a.m. The policy indicted, but was not limited to, “5. … e. The home health agency must provide the patent [sic] and caregiver with a copy of written instructions outlining: Visit schedule/instructions, including; medication name, dosage and frequency and which medications will be administered by agency personnel and personnel acting on behalf of agency. Any treatments to be administered by the agency personnel and personnel acting on behalf of the agency, including therapy services.” 2. Review of the QAPI (quality assurance performance improvement) binder included a mock survey performed by Person J in July of 2021. The mock survey did not indicate the agency was following agency policy regarding written instructions for the patient and caregiver. 3. During a home visit on 1/4/2022 at 12:58 p.m. RN C indicated everything went electronic and the agency does not provide a copy of the schedule for patient 3. 4. During a home visit on 1/5/2022 at 10:20 a.m. RN H indicated the agency used to provide a written schedule but now everything was in the tablet (mobile computer). Patient 5 caregiver indicated he/she no longer receives a written schedule. 5. During a home visit on 1/6/2022 at 3:20 p.m. RN F indicated the schedule was kept in the tablet and patient 4 no longer receives a written copy of the schedule.

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered 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 patients or caregivers were provided with a written copy of the patient medication schedule and instructions that includes medication name, dosage, and frequency and which medications will be administered by agency personnel and persons acting on behalf of the agency for 3 of 3 home visit observations, with the potential to affect all active patients. (Patient 3, 4, 5) Findings include: 1. A September 2012 policy titled Medication Profile was provided by Person J on 1/10/2022 at 9:15 a.m. The policy indicated, but was not limited to, “The Registered Nurse will complete the mediation profile for each client … 11. The original Medication Profile shall be filed in the clinical record … 12. Medication profiles created through electronic data entry will have a copy in the client record and client’s home …” 2. A January 2018 policy titled Admission Policy was provided by Person J on 1/10/2022 at 9:15 a.m. The policy indicted, but was not limited to, “5. … e. The home health agency must provide the patent [sic] and caregiver with a copy of written instructions outlining: Visit schedule/instructions, including; medication name, dosage and frequency and which medications will be administered by agency personnel and personnel acting on behalf of agency. Any treatments to be administered by the agency personnel and personnel acting on behalf of the agency, including therapy services.” 3. A signed September 20, 2021, Clinical Administrator job description was provided by the Administrator on 1/4/2022 at 4:00 p.m. The job description indicated, but was not limited to, “Provides direction, coordination, supervision, and implementation of professional and supportive services to clients … Assures compliance with the requirements of state licensure, Medicare certification, and compliance with regulatory agencies through policy and procedures, staff education, and ongoing monitoring activities …” 4. During a home visit on 1/4/2022 at 12:58 p.m. patient 3’s family/RN (registered nurse) G, indicated the agency no longer provides a written copy of the medication record / profile or plan of care for patient 3’s caregiver within the home. RN G indicated the medication record was kept in the agency tablet (mobile computer) that he/she documents in and would just access the medications in the tablet. The agency failed to ensure a written copy of medications were provided to the patient. 5. During a home visit on 1/5/2022 at 10:20 a.m. RN H indicated the agency no longer provides a written copy of the medication record / profile or plan of care for patient 5’s caregiver within the home. RN H indicated the medication record was kept in the agency tablet that he/she documents in and would just access the medications in the tablet. Queried if the agency had issues with the tablet what would you do. RN H indicated that’s a good question. During the visit, patient 5’s family was interviewed and stated the agency no longer sends the medication list or plan of care, but he/she had a copy of the physician orders from the doctor’s office. The agency failed to ensure a written copy of medications were provided to the patient. 6. During a home visit on 1/6/2022 at 3:30 p.m. RN F indicated the agency no longer provides a written copy of the medication record / profile or plan of care for patient 4’s caregiver within the home. RN F indicated the family hand-wrote a medication list with times to go by if there would be problems with the agency tablet. Patient 4’s family/RN C indicated the agency no longer provides written copies of medications or plans of care. RN C indicated his/her spouse keeps a record of patient 4’s medication on an excel spread sheet for emergencies. The agency failed to ensure a written copy of medications was provided to the patient. 7. During an interview on 1/4/2022 at 4:20 p.m. the Administrator was unable to provide any additional information or comments.

Other pertinent instructions CFR(s): 484.60(e)(4) Any other pertinent instruction related to the patient's care and treatments that the HHA will provide, specific to the patient's care needs. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure pertinent instructions specific to patient care needs for 3 of 7 records reviewed. (Patient 3, 4, 5) Findings include: 1. A 6/10/2021 policy titled Plan of Care was provided by Person J on 1/10/2022 at 9:15 a.m. The policy indicated, but was not limited to, “1. An individualized Plan of Care … shall be required for each client receiving home health … services … d. Specific procedures and modalities for therapy services … p. … goals … t. Other appropriate items … v. All of the above items must always be addressed on the Plan of Care.” 2. A revised June 2012 policy titled Comprehensive Client Assessment was provided by Person J on 1/10/2022 at 9:15 a.m. The policy indicated, but was not limited to, “… accurate assessment consistent with the clients’ immediate needs … 9. Assessments will be completed by registered nurses, physical therapists or speech therapists.” 3. A revised August 2016 policy titled Coordination of Client Services was provided by Person J on 1/10/2022 at 9:15 a.m. The policy indicated, but was not limited to, “All personnel furnishing services shall maintain a liaison to assure that their efforts are coordinated effectively and support the objectives outlined in the Plan of Care … through formal care conferences, maintaining complete, current Care Plans; and written and verbal interactions. … 8. Ongoing care conferences shall be conducted to evaluate the client’s status and progress. … 11. All caregivers, including any contracted services, shall have access to the client Plan of Care and will be expected to participate in care conferences and other coordination activities …” 4. The complete clinical record for patient 3 was reviewed on 1/4/2022 and included a plan of care for the certification period 11/20/2021 to 1/18/2022, SOC date 8/8/2018, with orders for “[skilled nurse] Hourly 49.00 Hour Weekly for 1 Certification Period(s) starting 11/20/2021 – Traditional 9[hours]/day [Monday, Wednesday, Friday] and 11 [hours] [Tuesday – Thursday] not to exceed 49 hrs a week …”. The Plan of Care indicated “Problems, Interventions, and Goals … ROM / Position changes Age appropriate activities as recommended by therapies”. The Plan of Care include a 60-day Summary that indicated “… continues with PT, OT and ST are all 1-2 X week … they are working with [patient 3] on jumping, jumping forwards & backwards for several steps. PT states [he/she] has some progress …” The agency failed to document communication with a specific therapist and receive coordination notes from each therapist from an unaffiliated therapy service regarding recommendations, age-appropriate activities, goals, and progress toward goals for patient 3. 5. During a home visit on 1/6/2022 at 3:30 p.m. patient 4’s parent RN C, who was a paid employee of the agency, indicated patient 4 received PT, OT, and ST through [school name] and through a second unaffiliated therapy agency. RN C indicated the school sends a calendar with an update home every day for review and the calendar gets sent back to the school. RN C was unsure if the agency received any communication or coordination notes from the school or unaffiliated therapy agency. RN C did not indicate specific names of the therapists. 6. The complete clinical record for patient 4 was reviewed on 1/6/2022 and included a plan of care for the certification period 12/20/2021 to 2/17/2022, SOC 3/7/2015, with orders for “SN hourly 24.00 Hour Daily 24 time(s) weekly … Traditional 2-12 hr/day, 2-4 days a week …” Review of the Plan of Care indicated, “Problems, Interventions, and Goals …ROM / Position changes Age/developmentally appropriate stimuli as tolerated every shift Per therapy recommendations”. The Plan of Care included a Narrative/Comments note that indicated “receives 45 min PT, 30 min OT and twice a week 20 min ST through [school name]. [He/She] also is attending OT, PT and ST through [therapy agency name], with PT and ST being done at [name of therapy] and OT at [name of therapy]”. During an interview on 1/3/2022 at 11:10 a.m. the Administrator indicated the agency did not provide contracted therapy services. During an interview on 1/10/2022 at 3:26 p.m. the Administrator indicated the agency had not used any contracted therapy services since he/she was hired [Oct. 4, 2022]. The Administrator indicated he/she had not received any progress notes from parents or unaffiliated therapy agencies. The agency failed to document communication with specific therapist and receive coordination notes from each therapist from an unaffiliated therapy service regarding recommendations. 7. During a home visit on 1/5/2022 at 10:20 a.m. patient 5’s parent indicated the unaffiliated therapist had printed and mailed the therapy notes to patient 5’s home. RN H indicted the most recent notes were not in the home binder when reviewed but the last copy in the binder was from 4/23/2021. 8. The complete clinical record for patient 5 was reviewed on 1/7/2022 and included a plan of care for the certification period 11/19/2021 to 1/17/2022, SOC date 6/13/2017, with orders for “[skilled nurse] Hourly 40.00 Hour Weekly for 1 Certification Period(s) starting 11/19/2021 – Traditional 6-10[hours]/day, 4-5 days/week, not to exceed 40 hours a week.” Review of the Plan of Care indicated “Problems, Interventions, and Goals … ROM / position change per therapy recommendations” The Plan of Care included a 60-day Summary that indicated “… receives OT, PT and ST weekly through [name of school]. PT is virtually 30 min/wk, OT is 30 min/wk virtually, and ST 20 min/wk virtually.” The agency failed to document communication or coordination notes with an unaffiliated therapy service regarding recommendations for agency nursing staff to follow.

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 record review and interview, the agency failed to ensure unvaccinated staff exposed to Covid-19 were allowed to quarantine for 1 of 2 administrative staff. (Administrator); failed to ensure the agency had adequate staffing during a Covid surge; and failed to maintain, document, and implement an infection control plan during a Covid-19 surge for employees that cover multiple roles for separate Entities for 1 of 1 home health agency. Findings include: 1. A December 17, 2021 media statement titled, CDC (Centers for Disease Control and Prevention) Updates and Shortens Recommended Isolation and Quarantine Period for General Population indicated, but was not limited to, “is updating the recommended quarantine period for anyone in the general public who is exposed to COVID-19 people who are unvaccinated or are more than six months out from their second mRNA dose (or more than 2 months after the J&J vaccine) and not yet boosted, CDC now recommends quarantine for 5 days followed by strict mask use for an additional 5 days. Alternatively, if a 5-day quarantine is not feasible, it is imperative that an exposed person wear a well-fitting mask when around others for 10 days after exposure”. 2. On 1/3/2022 at 9:27 a.m. arrived at agency, door locked, with a noted posted would be back at 2:30 p.m. A note posted on the agency door indicated the Administrator [name] could be reached at [1-740 number] or [1-812 number]. At 9:35 a.m. called [1-740 number] disconnected. Called [1-812 number] Administrator answered and indicated he/she was Covid positive and in isolation until Thursday, and no one was at the Evansville office. The Administrator indicated Person J was the Alternate Administrator from Ohio [4 hours away] and Administrator Q for [Entity 1] was 2.5 hours away. At 9:47 a.m. the Administrator indicated he/she had no one to fill the roles of Clinical Supervisor and he/she took the Administrator position on October 4, 2021. Asked the Administrator if there was an RN close by to open the agency to start the survey. The Administrator indicated he/she will place a call to Administrator Q. At 10:20 a.m. call was placed to Administrator who indicated Person J and Person B sent a letter to the state agency on October 28, 2021, regarding the changes in Administration. The Administrator stated he/she did not test positive for Covid, but his/her family tested positive on December 31 and was isolating as a precaution. At 11:00 a.m. the Administrator indicated that Administrator Q from Indianapolis was his/her back-up. The Administrator indicated he/she would come out of isolation to open the agency to begin the survey. The agency failed to provide adequate staffing, so an unvaccinated staff member exposed to Covid-19 could follow CDC recommendations to quarantine for 5 days and failed to ensure a qualified Alternate served in the absence of the Administrator during a pandemic. 3. During an interview on Sunday 1/9/2022 at 3:24 p.m. received a phone call from the Administrator indicated he/she tested positive for Covid-19 and the contracted Alternate Administrator family member tested positive for Covid-19 Friday. Person J was on his/her way from Ohio and would pick up the key to the agency at the Administrator’s house. The Administrator indicated Person O from Ohio instructed the Administrator to call the surveyor and ask what to do. Queried if the contracted Alternate Clinical Supervisor and/or the Governing Body was notified to which she/he indicated they would try. The agency failed to maintain, document, and implement an infection control program which has as its goal the prevention and control of infections and communicable diseases; and failed to adequately staff the agency during a Covid 19 surge; and failed to have a plan in place for administration that cover multiple roles for separate Entities during a Covid surge. 4. During an interview on Sunday 1/9/2022 at 4:46 p.m. received a phone call from the Administrator indicating he/she would be available by phone on Monday and that Person J called the contracted Clinical Nursing Supervisor to help with the survey on Monday but had not heard back from him/her. 5. During an interview on 1/10/2022 at 8:06 a.m. Person J indicated he/she had an emergency Governing Body meeting on 1/9/2022 at 6:40 p.m. with the Administrator, President O, Person B, and Person C. Queried if contracted Alternate Nursing Supervisor would be present for survey. Person J indicated the Alternate Nursing Supervisor for Evansville was to maintain the Entity 1 office in Indianapolis since Administrator Q of Entity 1 was exposed to Covid with symptoms. 6. On 1/11/2022 at 11:16 a.m. a Covid Call Log was provided by Person J. The Call Log indicated 1 patient tested positive for Covid and 2 registered nurses were exposed to Covid during the survey. 17-12-1(m)

Disclosure of ownership and management info. CFR(s): 484.100(a) Standard: Disclosure of ownership and management information. The HHA must comply with the requirements of part 420 subpart C, of this chapter. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure management information for Pediatric Nursing Specialist of Evansville was disclosed to the state agency for 1 of 1 home health agency. Findings include: 1. A revised January 2018 policy titled Governing Body was provided by the Administrator on 1/4/2022 at 3:00 p.m. The policy indicated, but was not limited, “The Governing Body shall assume full legal authority and responsibility for the operation of Agency. New governing body members are oriented to the agency as appropriate to responsibilities … To ensure the lines of authority are established … 6. Define the corporate structure and clearly indicate lines of authority.” A signed September 20, 2021, Clinical Administrator job description was provided by the Administrator on 1/4/2022 at 4:00 p.m. The job description indicated, but was not limited to, “… Assures compliance with the requirements of state licensure, Medicare certification, and compliance with regulatory agencies through policy and procedures, staff education, and ongoing monitoring activities …” 2. On 1/3/2022 at 11:30 a.m. the Administrator provided a document titled Home Care Network Division 71 Organizational Chart 2022. The chart indicated the Administrator reported to “Chief Operating Officer [Person B] *Board member”. Person B reports to the Board of Directors/Governing Body. On 1/3/2022 at 3:30 p.m. the Administrator provided a document titled Home Care Network, INC A-110 Disclosure of Ownership & Management. The document listed Person B under Ownership & Management. The backside of the document included Governing Body members President O, Secretary P, and Person C, Person D as secretaries. On 1/4/2022 at 10:30 a.m. the Administrator provided undated Minutes of the Annual Meeting of the Board of Directors/Governing Body and Administrator of Home Care Network, Inc. The meeting minutes indicated “That [Person J] was appointed to the Board of Directors/Governing Board for the position of Corporate trainer” signed by the Chairperson (President O). 3. Review of the State database information indicated Person B and Person J were not listed as administration, ownership, or management for the agency. 4. On 1/4/2022 at 10:30 a.m. Person J provided a document dated 2/8/2019 that indicated ownership and Governing Body information. The document included Governing Body members President O, Secretary P, Person C and Person D as secretaries and Person J as Trainer. The agency failed to ensure disclosure to the state agency of changes in management regarding Person J. On 1/4/2022 at 4:00 p.m. the Administrator provided a revised document titled Home Care Network, Inc. d/b/a: Pediatric Nursing Specialist Organizational Chart. The chart indicated the Administrator reported to Person B, Chief Operating Officer. Person B reports to the Board of Directors. The agency failed to ensure disclosure to the state agency of changes in management regarding Person B. 5. During an interview on 1/4/2022 at 10:30 a.m. Person J indicated Person B was not a Governing Body / Board of Director member but was a manager. Person J was queried about the undated Governing Body meeting minutes and list of Governing Body members to which he/she stated, “I am not a Governing Body member”. Person J was unable to explain why he/she was listed under the Governing Body content dated 2/8/2019. During an interview on 1/10/2022 at 8:06 a.m. Person J indicated he/she did not realize he/she was a member of the Governing Body until yesterday.

Information to the state survey agency CFR(s): 484.100(a) Standard: The HHA also must disclose the following information to the state survey agency at the time of the HHA's initial request for certification, for each survey, and at the time of any change in ownership or management: This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to disclose to the state agency any change in management for the Pediatric Nursing Specialty of Evansville for 1 of 1 home health agency. Findings include: 1. A revised January 2018 policy titled Governing Body was provided by the Administrator on 1/4/2022 at 3:00 p.m. The policy indicated, but was not limited, “The Governing Body shall assume full legal authority and responsibility for the operation of Agency. New governing body members are oriented to the agency as appropriate to responsibilities … To ensure the lines of authority are established … 6. Define the corporate structure and clearly indicate lines of authority.” A signed September 20, 2021, Clinical Administrator job description was provided by the Administrator on 1/4/2022 at 4:00 p.m. The job description indicated, but was not limited to, “… Assures compliance with the requirements of state licensure, Medicare certification, and compliance with regulatory agencies through policy and procedures, staff education, and ongoing monitoring activities …” 2. On 1/3/2022 at 11:30 a.m. the Administrator provided a document titled Home Care Network Division 71 Organizational Chart 2022. The chart indicated the Administrator reported to “Chief Operating Officer [Person B] *Board member”. Person B reports to the Board of Directors/Governing Body. On 1/3/2022 at 3:30 p.m. the Administrator provided a document titled Home Care Network, INC A-110 Disclosure of Ownership & Management. The document listed Person B under Ownership & Management. The backside of the document included Governing Body members President O, Secretary P, and Person C, Person D as secretaries. On 1/4/2022 at 10:30 a.m. the Administrator provided undated Minutes of the Annual Meeting of the Board of Directors/Governing Body and Administrator of Home Care Network, Inc. The meeting minutes indicated “That [Person J] was appointed to the Board of Directors/Governing Board for the position of Corporate trainer” signed by the Chairperson (President O). 3. Review of the State database information indicated Person B and Person J were not listed as administration, ownership, or management for the agency. 4. On 1/4/2022 at 10:30 a.m. Person J provided a document dated 2/8/2019 that indicated ownership and Governing Body information. The document included Governing Body members President O, Secretary P, Person C and Person D as secretaries and Person J as Trainer. The agency failed to ensure disclosure to the state agency of changes in management regarding Person J. On 1/4/2022 at 4:00 p.m. the Administrator provided a revised document titled Home Care Network, Inc. d/b/a: Pediatric Nursing Specialist Organizational Chart. The chart indicated the Administrator reported to Person B, Chief Operating Officer. Person B reports to the Board of Directors. The agency failed to ensure disclosure to the state agency of changes in management regarding Person B. 5. During an interview on 1/4/2022 at 10:30 a.m. Person J indicated Person B was not a Governing Body / Board of Director member but was a manager. Person J was queried about the undated Governing Body meeting minutes and list of Governing Body members to which he/she stated, “I am not a Governing Body member”. Person J was unable to explain why he/she was listed under the Governing Body content dated 2/8/2019. During an interview on 1/4/2022 at 4:20 p.m. the Administrator indicated he/she was not aware of Article 17, state licensure requirements, or the Administrative Code and was unable to provide any additional information or comments. During an interview on 1/10/2022 at 8:06 a.m. Person J indicated he/she did not realize he/she was a member of the Governing Body until yesterday. 17-10-1(d)

Officer, a director, agent, managing employee CFR(s): 484.100(a)(2) The name and address of each person who is an officer, a director, an agent, or a managing employee of the HHA as defined in §420.20l, §420.202, and §420.206 of this chapter. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to disclose to the state agency any officer, director, agent, or managing employee specific to Pediatric Nursing Specialist of Evansville for 1 of 1 home health agency. Findings include: 1. A revised January 2018 policy titled Governing Body was provided by the Administrator on 1/4/2022 at 3:00 p.m. The policy indicated, but was not limited, “The Governing Body shall assume full legal authority and responsibility for the operation of Agency. New governing body members are oriented to the agency as appropriate to responsibilities … To ensure the lines of authority are established … 6. Define the corporate structure and clearly indicate lines of authority.” A signed September 20, 2021, Clinical Administrator job description was provided by the Administrator on 1/4/2022 at 4:00 p.m. The job description indicated, but was not limited to, “… Assures compliance with the requirements of state licensure, Medicare certification, and compliance with regulatory agencies through policy and procedures, staff education, and ongoing monitoring activities …” 2. Review of the State database information indicated Person B and Person J were not listed as administration, ownership, or management for the agency. 3. On 1/3/2022 at 11:30 a.m. the Administrator provided a document titled Home Care Network Division 71 Organizational Chart 2022. The chart indicated the Administrator reported to “Chief Operating Officer [Person B] *Board member”. Person B reports to the Board of Directors/Governing Body. On 1/3/2022 at 3:30 p.m. the Administrator provided a document titled Home Care Network, INC A-110 Disclosure of Ownership & Management. The document listed Person B under Ownership & Management. The backside of the document included Governing Body members President O, Secretary P, and Person C, Person D as secretaries. On 1/4/2022 at 10:30 a.m. the Administrator provided undated Minutes of the Annual Meeting of the Board of Directors/Governing Body and Administrator of Home Care Network, Inc. The meeting minutes indicated “That [Person J] was appointed to the Board of Directors/Governing Board for the position of Corporate trainer” signed by the Chairperson (President O). On 1/4/2022 at 10:30 a.m. Person J provided a document dated 2/8/2019 that indicated ownership and Governing Body information. The document included Governing Body members President O, Secretary P, Person C and Person D as secretaries and Person J as Trainer. The agency failed to ensure disclosure to the state agency of changes in management regarding Person J. On 1/4/2022 at 4:00 p.m. the Administrator provided a revised document titled Home Care Network, Inc. d/b/a: Pediatric Nursing Specialist Organizational Chart. The chart indicated the Administrator reported to Person B, Chief Operating Officer. Person B reports to the Board of Directors. The agency failed to ensure disclosure to the state agency of changes in management regarding Person B. 4. During an interview on 1/4/2022 at 10:30 a.m. Person J indicated Person B was not a Governing Body / Board of Director member but was a manager. Person J was queried about the undated Governing Body meeting minutes and list of Governing Body members to which he/she stated, “I am not a Governing Body member”. Person J was unable to explain why he/she was listed under the Governing Body content dated 2/8/2019. During an interview on 1/4/2022 at 4:20 p.m. the Administrator indicated he/she was not aware of Article 17, state licensure requirements, or the Administrative Code and was unable to provide any additional information or comments. During an interview on 1/10/2022 at 8:06 a.m. Person J indicated he/she did not realize he/she was a member of the Governing Body until yesterday. 17-10-1(d)(2)

Responsible for the management of the HHA CFR(s): 484.100(a)(3) The name and business address of the corporation, association, or other company that is responsible for the management of the HHA, and the names and addresses of the chief executive officer and the chairperson of the board of directors of that corporation, association, or other company responsible for the management of the HHA. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to disclose to the state agency the name and address of any person that was responsible for the management specific to Pediatric Nursing Specialist of Evansville for 1 of 1 home health agency. Finding include: 1. A revised January 2018 policy titled Governing Body was provided by the Administrator on 1/4/2022 at 3:00 p.m. The policy indicated, but was not limited, “The Governing Body shall assume full legal authority and responsibility for the operation of Agency. New governing body members are oriented to the agency as appropriate to responsibilities … To ensure the lines of authority are established … 6. Define the corporate structure and clearly indicate lines of authority.” A signed September 20, 2021, Clinical Administrator job description was provided by the Administrator on 1/4/2022 at 4:00 p.m. The job description indicated, but was not limited to, “… Assures compliance with the requirements of state licensure, Medicare certification, and compliance with regulatory agencies through policy and procedures, staff education, and ongoing monitoring activities …” 2. Review of the State database information indicated Person B and Person J were not listed as administration, ownership, or management for the agency. 3. On 1/3/2022 at 11:30 a.m. the Administrator provided a document titled Home Care Network Division 71 Organizational Chart 2022. The chart indicated the Administrator reported to “Chief Operating Officer [Person B] *Board member”. Person B reports to the Board of Directors/Governing Body. On 1/3/2022 at 3:30 p.m. the Administrator provided a document titled Home Care Network, INC A-110 Disclosure of Ownership & Management. The document listed Person B under Ownership & Management. The backside of the document included Governing Body members President O, Secretary P, and Person C, Person D as secretaries. On 1/4/2022 at 10:30 a.m. the Administrator provided undated Minutes of the Annual Meeting of the Board of Directors/Governing Body and Administrator of Home Care Network, Inc. The meeting minutes indicated “That [Person J] was appointed to the Board of Directors/Governing Board for the position of Corporate trainer” signed by the Chairperson (President O). On 1/4/2022 at 10:30 a.m. Person J provided a document dated 2/8/2019 that indicated ownership and Governing Body information. The document included Governing Body members President O, Secretary P, Person C and Person D as secretaries and Person J as Trainer. The agency failed to ensure disclosure to the state agency of changes in management regarding Person J. On 1/4/2022 at 4:00 p.m. the Administrator provided a revised document titled Home Care Network, Inc. d/b/a: Pediatric Nursing Specialist Organizational Chart. The chart indicated the Administrator reported to the Person B, Chief Operating Officer. Person B reports to the Board of Directors. The agency failed to ensure disclosure to the state agency of changes in management regarding Person B. 4. During an interview on 1/4/2022 at 10:30 a.m. Person J indicated Person B was not a Governing Body / Board of Director member but was a manager. Person J was quired about the undated Governing Body meeting minutes and list of Governing Body members to which he/she stated, “I am not a Governing Body member”. Person J was unable to explain why he/she was listed under the Governing Body content dated 2/8/2019. During an interview on 1/4/2022 at 4:20 p.m. the Administrator indicated he/she was not aware of Article 17, state licensure requirements, or the Administrative Code and was unable to provide any additional information or comments. During an interview on 1/10/2022 at 8:06 a.m. Person J indicated he/she did not realize he/she was a member of the Governing Body until yesterday. 17-10-1(d)(4)

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: Based on record review and interview, the agency failed to ensure administrative and supervisory duties such as scheduling, documentation of missed visits, physician notification, and after hour phone calls were not delegated to a contracted Entity or another agency (See G940); the governing body failed to ensure the Administrator and Alternate Administrator were adequately trained, participated in the survey, and able to manage the day-to-day operations (See G942); failed to demonstrate distinct boundaries of the Medicaid certified program in relation to any other programs the larger organization has to offer (See G944); failed to ensure the administrator reported directly to the Governing Body without the use of intermediaries (See G946); failed to ensure the Administrator was responsible for the day-to-day operations of the agency (See G948); failed to ensure a person authorized by the governing body was able to assume the administrator role and was available during an emergency pandemic for Pediatric Nursing Specialist of Evansville (See G954); and failed to offer and provide one other therapeutic service such as physical or occupational therapy, speech-language therapy, medical social services, or home health aide available on a visiting basis in the patient’s home (See G982) The cumulative effect of this systemic problem resulted in the agency being out of compliance with the Condition of Participation 484.105 Organization and Administration of services Findings include for G940: 1. Administrative and Supervisor Duties: A revised January 2018 policy titled Governing Body was provided by the Administrator on 1/4/2022 at 3:00 p.m. The policy indicated, but was not limited, “The Governing Body shall assume full legal authority and responsibility for the Cooperation of Agency. New governing body members are oriented to the agency as appropriate to responsibilities … The duties and responsibilities of the Governing Body shall include: 1. Appoint a qualified Administrator. Delegate to that individual the authority and responsibility for the provision of home care services in accordance with state and federal regulations … To ensure the lines of authority are established …” A signed September 20, 2021, Clinical Administrator job description was provided by the Administrator on 1/4/2022 at 4:00 p.m. The job description indicated, but was not limited to, “Provides direction, coordination, supervision and implementation … 1. Coordinates and directs programs and staffing … Assures compliance with the requirements of state licensure, Medicare certification, and compliance with regulatory agencies through policy and procedures, staff education, and ongoing monitoring activities …” During entrance conference on 1/3/2022 at 11:10 a.m. asked the Administrator how 24-hour call was handled. The Administrator indicated he/she was not sure, but calls go to a Scheduler in Ohio who handles missed visits and physician notification of missed visit and was unsure of the Schedulers names. Asked the Administrator why administrative duties were delegated to a Scheduler in Ohio to which he/she replied, “I don’t know”. On 1/3/2022 at 3:30 p.m. the Administrator provided 4 Scheduler contracts as follows: Scheduler K dated 8/16/2021, Scheduler L dated 5/5/2021, Scheduler M dated 5/5/2021, and Scheduler N dated 5/5/2021. The contracts were all signed by the Alternate Administrator. Confirmed with the Administrator the contracts were not at the agency but were acquired from a different Entity. Review of contracted Scheduler K indicated but was not limited to “The Agreement is entered into on this August 16, 2021, by and between Pediatric Nursing Specialists of HCN … “Agency”, whose principal place of business is located at [address] Evansville … and [Scheduler K] (… referred to as “Contractor”) whose principal place of business is located at [address] Jackson, [Ohio] … The Contractor will initiate and change/modify Client schedules. The Contractor will complete missed visit forms and inform physician and payer CM of missed services or changes in schedules. The Contractor will verify schedules and clear EVV [electronic visit verification] exceptions. The Contractor will receive telephone calls and transfer those calls to the appropriate Indiana staff during working hours and after hours-24 hours 7 days per week. Responsibilities of the Agency: The agency will be responsible for supervision of the Contractor. The Agency will be responsible for providing direction/instruction. The Agency will be responsible for any disciplinary action. The Agency will be responsible for taking any action that requires follow-up for any transferred calls. The Agency will have set meetings with the Contractor to discuss staffing needs and missed visits.” Review of contracted Scheduler L indicated but was not limited to “The Agreement is entered into on this May 5th, 2021, by and between Pediatric Nursing Specialists of HCN … “Agency”, whose principal place of business is located at [address] Evansville … and [Scheduler L] (… referred to as “Contractor”) whose principal place of business is located at [address] Jackson, [Ohio] … The Contractor will initiate and change/modify Client schedules. The Contractor will complete missed visit forms and inform physician and payer CM of missed services or changes in schedules. The Contractor will verify schedules and clear EVV exceptions. The Contractor will receive telephone calls and transfer those calls to the appropriate Indiana staff during working hours and after hours-24 hours 7 days per week. Responsibilities of the Agency: The agency will be responsible for supervision of the Contractor. The Agency will be responsible for providing direction/instruction. The Agency will be responsible for any disciplinary action. The Agency will be responsible for taking any action that requires follow-up for any transferred calls. The Agency will have set meetings with the Contractor to discuss staffing needs and missed visits.” Review of contracted Scheduler M indicated but was not limited to “The Agreement is entered into on this 5/5/2021, by and between Pediatric Nursing Specialists of HCN … “Agency”, whose principal place of business is located at [address] Evansville … and [Scheduler M] (… referred to as “Contractor”) whose principal place of business is located at [address] Jackson, [Ohio] … The Contractor will initiate and change/modify Client schedules. The Contractor will complete missed visit forms and inform physician and payer CM of missed services or changes in schedules. The Contractor will verify schedules and clear EVV exceptions. The Contractor will receive telephone calls and transfer those calls to the appropriate Indiana staff during working hours and after hours-24 hours 7 days per week. Responsibilities of the Agency: The agency will be responsible for supervision of the Contractor. The Agency will be responsible for providing direction/instruction. The Agency will be responsible for any disciplinary action. The Agency will be responsible for taking any action that requires follow-up for any transferred calls. The Agency will have set meetings with the Contractor to discuss staffing needs and missed visits.” Review of contracted Scheduler N indicated but was not limited to “The Agreement is entered into on this 5th day of May 2021, by and between Pediatric Nursing Specialists of HCN … “Agency”, whose principal place of business is located at [address] Evansville … and [Scheduler N] (… referred to as “Contractor”) whose principal place of business is located at [address] Jackson, [Ohio] … The Contractor will initiate and change/modify Client schedules. The Contractor will complete missed visit forms and inform physician and payer CM of missed services or changes in schedules. The Contractor will verify schedules and clear EVV exceptions. The Contractor will receive telephone calls and transfer those calls to the appropriate Indiana staff during working hours and after hours-24 hours 7 days per week. Responsibilities of the Agency: The agency will be responsible for supervision of the Contractor. The Agency will be responsible for providing direction/instruction. The Agency will be responsible for any disciplinary action. The Agency will be responsible for taking any action that requires follow-up for any transferred calls. The Agency will have set meetings with the Contractor to discuss staffing needs and missed visits.” During an interview on 1/11/2022 at 2:00 p.m. the Administrator was asked if he/she supervised the contracted Schedulers to which he/she relied “I do not supervise them, they are not my employees, I have talked to them about the schedule, but I don’t talk to them daily” 2. Organizational Structure: A revised January 2018 policy titled Governing Body was provided by the Administrator on 1/4/2022 at 3:00 p.m. The policy indicated, but was not limited, “The Governing Body shall assume full legal authority and responsibility for the Cooperation of Agency. New governing body members are oriented to the agency as appropriate to responsibilities … To ensure the lines of authority are established … 6. Define the corporate structure and clearly indicate lines of authority.” A signed September 20, 2021, Clinical Administrator job description was provided by the Administrator on 1/4/2022 at 4:00 p.m. The job description indicated, but was not limited to, “… Assures compliance with the requirements of state licensure, Medicare certification, and compliance with regulatory agencies through policy and procedures, staff education, and ongoing monitoring activities …” Review of the state database indicated 2 owner/officers listed [President/Owner O and Owner P]. On 1/3/2022 at 11:30 a.m. the Home Care Network Division 71 Organizational Chart 2022 was provided by the Administrator. At that time, the Administrator indicated contracted Alternate Administrator Q based in Indianapolis would help him/her by phone during the survey. Review of the chart indicated, “Program Admin/Supervising RN [name of Administrator] **Back up Admin: [Alt. Admin. Q] **Back Up RN: [Alt. Clinical Sup. R]” all report to “Chief Operating Officer [Person B] *Board Member” who reports to “Board of Directors/Governing Body”. The agency failed to ensure the Administrator reports directly to the Governing Body without the use of intermediaries. On 1/3/2022 at 3:30 p.m. the Administrator indicated he/she spoke with Person J by phone in Ohio to confirm the Organizational chart was correct. Person J indicated Person B was a not a Board Member as indicated on the 2022 Organizational chart for the Evansville agency. Person J indicated Person B was not an owner or Board member but was a manager. At that time, the Administrator indicated he/she reported to contracted Alternate Administrator based in Indianapolis and Person B. The agency failed to ensure the Administrator reports directly to the Governing Body without the use of intermediaries. On 1/3/2022 at 3:35 p.m. the Administrator called the Alternate Administrator to confirm who the current Governing Body members were. The Alternate Administrator indicated there were 4 members of the Governing Body: President O, Owner P, Person C, and Person D. On 1/4/2022 at 10:30 a.m. the Administrator and Person J were both present at the agency. The Minutes of the Annual Meeting of the Board of Directors/Governing Body and Administrator of Home Care Network, INC [Ohio address] undated 2-page document signed by President/Owner O and Person B was provided by the Administrator. The Administrator provided a third document titled Minutes of the Annual Meeting of the Board of Directors/Governing Body and Administrator Home Care Network INC [Evansville address] Indiana Pediatric Division BU#71 Medicare #15-7276 signed by the Administrator, President/Owner O and Person J dated “4th day of October 2021.” Administrator was asked to verify the date on the first two pages due to the contents of information and conflicting interviews during the survey. The Administrator consulted with Person B and returned all three pages stapled together and stated all three pages were one meeting that took place on October 4, 2021. During an interview on 1/4/2022 at 10:30 a.m. Person J was asked if he/she was a Governing Body member to which he/she responded “no”. At that time, Person J was informed the contents of the undated Governing Body meeting indicated “… [Person J] RN was appointed to the Board of Directors/Governing Board for the position of Corporate trainer … There being no further business to come before the meeting upon motion, the same was duly adjourned. [Person O] Chairperson Attest: [Person B] Chief Operating Officer” Person J stated that he/she was not a Governing Body member but was the Corporate Trainer for all agencies in Ohio and Indiana. On 1/4/2022 at 3:05 p.m. the Administrator provided a second Organizational chart with a revised date April 2021 titled Home Care Network Pediatric Nursing Specialist / Maternal Child Health Organizational Chart. The Administrator was queried if Maternal Child Health was added as a new name for the Evansville agency. The Administrator indicated the chart was for the whole company. Review of the chart indicated the Program Administrator and Program Administrator backup for the Evansville agency both report to the Chief Operating Officer Person B. The agency failed to ensure the Administrator reports directly to the Governing Body without the use of intermediaries. On 1/4/2022 at 4:00 p.m. the Administrator provided a third Organizational chart with a revised date January 2022 titled Home Care Network, INC d/b/a: Pediatric Nursing Specialist Organizational Chart. Review of the chart indicated the Program Administrator and Program Administrator backup for the Evansville agency both report to the Chief Operating Officer Person B. The agency failed to ensure the agency accurately set forth in writing, its organizational structure, lines of authority, and services furnished and failed to ensure the Administrator reports directly to the Governing Body without the use of intermediaries. During an interview on 1/4/2022 at 4:20 p.m. the Administrator indicated he/she was not aware of Article 17, state licensure requirements, or the Administrative Code and was unable to provide any additional information or comments. During an interview on 1/10/2022 at 8:06 a.m. Person J indicated he/she did not realize he/she was a member of the Governing Body until yesterday. 3. Administration and Delegation to a 3rd party agency: During an interview on 1/10/2022 at 3:25 p.m. the Administrator was asked why the agency phones did not ring all last week (1/3-1/6) and today. Surveyor called the agency while at the agency and no office desk phones rang but forwarded to a call center. The Administrator was unsure why the office phones had not rung. The Administrator indicated the agency has a call center in Ohio. During an interview on 1/11/2022 at 2:30 p.m. Person J indicated during the day phone calls are routed to Ohio call center then to the agency. Person J indicated the agency had a contracted 3rd party after hours call service. Asked Person J to provide contract for review. Person J indicated he/she checked with Person O and the agency does not have a contract with the [name] 3rd party after hours call center. Person J indicated the December 2021 bill was paid for the 3rd party call center but would be eventually weaned out. Person J indicated the 3rd party call center should know HIPAA. The agency delegated administrative duties to a 3rd party after hours call agency without a contract/agreement that included how the call center handled patient health information for the agency, HIPAA compliance, training, functions, management, and turn- around time. 17-12-1(a)(1) 17-12-1(a)(2) 17-12-1(b)(1)

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on observation, record review, and interview, the governing body failed to ensure the Administrator and Alternate Administrator were adequately trained, participated in the survey, and able to manage the day-to-day operations for 1 of 1 home health agency. Findings include: A revised January 2018 policy titled Governing Body was provided by the Administrator on 1/4/2022 at 3:00 p.m. The policy indicated, but was not limited, “The Governing Body shall assume full legal authority and responsibility for the Cooperation of Agency. New governing body members are oriented to the agency as appropriate to responsibilities … To ensure the lines of authority are established … 6. Define the corporate structure and clearly indicate lines of authority.” A signed September 20, 2021, Clinical Administrator job description was provided by the Administrator on 1/4/2022 at 4:00 p.m. The job description indicated, but was not limited to, “… Assures compliance with the requirements of state licensure, Medicare certification, and compliance with regulatory agencies through policy and procedures, staff education, and ongoing monitoring activities …” On 1/3/2022 at 9:27 a.m. arrived at agency, door locked, with a noted posted would be back at 2:30 p.m. A note posted on the agency door indicated the Administrator [name] could be reached at [1-740 number] or [1-812 number]. At 9:35 a.m. called [1-740 number] disconnected. Called [1-812 number] Administrator answered and indicated he/she was Covid positive and in isolation until Thursday, and no one was at the Evansville office. The Administrator indicated Person J was the Alternate Administrator from Ohio [4 hours away] and Administrator Q for [Entity 1] was 2.5 hours away. At 9:47 a.m. the Administrator indicated he/she had no one to fill the roles of Clinical Supervisor and he/she took the Administrator position on October 4, 2021. Asked the Administrator if there was an RN close by to open the agency to start the survey. The Administrator indicated he/she will place a call to Administrator Q. At 10:20 a.m. call was placed to Administrator who indicated Person J and Person B sent a letter to the state agency on October 28, 2021, regarding the changes in Administration. The Administrator stated he/she did not test positive for Covid, but his/her family tested positive on December 31 and was isolating as a precaution. The Administrator indicated he/she would come out of isolation to open the agency and begin the survey. The Administrator indicated his/her Alternate would be available by phone. During entrance conference on 1/3/2022 at 11:10 a.m. the Administrator confirmed the office hours were 8 a.m. to 5 p.m. Monday to Friday. The Administrator indicated no other staff in the office, and he/she does home visits. The Administrator indicated the phone with the 1-740 number was disconnected because patient caregivers would not answer an out of state phone number when called. The Administrator was asked who the Alternate Administrator, Clinical Supervisor, and Alternate Clinical Supervisor were for the agency. The Administrator indicated [name Q] from Indianapolis was the Alternate, “I guess I am the Clinical Supervisor, and I guess the Alternate Administrator is the Alternate Clinical Supervisor”. The Administrator indicated the person the state agency had on file for Alternate Clinical Supervisor [name R] was no longer with the agency but was still with [Entity 1] and was the former Administrator for [Entity 2]. Asked Administrator for the appointment letters for those positions to which he/she relied “I don’t know what that is”. During entrance conference on 1/3/2022 at 11:10 a.m. the Administrator was asked what services the agency provides. The Administrator indicated the agency offers skilled nursing and home health aide services. Queried if the agency offers therapy services. The Administrator indicated the agency does not offer physical, occupational, or speech therapies. The agency does not offer attendant care services or social work. Queried if the agency has any services provided under contract to which he/she replied, “not that I’m aware of but I will find out”. The Administrator was asked if the agency shares any patients with another agency to which he/she replied, “I’m sure we do, therapy through school”. The Administrator indicated the agency coordinated care with other agencies by sending the plan of care to the agencies. During entrance conference on 1/3/2022 at 11:10 a.m. the Administrator was asked who the members of the Governing Body were to which he/she replied “I don’t know what that is, but I will find out” During entrance conference the Administrator was asked who implements the budget and accounting system for the agency. The Administrator indicated he/she had a weekly meeting on Mondays with Person B to go over the budget but does not do anything with the budget. Asked if he/she kept record of the meetings to which he/she replied, “no but [Person B] does and we talk about where everyone stands, nothing else”. Asked if Person B was aware no one was at the office this a.m. to which he/she replied, “no, but [Alternate Administrator] knows and is my back-up”. The Administrator was queried about his/her training and orientation to the agency. The Administrator indicated he/she went to Ohio for 2 weeks of training and the Administrator from Entity 1, who was the Alternate for the agency location, came down from Indianapolis for a few days to train at the agency. During entrance conference on 1/3/2022 at 11:10 a.m. the Administrator was asked how 24-hour call was handled. The Administrator indicated the schedulers from Ohio handle it. The Administrator indicated he/she does not know their names but would find out. Asked if there were any services the agency had trouble staffing and how it was handled to which he/she replied, “not that I’m aware of”. The Administrator indicated he/she case managed all patients. Asked the Administrator who was in charge of complaints to which he/she replied, “I would assume me, I have had no complaints since I started, I do know there is a complaint log that has guidance”. Asked the Administrator for the complaint log/resolutions for the past year at the end of conference. Asked the Administrator to explain the agency’s patient referral process to which he/she replied, “No, but I will find out. I have not gotten any phone calls from hospitals or doctors’ offices; I have not had any new admissions since I’ve been here. I have two separate numbers”. During an observation of the agency office along with the Administrator on 1/3/2022 at 3:00 p.m. reviewed the contents of one unlocked file cabinet that contained personnel files. Queried if the Alternate Administrator, Alternate Clinical Supervisor, and any other contracted employee files were kept in the file cabinet or anywhere else at the Evansville agency. The Administrator confirmed the files were not kept at the agency. The Administrator indicated the agency contracts 4 schedulers from separate licensed offices and their personnel files are not kept at the Evansville office. The agency failed to maintain personnel files specific for the Evansville location. During an interview on 1/3/2022 at 3:20 p.m. the Administrator returned the state personnel record form provided by the surveyor with hire dates for Schedulers L, M, N as 5/5/2021 and Schedular K as 8/16/2021 which he/she obtained from a separate licensed Entity. The agency did not have any personnel files for contracted therapist at the agency. The agency failed to maintain personnel files specific for the Evansville location. During an interview on 1/4/2022 at 10:30 a.m. Person J indicated the Alternate Administrator would not be available due to a dying family member and the Alternate Clinical Supervisor would not be available due to covering for the Administrator at Entity 1 Indianapolis. At that time, Person J indicated Person B was not a Governing Body / Board of Director member but was a manager. Person J was queried about the undated Governing Body meeting minutes and list of Governing Body members to which he/she stated, “I am not a Governing Body member”. Person J was unable to explain why he/she was listed as a Governing Body member in Governing Body meeting minutes dated 2/8/2019. Person J was asked if he/she was a Governing Body member to which he/she responded “no”. At that time, Person J was informed the contents of the undated Governing Body meeting indicated “… [Person J] RN was appointed to the Board of Directors/Governing Board for the position of Corporate trainer … There being no further business to come before the meeting upon motion, the same was duly adjourned. [Person O] Chairperson Attest: [Person B] Chief Operating Officer” Person J stated that he/she was not a Governing Body member but was the Corporate Trainer for all agencies in Ohio and Indiana. During an interview on 1/4/2022 at 11:00 a.m. Person J provided a copy of an email submitted to the state agency by Person L on 1/3/2022 that indicated the following: “Indiana License [Entity 1] (mailed back in 06/21/2021 and then resent August) Changing administration staff effective 06/01/2021 Alternate Administrator [name] RN Supervisor [Person P name] Indiana License [Entity 2] (mailed back in 06/21/2021 and then resent August) Changing administration staff effective 06/01/2021 Alternate Administrator [name] Alternate RN Supervisor [Person P name] Indiana License IN005942 (mailed 10/28/2021) Changing administration staff effective 10/4/2021) Administrator [name]” During an interview on 1/4/2022 at 4:20 p.m. the Administrator indicated he/she was not aware of Article 17, state licensure requirements, or the Administrative Code and was unable to provide any additional information or comments. During an interview on 1/5/2022 at 8:50 a.m. requested the complaint log for the past year from the Administrator again. The Administrator indicated he/she could not find it and would reach out to the Alternate Administrator. At 9:25 a.m. Person J and the Administrator located a white binder labeled complaint book on top of the personnel file cabinet. Review of the complaint log indicated the Administrator filled out 1 (one) complaint form for patient 2 dated 10/21/21 that indicated “lack of staff to fulfill all hours”. The Complaint Form indicated “staffing still not found- a sign on bonus has now been added -12/28/21 Pediatric nursing specialists will also be adding radio/tv commercials locally 12/28”. The Administrator did not comment as to why the surveyor was told he/she had no complaints since his/her hire date and did not have a problem with staffing in entrance conference. During an interview on 1/6/2022 at 10:10 a.m. requested that the Administrator provide consents from a paper chart from a discharged patient for review. The Administrator did not know where discharge records were. Person J indicated discharge records are not kept here and was not sure where those records were. Person J indicated it depends on if the office has space to store the records. At 10:30 a.m. the Administrator provided a copy of requested forms. On 1/10/2022 at 9:45 a.m. asked Person J where PPE was kept for staff. Person J indicated PPE was kept in a different office down the hall. Person J opened a locked door where PPE supplies were kept as well as discharged patient charts and past employee files. Person J and the Administrator lacked orientation and training to the Evansville office. During an interview on 1/6/2022 at 4:30 p.m. asked the Administrator if he/she was still in training to which he/she replied, “I’m training everyday”. At that time, Person J indicated he/she was here to train and trains for all agencies. Person J indicated if the Administrator needs something he/she can call. During an interview on Sunday 1/9/2022 at 3:24 p.m. received a phone call from the Administrator indicating he/she and the Alternate Administrator both tested positive for Covid with symptoms and are in isolation and Person J was on the way from Ohio. The Administrator indicated Person O from Ohio instructed him/her to call the surveyor for guidance. Asked if the Alternate Clinical Supervisor would be available and if the Governing Body was notified to which he/she would check and call back. At 4:46 p.m. the Administrator indicated Person J called the Alternate Clinical Supervisor but had not heard back. The agency failed to pre-plan or have a plan in place during a Covid surge. During an interview on 1/10/2022 at 8:06 a.m. at the agency, Person J indicated the Alternate Administrator would not assist in the survey due to Covid and the Alternate Clinical Supervisor was the back-up for the Administrator at Entity 1 in Indianapolis and would not be available for the survey. The Administrator for Entity 1 Indianapolis and the Alternate Administrator for the Evansville location are the same person. Person J indicated he/she did not realize he/she was a member of the Governing Body until yesterday. The agency failed to ensure the authorized Alternate Administrator was available to assume the role as Administrator / Clinical Supervisor for the Evansville location during the survey and in an emergency pandemic. During an interview on 1/10/2022 at 9:15 a.m. queried Person J about personnel files and would need to review the Administrator, contracted Alternate Administrator and Alternate Clinical Supervisor personnel files. Person J indicated the contracted Alternate Administrator and Alternate Clinical Supervisor files were sitting next to him/her loosely on the chair and would place them in a binder. Person J indicated the contracted files came from the Indianapolis office. Person J indicated the contracted scheduler files were not kept at the Evansville agency. The agency failed to maintain personnel files specific for the Evansville location. The Alternate Administrator’s file from Entity 1 was provided by Person J on 1/11/2022 at 11:15 a.m. Person J indicated the resume on file was what the agency submitted to state in June 2021 for the back-up position. Review of the Alternate Administrator’s resume did not indicate a specific hire date for the Evansville agency. The resume indicated he/she was the Program Administrator for Pediatric Nursing Specialist 1/1/2018 to present but did not indicate which licensed agency since he/she was employed by other separate licensed Entities under Home Care Network INC. The file indicated a physical exam on 11/1/00 and a criminal background check 6/11/21. The agency failed to accurately maintain personnel files specific for the Evansville agency location. During an interview on 1/11/2022 at 2:00 p.m. the Administrator was asked if he/she knew the Alternate Administrator hire date and if he/she approved the appointment / approval of the Alternate Administrator as the back-up for the Evansville location. The Administrator indicated he/she did not know the hire date, nor did he/she approve the appointment of the Alternate Administrator. The Administrator was asked why the contracted scheduler personnel files were not maintained at the agency. The Administrator indicated the schedulers were not his/her employees. No contracted therapist personnel files were at the agency. On 1/11/2022 at 2:05 p.m. asked Person J to confirm the hire dates for the contracted Alternate Administrator 3/4/07 and Alternate Clinical Supervisor 1/16/11 that he/she provided. Person J found the hire dates in a new software system from another company that was bought out. Cerner system was the old system. Person J indicated the Alternate Administrator’s hire date was 10/10/01 but was unable to verify the hire date specifically for the Evansville license. The agency failed to accurately maintain personnel files specific for the Evansville agency location. During an interview on 1/11/2022 at 4:25 p.m. the Administrator and Person J were made aware of caregiver interviews of not knowing the agency provided therapy service and were not offered therapy services from the agency. Person J stated, “I showed you that we would be losing money using if we bill Medicaid for those services and we would need prior authorization”. The agency failed to offer or provide one other therapeutic service. 17-12-1(b)

Administrator must: CFR(s): 484.105(b)(1) Standard: Administrator. The administrator must: This STANDARD is not met as evidenced by: Based on record review and interview, the Administrator failed to demonstrate distinct boundaries of the Medicaid certified program in relation to any other programs the larger organization has to offer for 1 of 1 home health agency. Findings include: 1. A revised 10/2014 CMS State Operation Manual, indicated but was not limited to, "Operation of the HHA (Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) 2183.1 ... other programs should be separate and distinct from the HHA. Ensure that the HHA has: Separate policies and procedures for admission to the HHA, including separate consent forms; ... Personnel Records ... Time sheets or other records to demonstrate distinct assignment of personnel to the HHA; and separate budgets." 2. During an observation of the agency office along with the Administrator on 1/3/2022 at 3:00 p.m. confirmed that contracted staff files for the Alternate Administrator, Alternate Clinical Supervisor, and schedulers were not kept in the file cabinet along with other files or at the Evansville office. 3. Review of the Governing Body meeting minutes dated 10/4/2021, indicated ““… In the absence or unavailability of [Administrator], then [Alternate Administrator] will assume the responsibilities as the Administrator of the Home Care Network, Inc. agency in Evansville, Indiana.” Review of the Governing Body meeting minutes dated March 12, 2021, indicated “… in the absence of or unavailability of [Person G], then [Alternate Administrator] will assume the responsibilities as the Administrator of the Home Care Network, Inc. agency (Division 2-13) in Evansville, Indiana.” Review of the Governing Body meeting minutes dated March 2020 indicated “… in the absence of or unavailability of [Person G], then [Alternate Administrator] will assume the responsibilities as the Administrator of the Home Care Network, Inc. agency (Division 2-13) in Evansville, Indiana.” 4. During an interview on 1/10/2022 at 9:15 a.m. queried Person J about personnel files and would need to review the Administrator, contracted Alternate Administrator and Alternate Clinical Supervisor files. Person J indicated the contracted files were sitting next to him/her loosely on the chair and would place them in a binder. Person J indicated the contracted files came from the Indianapolis office. 5. Review of the Alternate Administrator file on 1/10/2022 failed to indicate a specific hire date for the Evansville agency. The record included a current LPN license. The resume indicated he/she received an Associate of Applied Science as an LPN, no other undergraduate degrees listed. The agency failed to maintain accurate information regarding hire dates for contracted staff at the Evansville location. During an interview on 1/10/2022 at 11:00 a.m. Person J provided hire dates for Alternate Administrator 3/4/07 and Alternate Clinical Supervisor 1/16/11. Queried Person J as to when the contracted Alternate Administrator and Alternate Clinical Supervisor were hired specifically for the Evansville location since the files came from Entity 1’s office. During an interview on 1/11/2022 at 2:05 p.m. asked Person J to confirm the contracted Alternate Administrator hire date 3/4/07 and Alternate Clinical Supervisor hire date 1/16/11 specific for the Evansville agency. Person J found the hire dates in new software system from other company that was bought out. Cerner system was the old system. Person J indicated the Alternate Administrator hire date was 10/10/01 but was unable to verify the hire date specifically for the Evansville license. The agency failed to separate and maintain personnel files from another licensed Entity and failed to demonstrate distinct assignment of personnel to the Evansville agency.

Administrator appointed by governing body CFR(s): 484.105(b)(1)(i) (i) Be appointed by and report to the governing body; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the administrator reported directly to the Governing Body without the use of intermediaries for 1 of 1 home health agency. Findings include: A revised January 2018 policy titled Governing Body was provided by the Administrator on 1/4/2022 at 3:00 p.m. The policy indicated, but was not limited, “The Governing Body shall assume full legal authority and responsibility for the Cooperation of Agency. New governing body members are oriented to the agency as appropriate to responsibilities … To ensure the lines of authority are established … 6. Define the corporate structure and clearly indicate lines of authority.” A signed September 20, 2021, Clinical Administrator job description was provided by the Administrator on 1/4/2022 at 4:00 p.m. The job description indicated, but was not limited to, “… Assures compliance with the requirements of state licensure, Medicare certification, and compliance with regulatory agencies through policy and procedures, staff education, and ongoing monitoring activities …” Review of the state database indicated 2 owner/officers listed [President/Owner O and Owner P]. During entrance conference on 1/3/2022 at 11:10 a.m. the Administrator was asked who the members of the Governing Body were to which he/she replied “I don’t know what that is, but I will find out” On 1/3/2022 at 11:30 a.m. the Home Care Network Division 71 Organizational Chart 2022 was provided by the Administrator. At that time, the Administrator indicated contracted Alternate Administrator Q based in Indianapolis would help him/her by phone during the survey. Review of the chart indicated, “Program Admin/Supervising RN [name of Administrator] **Back up Admin: [Alt. Admin. Q] **Back Up RN: [Alt. Clinical Sup. R]” all report to “Chief Operating Officer [Person B] *Board Member” who reports to “Board of Directors/Governing Body”. The agency failed to ensure the Administrator reports directly to the Governing Body without the use of intermediaries. On 1/3/2022 at 3:30 p.m. the Administrator indicated he/she spoke with Person J by phone in Ohio to confirm the Organizational chart was correct. Person J indicated Person B was a not a Board Member as indicated on the 2022 Organizational chart for the Evansville agency. Person J indicated Person B was not an owner or Board member but was a manager. At that time, the Administrator indicated he/she reported to contracted Alternate Administrator based in Indianapolis and Person B. The agency failed to ensure the Administrator reports directly to the Governing Body without the use of intermediaries. On 1/3/2022 at 3:35 p.m. the Administrator called the Alternate Administrator to confirm who the current Governing Body members were. The Alternate Administrator indicated there were 4 members of the Governing Body: President O, Owner P, Person C, and Person D. On 1/4/2022 at 10:30 a.m. the Administrator and Person J were both present at the agency. The Minutes of the Annual Meeting of the Board of Directors/Governing Body and Administrator of Home Care Network, INC [Ohio address] undated 2-page document signed by President/Owner O and Person B was provided by the Administrator. The Administrator provided a third document titled Minutes of the Annual Meeting of the Board of Directors/Governing Body and Administrator Home Care Network INC [Evansville address] Indiana Pediatric Division BU#71 Medicare #15-7276 signed by the Administrator, President/Owner O and Person J dated “4th day of October 2021.” Administrator was asked to verify the date on the first two pages due to the contents of information and conflicting interviews during the survey. The Administrator consulted with Person B and returned all three pages stapled together and stated all three pages were one meeting that took place on October 4, 2021. During an interview on 1/4/2022 at 10:30 a.m. Person J was asked if he/she was a Governing Body member to which he/she responded “no”. At that time, Person J was informed the contents of the undated Governing Body meeting indicated “… [Person J] RN was appointed to the Board of Directors/Governing Board for the position of Corporate trainer … There being no further business to come before the meeting upon motion, the same was duly adjourned. [Person O] Chairperson Attest: [Person B] Chief Operating Officer” Person J stated that he/she was not a Governing Body member but was the Corporate Trainer for all agencies in Ohio and Indiana. On 1/4/2022 at 3:05 p.m. the Administrator provided a second Organizational chart with a revised date April 2021 titled Home Care Network Pediatric Nursing Specialist / Maternal Child Health Organizational Chart. The Administrator was queried if Maternal Child Health was added as a new name for the Evansville agency. The Administrator indicated the chart was for the whole company. Review of the chart indicated the Program Administrator and Program Administrator backup for the Evansville agency both report to the Chief Operating Officer Person B. The agency failed to ensure the Administrator reports directly to the Governing Body without the use of intermediaries. On 1/4/2022 at 4:00 p.m. the Administrator provided a third Organizational chart with a revised date January 2022 titled Home Care Network, INC d/b/a: Pediatric Nursing Specialist Organizational Chart. Review of the chart indicated the Program Administrator and Program Administrator backup for the Evansville agency both report to the Chief Operating Officer Person B. The agency failed to ensure the Administrator reports directly to the Governing Body without the use of intermediaries. During an interview on 1/4/2022 at 4:20 p.m. the Administrator indicated he/she was not aware of Article 17, state licensure requirements, or the Administrative Code and was unable to provide any additional information or comments. During an interview on 1/10/2022 at 8:06 a.m. Person J indicated he/she did not realize he/she was a member of the Governing Body until yesterday. 17-12-1(b)(1)

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, the administrator failed to provide overall direction and leadership of agency services, failed to ensure the agency met all rules and regulations for recertification, and failed ensure the responsibility for all day-to-day operations for 1 of 1 home health agency. Findings include: 1. The administrator failed to ensure compliance with the Condition of Participation 484.55 Care planning, coordination, quality of care for the following: The Administrator failed to ensure all services in the plan of care were met, with the potential to affect all patients (See G572); failed to ensure all orders were record in the plan of care to ensure staff were working from a current plan of care (See G576); failed to review and revise the plan of care to ensure staff were working from a current plan of care (See G586); failed to provide a written schedule that included visit frequencies that affects all active patients (See G614); failed to ensure patients or caregivers were provided with a written copy of the patient medication schedule and instructions that includes medication name, dosage, and frequency and which medications will be administered by agency personnel and persons acting on behalf of the agency, with the potential to affect all active patients (See G616); and failed to ensure any other pertinent instructions specific to patient care needs (See G620) 2. The administrator failed to ensure compliance with the Condition of Participation 484.105 Organization and Administration of services for the following: The Administrator failed to ensure administrative and supervisory duties such as scheduling, documentation of missed visits, and physician notification was not delegated to a contracted Entity (See G940); failed to demonstrate distinct boundaries of the Medicaid certified program in relation to any other programs the larger organization has to offer (See G944); failed to ensure the administrator reported directly to the Governing Body without the use of intermediaries (See G946); failed to ensure the Administrator was responsible for the day-to-day operations of the agency (See G948); failed to ensure a person authorized by the governing body was able to assume the administrator role and was available during an emergency pandemic for Pediatric Nursing Specialist of Evansville (See G954); the agency failed to offer and provide one other therapeutic service such as physical or occupational therapy, speech-language therapy, medical social services, or home health aide available on a visiting basis in the patient’s home (See G982) 3. The Administrator failed to adequately prepare and describe a plan for a surge in Covid-19 among administrative personnel that assume responsibility for two separate licensed agencies during a pandemic for Pediatric Nursing Specialists of Evansville and failed to ensure all employees participated in a tabletop exercise to test the agency’s emergency plan specifically for Pediatric Nursing Specialist located in Evansville (See E0037) 4. The Administrator failed to ensure patient/caregivers had current written contact information for the agency administrator to receive complaints (See G414) 5. The Administrator failed to ensure patients received all services outlined in the plan of care (See G436) 6. The Administrator failed to ensure the medication review addressed compliance, response to drug therapy, adverse drug reactions, duplicate medications, side effects, and drug interactions (See G536) 7. The Administrator failed to ensure unvaccinated staff exposed to Covid-19 were allowed to quarantine; failed to ensure the agency had adequate staffing during a Covid surge; and failed to maintain, document, and implement an infection control plan during a Covid-19 surge for employees that cover multiple roles for separate Entities (See G682) 8. The Administrator failed to ensure the agency policy was followed regarding medication changes (See G702) 9. The Administrator failed to ensure management information for Pediatric Nursing Specialist of Evansville was disclosed to the state agency (See G850) 10. The Administrator failed to disclose to the state agency any change in management (See G852) 11. The Administrator failed to disclose to the state agency any officer, director, agent, or managing employee specific to Pediatric Nursing Specialist of Evansville (See G856) 12. The Administrator failed to disclose to the state agency the name and address of any person that was responsible for the management specific to Pediatric Nursing Specialist of Evansville (See G858) 13. The Administrator failed to ensure clinical records were appropriately authenticated, dated, and timed; and failed to update policies that accurately reflect services the agency provides (See 1024) 14. The Administrator failed to appoint a qualified Alternate Administrator (See G1052) 15. The Administrator failed to ensure an annual performance evaluation was completed (See N460) 16. The Administrator failed to ensure public information was accurate for the agency website and for an agency RN job posting on a website (See N477) 17. The Administrator failed to maintain personnel records for all employees specific for Pediatric Nursing Specialists of Evansville agency (See N468)

Ensures qualified pre-designated person CFR(s): 484.105(b)(2) When the administrator is not available, a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator. The pre-designated person may be the clinical manager as described in paragraph (c) of this section. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure a person authorized by the governing body was able to assume the administrator role and was available during an emergency pandemic for Pediatric Nursing Specialist of Evansville for 1 of 1 home health agency. (Alternate Administrator, Clinical Supervisor, Alternate Clinical Supervisor) Findings include: 1. A 10/4/21 signed Agency Ancillary Services Agreement was provided by Person J on 1/10/2022 at 3:20 p.m. The agreement indicated but was not limited to, “This Agreement is entered into on this date 10/4/21, by and between Pediatric Nursing Specialists of HCN (… “Agency”), whose principal place of business is located at … [Evansville] and [Alternate Clinical Supervisor] (… “Contractor”), whose principal place of business is located at [Entity 1] Indianapolis. … Responsibilities of the Contractor: The Contractor will fulfill the duties of the RN Supervisor when back up is required.” The agreement was signed by the Administrator and Alternate Clinical Supervisor on 10/4/21. The agency failed to ensure an authorized person by the governing body was available to assume the Administrator role / Clinical Supervisor role during an emergency pandemic. 2. A 10/4/21 signed Agency Ancillary Services Agreement was provided by Person J on 1/10/2022 at 3:20 p.m. The agreement indicated but was not limited to, “This Agreement is entered into on this date 10/4/21, by and between Pediatric Nursing Specialists of HCN (… “Agency”), whose principal place of business is located at … [Evansville] and [Alternate Administrator] (… “Contractor”), whose principal place of business is located at [Entity 1] Indianapolis. … Responsibilities of the Contractor: The Contractor will fulfill the duties of the administrator when back up is required.” The agreement was signed by the Administrator and Alternate Administrator on 10/4/21. The agency failed to ensure the authorized person by the governing body was available to assume the Administrator role during an emergency pandemic. 3. During a phone interview on 1/3/2022 at 9:27 a.m. the Administrator indicated he/she was in isolation (no symptoms) until Thursday due to a family member testing positive for Covid and that was why the office was closed. At 10:20 a.m. the Administrator called and stated he/she would come out of isolation to open the agency and begin the survey. The Administrator indicated his/her Alternate would be available by phone. During an interview on 1/4/2022 at 10:30 a.m. Person J indicated the Alternate Administrator would not be available due to a dying family member and the Alternate Clinical Supervisor would not be available due to covering for the Administrator at Entity 1 Indianapolis. During an interview on Sunday 1/9/2022 at 3:24 p.m. received a phone call from the Administrator indicating he/she and the Alternate Administrator both tested positive for Covid with symptoms and are in isolation and Person J was on the way from Ohio. The Administrator indicated Person O from Ohio instructed him/her to call the surveyor for guidance. Asked if the Alternate Clinical Supervisor would be available and if the Governing Body was notified to which he/she would check and call back. At 4:46 p.m. the Administrator indicated Person J called the Alternate Clinical Supervisor but had not heard back. During an interview on 1/10/2022 at 8:06 a.m. at the agency, Person J indicated the Alternate Administrator would not assist in the survey due to Covid and the Alternate Clinical Supervisor was the back-up for the Administrator at Entity 1 in Indianapolis and would not be available for the survey. The Administrator for Entity 1 Indianapolis and the Alternate Administrator for the Evansville location are the same person. The agency failed to ensure the authorized Alternate Administrator was available to assume the role as Administrator / Clinical Supervisor for the Evansville location during the survey and in an emergency pandemic. 4. Review of the Governing Body Meeting minutes on 1/10/2022 for the following dates: 1/9/2022, 10/4/2021, 3/20/2021, 3/12/2021, 3/2020 (10 a.m.), and 2/8/2019 failed to indicate the Governing Body appointed / authorized a Clinical Supervisor and Alternate Clinical Supervisor for the Evansville location. 17-12-1(c)(8)

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 observation, record review, and interview, the agency failed to offer and provide one other therapeutic service such as physical or occupational therapy, speech-language therapy, medical social services, or home health aide available on a visiting basis in the patient’s home for 4 of 4 interviews. (Patient 1, 3, 8, 9) Findings include: 1. A revised January 2018 policy titled Governing Body was provided by the Administrator on 1/4/2022 at 3:00 p.m. The policy indicated, but was not limited, “The Governing Body shall assume full legal authority and responsibility for the Cooperation of Agency. New governing body members are oriented to the agency as appropriate to responsibilities … To ensure the lines of authority are established … 6. Define the corporate structure and clearly indicate lines of authority.” 2. A signed September 20, 2021, Clinical Administrator job description was provided by the Administrator on 1/4/2022 at 4:00 p.m. The job description indicated, but was not limited to, “… Assures compliance with the requirements of state licensure, Medicare certification, and compliance with regulatory agencies through policy and procedures, staff education, and ongoing monitoring activities …” 3. During entrance conference on 1/3/2022 at 11:10 a.m. the Administrator was asked what services the agency provides. The Administrator indicated the agency offers skilled nursing and home health aide services. Queried if the agency offers therapy services. The Administrator indicated the agency does not offer physical, occupational, or speech therapies. The agency does not offer attendant care services or social work. Queried if the agency has any services provided under contract to which he/she replied, “not that I’m aware of but I will find out”. 4. On 1/3/2022 at 3:10 p.m. the Administrator provided a contract titled [Entity 3] Agreement for Therapy Services. The agreement indicated, but was not limited to, “This Agreement, herein after referred to as “Agreement”, is made on 2/21/2019, by and between [Entity 3], Texas LLC hereinafter referred to as “Contractor” and Home Care Network, Inc d/b/a Pediatric Nursing Specialist of Indiana a Ohio Corporation, herein after referred to as “Agency”. 5. During a home visit observation on 1/3/2022 at 12:58 p.m. patient 3’s caregiver indicated patient 3 receives PT, OT, and ST therapy services from an outside agency and skilled nursing services from Pediatric Nursing Specialists. The caregiver did not indicate why patient 3 does not receive therapy services from the home health agency. The agency failed to offer or provide one other therapeutic service besides skilled nursing. During an interview on 1/10/2022 at 3:26 p.m. the Administrator indicated the agency had not used the contracted therapy services since he/she started [Oct 4, 2021]. 6. During a phone interview on 1/11/2022 at 8:40 a.m. patient 9’s caregiver indicated the patient receives outside therapy from school and Easter Seals and skilled nursing services from Pediatric Nursing Specialists. Patient 9’s caregiver was asked if he/she was aware the home health agency provided therapy services. Patient 9’s caregiver indicated no one from the agency talked to him/her about therapy services or offered the agency’s therapy services. Patient 9’s caregiver had been with the home health agency for 10 years. The agency failed to offer or provide one other therapeutic service besides skilled nursing. 7. During a phone interview on 1/11/2022 at 8:57 a.m. patient 1’s caregiver indicated the patient receives outside therapy from Easter Seals and skilled nursing services from Pediatric Nursing Specialists. Patient 1’s caregiver was asked if he/she was aware the home health agency provided therapy services. Patient 1’s caregiver indicated no one from the agency talked to him/her about therapy services or offered the agency’s therapy services. Patient 1’s caregiver indicated he/she never knew the agency provided therapy and would be interested in the agency’s therapy services. The agency failed to offer or provide one other therapeutic service besides skilled nursing. 8. During a phone interview on 1/11/2022 at 3:30 p.m. patient 8’s caregiver indicated the patient receives outside therapy services from school and Easter Seals and skilled nursing services from Pediatric Nursing Specialists. Patient 8’s caregiver was asked if he/she was aware the home health agency provided therapy services. Patient 8’s caregiver indicated no one talked to him/her about therapy services or offered the agency’s therapy services. Patient 8’s caregiver indicated he/she would be interested in the agency’s therapy services. Patient 8’s caregiver has been with the agency for 7 years. The agency failed to offer or provide one other therapeutic service besides skilled nursing. 9. During an interview on 1/11/2022 at 4:25 p.m. the Administrator and Person J were made aware of caregiver interviews of not knowing the agency provided therapy service and were not offered therapy services from the agency. Person J stated, “I showed you that we would be losing money if we bill Medicaid for those services and we would need prior authorization”.

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 facility failed to ensure clinical records were appropriately authenticated, dated, and timed for 5 of 7 records reviewed (Patient 2,3,5,6,7); and failed to update policies that accurately reflect services the agency provides for 1 of 1 admission policy reviewed. Findings include: 1. A revised January 2018 policy titled Governing Body was provided by the Administrator on 1/4/2022 at 3:00 p.m. The policy indicated, but was not limited, “The Governing Body shall assume full legal authority and responsibility for the Cooperation of Agency. New governing body members are oriented to the agency as appropriate to responsibilities … To ensure the lines of authority are established … 6. Define the corporate structure and clearly indicate lines of authority.” A signed September 20, 2021, Clinical Administrator job description was provided by the Administrator on 1/4/2022 at 4:00 p.m. The job description indicated, but was not limited to, “… Assures compliance with the requirements of state licensure, Medicare certification, and compliance with regulatory agencies through policy and procedures, staff education, and ongoing monitoring activities …” 2. The complete clinical record for patient 2 was reviewed on 1/6/2022 and included a plan of care for the certification period 10/25/2021 to 12/23/2021, SOC date 9/6/2019, with orders for “[skilled nurse] hourly 39.00 Hour Weekly for 1 Certification Period (s) starting 10/25/2021 – Traditional 8-10 [hours]/day, 4-5 days/week. Not to exceed 39 [hours] in a calendar week …” The agency failed to ensure all entries in patient 2’s clinical record were appropriately dated, timed, and authenticated (must include a signature and a title or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry) by the Administrator and ensure that Missed Visit notes were reviewed as follows: Review of a Patient Care Conference Note dated 12/20/2021 by the Administrator indicated the plan was to continue with the frequency and duration. Review of a Case Communication note dated 11/29/2022 did not indicate the number of hours missed and if there were any changes or orders to be made to the Plan of Care. Review of the Missed Visit note dated 12/18/2021 indicated “Cancelled by Agency-No Available Staff. Describe How the Patient’s Need Was Met: 30.5 out of 39 hrs [hours] not staffed over the course of 7 days. This is due to the caregiver being unable to cover all PA hours. The agency is actively seeking staff in the client area. Parent to provide care to the patient. These hours are out of MD ordered staffing frequency … Follow-Up Actions: Notified Caregiver [Administrator] Notified Physician [MD name] Notification Date: 12/18/2021 … Additional Follow-Up Comments: [Blank] … [Person N] signature, Date 12/18/2021” The agency failed to authenticate the Administrator reviewed and approved the entry with his/her signature and title or a secured computer entry by a unique identifier. Review of the Missed Visit note dated 12/11/2021 indicated “Cancelled by Agency-No Available Staff. Describe How the Patient’s Need Was Met: 30 out of 39 hrs not staffed over the course of 7 days. This is due to the caregiver being unable to cover all PA hours. The agency is actively seeking staff in the client area. Parent to provide care to the patient. These hours are out of MD ordered staffing frequency … Follow-Up Actions: Notified Caregiver [Administrator] Notified Physician [MD name] Notification Date: 12/11/2021 … Additional Follow-Up Comments: [Blank] … [Person L] signature, Date 12/11/2021” Review of the Missed Visit note dated 12/4/2021 indicated “Cancelled by Agency-No Available Staff. Describe How the Patient’s Need Was Met: 31 out of 39 hrs not staffed over the course of 7 days. This is due to the caregiver being unable to cover all PA hours. The agency is actively seeking staff in the client area. Parent to provide care to the patient. These hours are out of MD ordered staffing frequency … Follow-Up Actions: Notified Caregiver [Blank] Notified Physician [MD name] Notification Date: 12/4/2021 … Additional Follow-Up Comments: [Blank] … [Person L] signature, Date 12/8/2021” Review of the Missed Visit note dated 11/27/2021 indicated “Cancelled by Agency-No Available Staff. Describe How the Patient’s Need Was Met: 31 out of 39 hrs not staffed over the course of 7 days. This is due to the caregiver being unable to cover all PA hours. The agency is actively seeking staff in the client area. Parent to provide care to the patient. These hours are out of MD ordered staffing frequency … Follow-Up Actions: Notified Caregiver [Blank] Notified Physician [MD name] Notification Date: 11/27/2021 … Additional Follow-Up Comments: [Blank] … [Person L] signature, Date 12/1/2021” Review of the Missed Visit note dated 11/20/2021 indicated “Cancelled by Agency-No Available Staff. Describe How the Patient’s Need Was Met: 39 out of 39 hrs not staffed over the course of 7 days. This is due to the caregiver being unable to cover all PA hours. The agency is actively seeking staff in the client area. Parent to provide care to the patient. These hours are out of MD ordered staffing frequency … Follow-Up Actions: Notified Caregiver [Blank] Notified Physician [MD name] Notification Date: 11/20/2021 … Additional Follow-Up Comments: [Blank] … [Person N] signature, Date 11/20/2021” Review of the Missed Visit note dated 11/13/2021 indicated “Cancelled by Agency-No Available Staff. Describe How the Patient’s Need Was Met: 31 out of 39 hrs not staffed over the course of 7 days. This is due to the caregiver being unable to cover all PA hours. The agency is actively seeking staff in the client area. Parent to provide care to the patient. These hours are out of MD ordered staffing frequency … Follow-Up Actions: Notified Caregiver [Blank] Notified Physician [MD name] Notification Date: 11/13/2021 … Additional Follow-Up Comments: [Blank] … [Person L] signature, Date 11/17/2021” Review of the Missed Visit note dated 11/6/2021 indicated “Cancelled by Agency-No Available Staff. Describe How the Patient’s Need Was Met: 31 out of 39 hrs not staffed over the course of 7 days. This is due to the caregiver being unable to cover all PA hours. The agency is actively seeking staff in the client area. Parent to provide care to the patient. These hours are out of MD ordered staffing frequency … Follow-Up Actions: Notified Caregiver [Blank] Notified Physician [MD name] Notification Date: 11/6/2021 … Additional Follow-Up Comments: [Blank] … [Person L] signature, Date 11/10/2021” Review of the Missed Visit note dated 10/30/2021 indicated “Cancelled by Agency-No Available Staff. Describe How the Patient’s Need Was Met: 31 out of 39 hrs not staffed over the course of 7 days. This is due to the caregiver being unable to cover all PA hours. The agency is actively seeking staff in the client area. Parent to provide care to the patient. These hours are out of MD ordered staffing frequency … Follow-Up Actions: Notified Caregiver [Blank] Notified Physician [MD name] Notification Date: 11/6/2021 … Additional Follow-Up Comments: [Blank] … [Person L] signature, Date 11/5/2021” 3. The complete clinical record for patient 3 was reviewed on 1/4/2022 and included a plan of care for the certification period 11/20/2022 to 1/18/2022, SOC date 8/8/2018, with orders for “[skilled nurse] Hourly 49.00 Hour Weekly for 1 Certification Period(s) starting 11/20/2021 – Traditional 9[hours]/day [Monday, Wednesday, Friday] and 11 [hours] [Tuesday – Thursday] not to exceed 49 hrs a week …” The agency failed to ensure all entries in patient 3’s clinical record were appropriately dated, timed, and authenticated (must include a signature and a title or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry) by the Administrator and ensure that Missed Visit notes were reviewed as follows: Review of the Missed Visit note dated 12/25/2021 indicated “Cancelled by Agency-No Available Staff. Describe How the Patient’s Need Was Met: 20 out of 49 hrs not staffed over the course of 7 days. This is due to the caregiver being unable to cover all PA hours. The agency is actively seeking staff in the client area. Parent to provide care to the patient. These hours are out of MD ordered staffing frequency … Follow-Up Actions: Notified Caregiver [Administrator] Notified Physician [MD name] Notification Date: 12/25/2021 … Additional Follow-Up Comments: [Blank] … [Person L] signature, Date 12/29/2021” Review of the Missed Visit note dated 12/18/2021 indicated “Cancelled by Agency-No Available Staff. Describe How the Patient’s Need Was Met: 9 out of 49 hrs not staffed over the course of 7 days. This is due to the client being out of town for a medical appointment. Parent to provide care to the patient. These hours are out of MD ordered staffing frequency … Follow-Up Actions: Notified Caregiver [Administrator] Notified Physician [MD name] Notification Date: 12/18/2021 … Additional Follow-Up Comments: [Blank] … [Person N] signature, Date 12/18/2021” Review of the Missed Visit note dated 11/27/2021 indicated “Cancelled by Agency-No Available Staff. Describe How the Patient’s Need Was Met: 29 out of 49 hrs not staffed over the course of 7 days. This is due to the caregiver unable to staff all PA hours. Agency is actively recruiting for this client. Parent to provide care to the patient. These hours are out of MD ordered staffing frequency … Follow-Up Actions: Notified Caregiver [Blank] Notified Physician [MD name] Notification Date: 11/27/2021 … Additional Follow-Up Comments: [Blank] … [Person L] signature, Date 12/1/2021” 4. The complete clinical record for patient 5 was reviewed on 1/7/2022 and included a plan of care for the certification period 11/19/2022 to 1/17/2022, SOC date 6/13/2017, with orders for “[skilled nurse] Hourly 40.00 Hour Weekly for 1 Certification Period(s) starting 11/19/2021 – Traditional 6-10[hours]/day, 4-5 days/week, not to exceed 40 hours a week …” The agency failed to ensure all entries in patient 5’s clinical record were appropriately dated, timed, and authenticated (must include a signature and a title or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry) by the Administrator and ensure that Missed Visit notes were reviewed as follows: Review of the Missed Visit note dated 12/25/2021 indicated “Cancelled by Agency-No Available Staff. Describe How the Patient’s Need Was Met: 26 hours missed out of 40 over the course of 7 days. This is due to the caregiver being unable to staff all PA hours. Agency is seeking coverage in the client area. Parent to provide care to the patient. These hours are out of MD ordered staffing frequencies … Follow-Up Actions: Notified Caregiver [Administrator] Notified Physician [MD name] Notification Date: 12/25/2021 … Additional Follow-Up Comments: [Blank] … [Person L] signature, Date 12/29/2021” Review of the Missed Visit note dated 12/18/2021 indicated “Cancelled by Agency-No Available Staff. Describe How the Patient’s Need Was Met: 10 hours missed out of 40 over the course of 7 days. This is due to the caregiver being unable to staff all PA hours. Agency is seeking coverage in the client area. Parent to provide care to the patient. These hours are out of MD ordered staffing frequencies … Follow-Up Actions: Notified Caregiver [Administrator] Notified Physician [MD name] Notification Date: 12/18/2021 … Additional Follow-Up Comments: [Blank] … [Person N] signature, Date 12/18/2021” Review of the Missed Visit note dated 12/11/2021 indicated “Cancelled by Agency-No Available Staff. Describe How the Patient’s Need Was Met: 17 hours out of 40 not staffed over the course of 7 days. This is due to the caregiver being unable to staff all PA hours. Agency is seeking coverage in the client area. Parent to provide care to the patient. These hours are out of MD ordered staffing frequencies … Follow-Up Actions: Notified Caregiver [Administrator] Notified Physician [MD name] Notification Date: 12/11/2021 … Additional Follow-Up Comments: [Blank] … [Person L] signature, Date 12/14/2021” Review of the Missed Visit note dated 12/04/2021 indicated “Cancelled by Agency-No Available Staff. Describe How the Patient’s Need Was Met: 24 hours out of 40 not staffed over the course of 7 days. This is due to the caregiver being unable to staff all PA hours. Agency is seeking coverage in the client area. Parent to provide care to the patient. These hours are out of MD ordered staffing frequencies … Follow-Up Actions: Notified Caregiver [Blank] Notified Physician [MD name] Notification Date: 12/04/2021 … Additional Follow-Up Comments: [Blank] … [Person L] signature, Date 12/8/2021” Review of the Missed Visit note dated 11/27/2021 indicated “Cancelled by Agency-No Available Staff. Describe How the Patient’s Need Was Met: 24 hours out of 40 not staffed over the course of 7 days. This is due to the caregiver being unable to staff all PA hours. Agency is seeking coverage in the client area. Parent to provide care to the patient. These hours are out of MD ordered staffing frequencies … Follow-Up Actions: Notified Caregiver [Blank] Notified Physician [MD name] Notification Date: 11/27/2021 … Additional Follow-Up Comments: [Blank] … [Person L] signature, Date 12/1/2021” Review of the Missed Visit note dated 11/20/2021 indicated “Cancelled by Agency-No Available Staff. Describe How the Patient’s Need Was Met: 5 hours out of 40 not staffed over the course of 7 days. This is due to the caregiver being unable to staff all PA hours. Agency is seeking coverage in the client area. Parent to provide care to the patient. These hours are out of MD ordered staffing frequencies … Follow-Up Actions: Notified Caregiver [Administrator] Notified Physician [MD name] Notification Date: 11/20/2021 … Additional Follow-Up Comments: [Blank] … [Person N] signature, Date 11/20/2021” 5. The complete clinical record for patient 6 was reviewed on 1/7/2022 and included a plan of care for the certification period 6/30/2021 to 8/22/2021, SOC date 3/23/2017, with orders for “[skilled nurse] 32.00 Hour Weekly for 1 Certification Period(s) starting 6/30/2021 – Traditional; 7-9 hours a day, 3-4 days a week, not to exceed 32 hours a week …” The agency failed to ensure all entries in patient 6’s clinical record were appropriately dated, timed, and authenticated (must include a signature and a title or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry) by the Administrator and ensure that Missed Visit notes were reviewed as follows: Review of the Missed Visit note dated 08/07/2021 indicated “Cancelled by Agency-No Available Staff. Describe How the Patient’s Need Was Met: 22 out of 32 hrs not staffed over the course of 7 days. This is due to the caregiver being not being unable to staff all PA hours. The agency is actively seeking staff in the client area. Parent to provide care to the patient. These hours are out of MD ordered staffing frequency … Follow-Up Actions: Notified Caregiver [Person H] Notified Physician [MD name] Notification Date: 08/07/2021 … Additional Follow-Up Comments: [Blank] … [Person H] signature, Date 08/13/2021” Review of the Missed Visit note dated 07/24/2021 indicated “Cancelled by Agency-No Available Staff. Describe How the Patient’s Need Was Met: 2 out of 32 hrs not staffed over the course of 7 days. This is due to the caregiver not being unable to staff all PA hours. Agency is seeking coverage for this need. Parent to provide care to the patient. These hours are out of MD ordered staffing frequency … Follow-Up Actions: Notified Caregiver [Person H] Notified Physician [MD name] Notification Date: 07/24/2021 … Additional Follow-Up Comments: [Blank] … [Person H] signature, Date 07/24/2021” Review of the Missed Visit note dated 07/10/2021 indicated “Cancelled by Agency-No Available Staff. Describe How the Patient’s Need Was Met: 2 out of 32 hrs not staffed over the course of 7 days. This is due to the caregiver not being able staff all PA hours. Agency is seeking coverage for this need. Parent to provide care to the patient. These hours are out of MD ordered staffing frequency … Follow-Up Actions: Notified Caregiver [Person H] Notified Physician [MD name] Notification Date: 07/10/2021 … Additional Follow-Up Comments: [Blank] … [Person H] signature, Date 07/19/2021” Review of the Missed Visit note dated 07/-2/2021 indicated “Cancelled by Agency-No Available Staff. Describe How the Patient’s Need Was Met: 15.5 hrs not staffed out of 32 hrs over the course of 7 days. Caregiver not able to cover all PA hrs this week. Parent to provide care to patient. These hours are out of the MD ordered staffing frequency … Follow-Up Actions: Notified Caregiver [Person H] Notified Physician [MD name] Notification Date: 07/02/2021 … Additional Follow-Up Comments: [Blank] … [Person H] signature, Date 7/19/2021” 6. The complete clinical record for patient 7 was reviewed on 1/7/2022 and included a plan of care for the certification period 6/24/20211 to 8/22/2021, SOC date 7/10/2018, with orders for “[skilled nurse] hourly 80.00 Hour Weekly for 1 Certification Period (s) starting 6/24/2021 – Traditional 8-10 [hours]/day, 5-6 days/week, 1-2 shifts/day. Not to exceed 80 [hours] a week …” The agency failed to ensure all entries in patient 7’s clinical record were appropriately dated, timed, and authenticated (must include a signature and a title or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry) by the Administrator and ensure that Missed Visit notes were reviewed as follows: Review of the Missed Visit note dated 08/07/2021 indicated “Cancelled by Agency-No Available Staff. Describe How the Patient’s Need Was Met: 64 out of 80 hrs not staffed over the course of 7 days. This is due to the caregiver being unable to cover all PA hours. The agency is actively seeking staff in the client area. Parent to provide care to the patient. These hours are out of MD ordered staffing frequency … Follow-Up Actions: Notified Caregiver [Person H] Notified Physician [MD name] Notification Date: 008/07/2021 … Additional Follow-Up Comments: [Blank] … [Person H] signature, Date 8/13/2021” Review of the Missed Visit note dated 07/24/2021 indicated “Cancelled by Agency-No Available Staff. Describe How the Patient’s Need Was Met: 58 out of 80 hrs not staffed over the course of 7 days. This is due to the caregiver being unable to cover all PA hours. The agency is actively seeking coverage for this need. Parent to provide care to the patient. These hours are out of MD ordered staffing frequency … Follow-Up Actions: Notified Caregiver [Person H] Notified Physician [MD name] Notification Date: 07/24/2021 Unable to Reschedule Due to [Blank] Additional Follow-up Comments: [Blank] … [Person H] signature, Date 7/26/2021” Review of the Missed Visit note dated 07/10/2021 indicated “Cancelled by Agency-No Available Staff. Describe How the Patient’s Need Was Met: 65.5 out of 80 hrs not staffed over the course of 7 days. This is due to the caregiver being unable to cover all PA hours. The agency is actively seeking coverage for this need. Parent to provide care to the patient. These hours are out of MD ordered staffing frequency … Follow-Up Actions: Notified Caregiver [Person H] Notified Physician [MD name] Notification Date: 07/10/2021 Unable to Reschedule Due to [Blank] Additional Follow-up Comments: [Blank] … [Person H] signature, Date 7/19/2021” Review of the Missed Visit note dated 07/02/2021 indicated “Cancelled by Agency-No Available Staff. Describe How the Patient’s Need Was Met: 58.5 out of 80 hrs not staffed over the course of 7 days. This is due to the caregiver being unable to cover all PA hours. The agency is actively seeking coverage for this need. Parent to provide care to the patient. These hours are out of MD ordered staffing frequency … Follow-Up Actions: Notified Caregiver [Person H] Notified Physician [MD name] Notification Date: 07/02/2021 Unable to Reschedule Due to [Blank] Additional Follow-up Comments: [Blank] … [Person H] signature, Date 7/19/2021” 7. During entrance conference on 1/3/2022 at 11:10 a.m. the Administrator was asked how 24-hour call was handled. The Administrator indicated the schedulers from Ohio handle it. The Administrator indicated he/she does not know their names but would find out. Asked if there were any services the agency has trouble staffing and how it was handled to which he/she replied, “not that I’m aware of”. The Administrator indicated he/she case managed all patients. Asked the Administrator who was in charge of complaints to which he/she replied, “I would assume me, I have had no complaints since I started, I do know there is a complaint log that has guidance”. Asked the Administrator for the complaint log/resolutions for the past year at the end of conference. During an interview on 1/5/2022 at 8:50 a.m. requested the complaint log for the past year from the Administrator again. The Administrator indicated he/she could not find it and would reach out to the Alternate Administrator. At 9:25 a.m. Person J and the Administrator located a white binder labeled complaint book on top of the personnel file cabinet. Review of the complaint log indicated the Administrator filled out 1 (one) complaint form for patient 2 dated 10/21/21 that indicated “lack of staff to fulfill all hours”. The Complaint Form indicated “staffing still not found- a sign on bonus has now been added -12/28/21 Pediatric nursing specialists will also be adding radio/tv commercials locally 12/28”. The Administrator did not comment as to why the surveyor was told he/she had no complaints since his/her hire date and did not have a problem with staffing in entrance conference. During an interview on 1/11/2022 at 2:00 p.m. the Administrator was asked why the contracted scheduler personnel files were not maintained at the agency. The Administrator indicated the schedulers were not his/her employees and does not supervise the schedulers. No contracted therapist personnel files were at the agency. 8. Review of a policy titled Extended Hours of Services C-280 indicated “may be provided to respond to client needs or requests … Home Health Aides” 9. Review of the admission packet provided to patients included an Admission policy that indicated “Services for a client receiving Skilled Nursing, Therapy, Medical Social Services, and Home Health aide services …” Review of the Governing Body meeting minutes dated March 12, 2021, indicated “Board of Directors Home Care Network Inc … approves … home health care and employment policies … Emergency Preparedness Plan for 2021 … Evansville” Review of the Governing Body meeting minutes dated March 2020 at 10:00 a.m. indicated “Board of Directors Home Care Network Inc … approves … home health care and employment policies … Emergency Preparedness Plan for 2020 … Evansville” Review of the Governing Body meeting minutes dated February 8, 2019, indicated “Board of Directors Home Care Network Inc … approves … home health care and employment policies … Evansville” 10. During entrance conference on 1/3/2022 at 11:10 a.m. asked the Administrator what services the agency provides to which he/she replied, “skilled nursing and home health aide”. The Administrator indicated the agency does not provide physical, occupational, speech therapies, Social Worker, or attendant care services. Asked if there were any services provided under contracts to which he/she replied, “not that I’m aware of”. During an interview on 1/10/2022 at 8:06 a.m. Person J indicated the agency does not use home health aides because of insurance reasons and the need for a waiver. During an interview on 1/11/2022 at 8:50 a.m. Person J indicated the agency does not have a policy on authentication. During an interview on 1/11/2022 at 4:25 p.m. the Administrator and Person J were made aware of caregiver interviews of not knowing the agency provided therapy service and were not offered therapy services from the agency. Person J stated, “I showed you that we would be losing money using if we bill Medicaid for those services and we would need prior authorization”. The agency failed to offer or provide one other therapeutic service. The agency failed to update the admission policy to accurately reflect the services provided. 17-15-1-(a)(7)

Administrator CFR(s): 484.115(a) Standard: Administrator, home health agency. (1) For individuals that began employment with the HHA prior to January 13, 2018, a person who: (i) Is a licensed physician; (ii) Is a registered nurse; or (iii) Has training and experience in health service administration and at least 1 year of supervisory administrative experience in home health care or a related health care program. (2) For individuals that begin employment with an HHA on or after January 13, 2018, a person who: (i) Is a licensed physician, a registered nurse, or holds an undergraduate degree; and (ii) Has experience in health service administration, with at least 1 year of supervisory or administrative experience in home health care or a related health care program. This STANDARD is not met as evidenced by: Based on record review and interview, the Governing Body and Administrator failed to appoint a qualified Alternate Administrator to act in the Administrator's absence for 1 of 1 home health agency. Findings include: A revised January 2018 policy titled Governing Body was provided by the Administrator on 1/4/2022 at 3:00 p.m. The policy indicated, but was not limited, “The Governing Body shall assume full legal authority and responsibility for the Cooperation of Agency. New governing body members are oriented to the agency as appropriate to responsibilities … To ensure the lines of authority are established … 6. Define the corporate structure and clearly indicate lines of authority.” A 2018 policy titled Job Description: Alternate Program Administrator was provided by Person J on 1/11/2022 at 9:00 a.m. The job description indicated, but was not limited to, “1. Graduate of an accredited nursing program with a current license as a Registered Nurse in the state(s) of practice or holds an undergraduate degree.” An October 2016 policy titled Job Description: RN Supervisor-Indiana was provided by Person J on 1/10/2022 at 3:20 p.m. The job description indicated, but was not limited to, “The RN Case Manager reports to the Clinical Administrator … signed by [Alternate Clinical Supervisor] Date 10/4/21” Person J confirmed the RN Case Manager and RN-Supervisor are the same. Review of the state agency database indicated the Administrator as [Person G], Alternate Administrator [name Q], Clinical Nursing Supervisor [Person H], and Alternate Clinical Nursing Supervisor [name R]. On 1/3/2022 at 9:27 a.m. arrived at agency, door locked, with a noted posted would be back at 2:30 p.m. A note posted on the agency door indicated the Administrator [name] could be reached at [1-740 number] or [1-812 number]. At 9:35 a.m. called [1-740 number] disconnected. Called [1-812 number] Administrator answered and indicated he/she was Covid positive and in isolation until Thursday, and no one was at the Evansville office. The Administrator indicated Person J was the Alternate Administrator from Ohio [4 hours away] and Administrator Q for [Entity 1] was 2.5 hours away. At 9:47 a.m. the Administrator indicated he/she had no one to fill the roles of Clinical Supervisor and he/she took the Administrator position on October 4, 2021. Asked the Administrator if there was an RN close by to open the agency to start the survey. The Administrator indicated he/she will place a call to Administrator Q. At 10:20 a.m. call was placed to Administrator who indicated Person J and Person B sent a letter to the state agency on October 28, 2021, regarding the changes in Administration. The Administrator stated he/she did not test positive for Covid, but his/her family tested positive on December 31 and was isolating as a precaution. At 11:00 a.m. the Administrator indicated that Administrator Q from Indianapolis was his/her back-up. The Administrator indicated he/she would come in out of isolation to open the agency to begin the survey. During entrance conference on 1/3/2022 at 11:10 a.m. the Administrator was asked who the Alternate Administrator, Clinical Supervisor, and Alternate Clinical Supervisor were for the agency. The Administrator indicated [name Q] from Indianapolis was the Alternate, “I guess I am the Clinical Supervisor, and I guess the Alternate Administrator is the Alternate Clinical Supervisor”. The Administrator indicated the person the state agency had on file for Alternate Clinical Supervisor [name R] was no longer with the agency but was still with [Entity 1] and was the former Administrator for [Entity 2]. Asked Administrator for the appointment letters for those positions to which he/she relied “I don’t know what that is”. During an observation of the agency office along with the Administrator on 1/3/2022 at 3:00 p.m. confirmed that contracted staff files for the Alternate Administrator, Alternate Clinical Supervisor, and schedulers were not kept in the file cabinet along with other files or at the Evansville office. Review of the state landscape form completed by the Administrator on 1/4/2022 at 4:00 p.m. indicated him/herself as the Administrator, Alternate Administrator [Administrator Q], Clinical Supervisor [Administrator name], Alternate Clinical Supervisor [name R]. During an interview on Sunday 1/9/2022 at 3:24 p.m. received a phone call from the Administrator indicated he/she tested positive for Covid-19 and the contracted Alternate Administrator family member tested positive for Covid-19 Friday. Person J was on his/her way from Ohio and would pick up the key to the agency at the Administrator’s house. The Administrator indicated Person O from Ohio instructed the Administrator to call the surveyor and ask what to do. Queried if the contracted Alternate Clinical Supervisor and/or the Governing Body was notified to which she/he indicated they would try. During an interview on Sunday 1/9/2022 at 4:46 p.m. received a phone call from the Administrator indicating he/she would be available by phone on Monday and that Person J called the contracted Clinical Nursing Supervisor to help with the survey on Monday but had not heard back from him/her. During an interview on 1/10/2022 at 8:06 a.m. Person J indicated he/she had an emergency Governing Body meeting on 1/9/2022 at 6:40 p.m. with the Administrator, President O, Person B, and Person C. Person J indicated he/she was a member of the Governing Body and did not realize it at that time. Queried if contracted Alternate Nursing Supervisor would be present for survey. Person J indicated the Alternate Nursing Supervisor for Evansville was to maintain the Entity 1 office in Indianapolis since Administrator Q of Entity 1 was out with Covid-19. During an interview on 1/10/2022 at 9:15 a.m. queried Person J about personnel files and would need to review the Administrator, contracted Alternate Administrator and Alternate Clinical Supervisor files. Person J indicated the contracted files were sitting next to him/her loosely on the chair and would place them in a binder. Person J indicated the contracted files came from the Indianapolis office. During an interview on 1/10/2022 at 11:00 a.m. queried as to when the contracted Alternate Administrator and Alternate Clinical Supervisor were hired since the files came from Entity 1’s office. Person J provided hire dates for Alternate Administrator 3/4/07 and Alternate Clinical Supervisor 1/16/11. On 1/11/2022 at 9:00 a.m. a document titled Agency Ancillary Services Agreement was provided by Person J. The agreement indicated, but was not limited to, “This Agreement is entered into on this date 10/4/21, by and between Pediatric Nursing Specialists of HCN (hereininafter referred to as “Agency”), whose principal place of business is located at 5200 Washington Ave. STE C Evansville, IN. 47715 and [Alternate Administrator name] (hereinafter referred to as “Contractor”), whose principal place of business is located at [Entity 1 address]. … The Contractor is qualified to perform tasks related to Administrator duties as described in the job description … Responsibilities of the Contractor: The Contractor will fulfill the duties of the administrator when back up is required. See the Program Administrator job description for essential functions and areas of accountability.” Review of the Program Administrator job description attached to the contract indicated, “Graduate of an accredited nursing program with a current license as a Registered Nurse in the state(s) of practice or holds an undergraduate degree …” On 1/11/2022 at 11:15 a.m. a copy of the contracted Alternate Administrator resume was provided by Person J. Review of the PLA (Professional Licensing Agency) database indicated the contracted Alternate Administrator was an LPN (licensed practical nurse). Review of the Governing Body Meeting minutes dated 1/9/2022 indicated Administrator Q of Entity 1 as the back-up Alternate Administrator for the Evansville agency. Governing Body meeting minutes dated 10/4/2021 indicated Administrator Q as the Alternate Administrator for the Evansville agency. Governing Body meeting minutes dated 3/12/2021 indicated Administrator Q as the Alternate Administrator for the Evansville agency. Governing Body meeting minutes dated 3/2020 indicated Administrator Q as the Alternate Administrator for the Evansville agency. Governing Body Meeting minutes dated 2/8/2019 indicated former Person Q as the Alternate Administrator. During an interview on 1/11/2022 at 11:30 a.m. Person J was asked to confirm if the Alternate Administrator had another degree. Person J spoke with the Alternate Administrator and indicated he/she does not hold any other degrees and was an LPN. On 1/11/2022 at 2:05 p.m. asked Person J to confirm the contracted Alternate Administrator hire date 3/4/07 and Alternate Clinical Supervisor hire date 1/16/11. Person J found the hire dates in new software system from other company that was bought out. Cerner system was the old system. Person J indicated the Alternate Administrator hire date was 10/10/01 but was unable to verify the hire date specifically for the Evansville license. The agency failed to appoint a qualified Alternate Administrator based on an unconfirmed hire date specific to the Evansville agency and the lack of being a registered nurse or holding an undergraduate degree to fulfill the Administrator’s role when absent.